NAMI Texas recommends the following federal policy items for consideration by affiliates:
Increased Access to Community Mental Health Services for Uninsured and Low-Income Americans with Serious Mental Illness (by establishing federal status for community behavioral health organizations)
The establishment of Certified Community Behavioral Health Centers (as outlined in the Excellence in Mental Health Act) would bolster our nation’s community mental health and addictions system, providing new support for integrated and simplified treatment that will improve Americans’ health and lower costs for the federal and state governments.
In 2003, President George W. Bush’s New Freedom Commission on Mental Health found that “the [mental healthcare] system is in shambles.” Since that time, the situation has only gotten worse, as states have cut over $4 billion from mental and addictions healthcare during the course of the recession. Community mental health and addictions treatment centers are struggling to continue providing services that help people lead healthy and productive lives – but funding cuts have left them to treat growing caseloads with fewer dollars.
The Excellence in Mental Health Act (S. 264) will strengthen our nation’s community mental health and addictions system by establishing federal status for qualifying provider organizations and granting them access to payment structures that support the cost of doing business.
This legislation will create a new, voluntary pathway for community mental health and addictions organizations to become Certified Community Behavioral Health Centers (CCBHCs).Organizations would have to deliver specified services and meet requirements with respect to reporting, standards of care, and oversight. In return, CCBHC status would offer a foundation for a whole-person approach to health that recognizes community behavioral healthcare organizations’ experience and potential in treating complex patients with difficult healthcare needs.
Promoting Federal Initiatives that Bring Together Mental Health and Criminal Justice Agencies to Address the Unique Needs of Persons with Mental Health Conditions, Diverting Individuals with Mental Illness from the Criminal Justice System and Improving Services for Those Involved with the Criminal Justice System
The U.S. Senate is currently considering the Justice and Mental Health Collaboration Act. This Act reauthorizes and expands on Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA) that Congress passed in 2004, by:
• Continuing support for mental health courts and crisis intervention teams, both of which save lives and money;
• Emphasizing evidence-based practices that have been proven effective through empirical evidence;
• Authorizing investments in veterans treatment courts, which serve arrested veterans who suffer from PTSD, substance addiction, and other mental health conditions;
• Supporting the development of curricula for police academies and orientations;
• Increasing focus on corrections-based programs, like transitional services that reduce recidivism rates and screening practices that identify inmates with mental health conditions; and
• Giving local officials greater control over program participation eligibility.
Early Intervention, Screening, School Violence Prevention, and Comprehensive School-Based Mental Health Services and Supports
Millions of children in our nation live with mental health conditions. Most are not identified and do not receive mental health services and supports. This often has dire consequences including school drop-out and failure, involvement with law enforcement and suicide. A national dialogue has begun about the critical need to better address the mental health and well-being of our nation’s children in the wake of recent tragedies. With adequate support, schools can play a key role in the early identification of mental health related concerns and helping to link students and their families with mental health services and supports.
The Mental Health in Schools Act (House bill 628 and Senate bill 195) is critically important legislation that provides federal funding to increase the availability of comprehensive school-based mental health services and supports and to build effective links between schools and the community mental health system.
This legislation will improve the early identification of mental illness by funding school and community-based mental health services and linking students with effective services and supports so they have the chance to thrive and reach their full potential. This legislation promises to give youth the future they deserve.
The Mental Health Awareness and Improvement Act of 2013 (which includes language in the Mental Health and Schools Act) is another important bill for early intervention and suicide prevention. NAMI is especially supportive of provisions in the Mental Health Awareness and Improvement Act that will expand access to early intervention services designed to help identify mental illness earlier in children and adolescents. Scientific research is doing more to help us understand what can be done to identify mental illness earlier and to intervene early to avoid long-term disability. We simply must do more to ensure that early identification and intervention services are available in school-based settings.
NAMI also strongly supports inclusion of reauthorization of the Garrett Lee Smith Act (GLS) in this legislation. The GLS Act has led to the replication of effective suicide prevention strategies targeting at risk youth. It is critical that we expand this effort to reach adult populations. As a nation, we must make progress in addressing the 36,000 deaths by suicide that occur annually – 90% of which involve mental illness.
Finally, there is cause for strong support of the Mental Illness Awareness Training Grants contained in this legislation. We are learning more about effective training programs to help educate emergency medical personnel and first responders on how to identify untreated mental illness, how to de-escalate crises and refer individuals to treatment services. These effective strategies must be made available in communities across the country.
Funding of Mental Illness Research Through NIMH
The National Institute of Mental Health (NIMH) is the principal federal agency in charge of funding biomedical research into brain disorders. Through its $1.46 billion budget, NIMH supports and conducts an integrated program of basic and clinical research and research training in biology, neuroscience, and epidemiology. Research initiatives include programs in major brain disorders such as schizophrenia, major depression, bipolar disorder, panic disorder, and obsessive-compulsive disorder. NAMI strongly supports efforts to substantially increase federal funding to ensure that there are adequate resources for promising biomedical research into brain disorders and genetics and supports initiatives focused on neural receptors, receptor subtypes, and modulators. NAMI also supports changes in the NIMH mission that will place greater emphasis on the most serious brain disorders—including schizophrenia, major depression and bipolar disorder—in its research portfolio.
Given the role culture plays in all aspects of mental health, it is imperative to focus more attention on culture specific mental health and substance use research. The National Institutes of Health (NIH) and its National Institute of Mental Health (NIMH) must increase funding for culturally specific mental health research, specifically in reference to persons of different ages and of varying cultures, racial, religious, ethnic, sexual orientation, gender, gender identity, and disability, including persons who are deaf and hearing impaired, and those for whom English is not the primary language. Particular attention must be given to areas such as epidemiology, psychopharmacology, diagnosis and assessment, prevention, evidence based practices, disparities, and cultural competence.
Supportive Housing and Employment
Access to decent, safe, and affordable housing remains a tremendous challenge for adults with severe mental illnesses. Unfortunately, in virtually every part of the United States people with severe mental illnesses struggle to find good-quality housing they can afford. Many people with the most severe and disabling mental illnesses also need access to appropriate services and supports so that they can successfully live in community-based housing, which promotes their independence and dignity.
NAMI supports increasing access to permanent housing and appropriate supports and services that allow persons with serious mental illnesses (or brain disorders) to live in the community. These permanent housing resources include HUD programs such as Section 811 and Shelter Plus Care, as well as tenant-based rental assistance linked to the emerging “elderly only” housing designation crisis. NAMI believes that the widely recognized failure of “deinstitutionalization” in recent decades is due in large part to the failure of states and communities to invest in housing and supports for people with severe mental illnesses.
NAMI supports efforts to link supports and services to housing specifically for adults with severe and disabling brain disorders. Where linked to housing, such services should be flexible and based on an individualized plan with meaningful consumer and family input. This housing approach also reduces isolation experienced by many adults with severe and disabling brain disorders.
NAMI opposes efforts to weaken protections under the Fair Housing Act for people with severe mental illnesses in group homes and community residences. These proposals to weaken the Fair Housing Act would significantly scale back provisions in the law that bar discriminatory zoning and land-use policies intended to exclude group homes from residential communities. These are policies typically implemented in response to Not in My Backyard (NIMBY), or community opposition to group homes.
Regarding supportive employment, government income-support programs (including SSI and SSDI) and the healthcare programs that accompany them (Medicare and Medicaid) should never force people with disabilities to be trapped in poverty and dependence by preventing even part-time work that promotes dignity and independence. These public disability programs (SSDI, SSI, Medicare, and Medicaid) must start moving toward including a new purpose of supporting individuals with disabilities in the workforce, especially people with serious brain disorders who have never been given the opportunity to move toward work and independence. SSI and SSDI should be transformed from a safety net into a trampoline, not only to catch people with disabilities as they fall out of work, but also to give them a boost back up into work when they are ready; thereby: a) benefiting individuals by enabling them to remain in the workforce as wage earners; b) adding skilled workers to the labor pool; c) allowing employment-service providers to serve many more participants; and c) benefiting taxpayers by assisting workers with disabilities to begin or continue to pay taxes.
Limiting/Ending Restraint and Seclusion in Schools
Physical restraint and seclusion have resulted in serious injury, psychological trauma and death to numerous students in schools across the country. This has been well documented by the media and in numerous reports. The inappropriate and harmful use of restraint and seclusion has disproportionately impacted students with disabilities, including those with mental illness. The ability of schools to use restraint and seclusion with children should be restricted. NAMI strongly supports and urges swift action on the Keeping All Students Safe Act (H.R. 1893).
Full Implementation of Parity Law
NAMI’s public policy platform supports health care for all persons with mental illness that is affordable, nondiscriminatory and includes coverage for the most effective and appropriate treatment. NAMI supports equal access to affordable health care for every American. NAMI supports mandatory coverage and full parity for mental illness that is equal in scope and duration to coverage for other illnesses. While NAMI’s platform supports “federally mandated, minimum standards for health insurance coverage, federal standards must not pre-empt state laws that provide higher standards.” All insurance plans, public or private, must provide mental health coverage on par with their coverage of other health conditions.
NAMI worked to ensure passage of the federal parity law in 2008. This landmark law requires equal coverage for mental health and substance abuse treatment in all group health plans sponsored by employers with 50 or more workers.
Even through the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was signed into law in 2008, final regulations implementing the law have still not been issued. On January 16, 2013, President Obama declared his intention for the Administration to issue a final regulation. These final regulations are needed in order to ensure that:
• Group health plans once and for all remove discriminatory limits on inpatient and outpatient mental illness treatment services and establish equal financial requirements such as deductibles, cost sharing and out-of-pocket limits in their policies;
• Non-Quantitative Treatment Limits (NQTLs) such as a prospective and retrospective utilization review that are inequitably applied only to mental illness treatment services are ended; and
• The “scope of services” for covered mental health treatments is equal to that for medical-surgical coverage, including rehabilitative services and residential treatment.
The Affordable Care Act of 2010 contains an important expansion of the federal parity law by requiring that all health plans marketed through the Health Insurance Exchanges that will offer expanded coverage options for the uninsured, underinsured and small businesses comply with the federal parity law. This will go a long way toward eliminating the exemptions in the federal parity law for the individual and small group markets.
As we move forward, it will be important to advocate for:
• Final federal regulations for the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act.
• Assertive enforcement by the U.S. Departments of Labor and Health and Human Services and the Texas Department of Insurance.
• Enforcement of the federal parity requirement for all health plans sold through federal Health Insurance Exchange when this is established in Texas in January 2014.
Veterans Mental Health Care / VA Funding
NAMI believes that veterans should receive the same full range of integrated services within the hospital and upon discharge to the community that are received by other people with serious mental illnesses. NAMI calls for veterans hospitals and veterans outpatient treatment programs to be held to the same standards of performance as all other hospitals and outpatient treatment programs. Individuals who are veterans, on active military duty, in the National Guard, or in the Reserves, as well as their family members must receive the same level of care and treatment regardless of the provider.
Protecting Federal Funding for Medicaid and Social Security Disability Programs
Congressional proposals to block grant Medicaid have been known to come to the surface from time to time. This would give each state a fixed dollar amount to operate its program. States would be able to construct their own Medicaid plans with their own standards and rules for coverage and enrollment. The total dollar amount of each state’s block grant would increase with population growth and the consumer price index, but would not automatically increase during times of economic recession or other enrollment spikes. State-by-state levels of funding for the first year of the block grant would be determined at a later date in the appropriations process and could be modified each year as Congress crafts its budget.
Block granting Medicaid would result in cuts in the hundreds of billions of dollars to the federal Medicaid program over the next 10 years. Under a block grant, if federal funding proved to be inadequate to meet the need for services in a state, that state would be responsible for contributing more of its own funds or cutting back eligibility, provider payments, and benefits. The pressure on state Medicaid programs during the recession – and states’ corresponding efforts to reduce funding and eligibility, despite federal rules limiting their ability to do so – suggest that were Medicaid to be converted to a block grant, it would be nearly impossible to maintain current levels of services. Mental health and substance abuse services would be at high risk for cutbacks because they are optional services under current Medicaid law. With many states now cutting general fund dollars that are allocated to behavioral health programs, a loss of Medicaid funding would further drain crucial resources from the behavioral health safety net.
Proponents of the block grant approach have argued that states would have greater flexibility in designing and managing their programs so as to deliver care in a more efficient manner. However, an analysis by the Congressional Budget Office found that the magnitude of the loss of federal funding would far outweigh any potential savings that could be achieved through greater efficiency. The CBO report concludes that beneficiaries would face higher out of pocket costs and limited access to care, while providers could see rate decreases or find their services removed from benefits packages. Most states already face a crucial shortage of Medicaid providers due to low reimbursement rates and extensive regulatory requirements. Overall, block grating Medicaid would stabilize the federal government’s share of expenditures on the program over the next 10 years – but it does so by putting states and beneficiaries at risk for higher costs and reduced benefits, a burden that falls most heavily on low-income and disabled populations.
Preserving Funding for Important Behavioral Health Programs Such as Those Funded by the Substance Abuse and Mental Health Services Administration
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the lead public health agency charged with coordinating the nation’s behavioral health safety net. By helping people get back on their feet and regain their health, SAMHSA programs reduce expensive inpatient hospitalizations, emergency department usage, and involvement with the criminal justice system.
KEY SAMHSA PROGRAMS:
• Primary Care-Behavioral Health Integration (PBHCI). The PBHCI program, begun in 2009, provides critical support to community behavioral health and primary care organizations that are joining together to provide essential primary care services to adults with serious mental illness and addiction disorders. Over 15,000 people are being screened and treated for diabetes, heart disease and other common and deadly illnesses in an effort to stem the alarming early death rate from these health conditions in this population. Essential to the success of this program is the technical assistance offered by the Center for Integrated Health Solutions (CIHS) funded by SAMHSA as “Primary/Behavioral Health Integration TA.” Services provided by CIHS support rapid and successful implementation of grant activities.
• Block Grants. The FY 2012 budget included a $40 million increase for the Mental Health Block Grant and a $20 million increase for the Substance Abuse Prevention and Treatment Block Grant, the first much-needed increases in years. These increases will support many important initiatives for people with severe mental illness and addictions throughout the country, including employment and housing assistance, case management, school-based support services, family and parenting education, and peer support. Yet, with states continuing to experience the effects of the recession, increased funding for the block grants is needed to meet the growing demand for services.
Other important SAMHSA programs include: Children’s Mental Health Services (Systems of Care); Garrett Lee Smith Suicide Prevention; Youth Violence Prevention (Safe Schools/Healthy Students); Screening, Brief Intervention, and Referral to Treatment; and more. These programs must be adequately funded.
Loan Repayment for Child and Adolescent Psychiatry Residents
Our nation is facing a critical shortage of child mental health providers. Families routinely wait many months for an assessment, treatment and services for their child. The Pediatric Subspecialty Loan Repayment Program must be funded adequately. This program will provide loan repayment to child and adolescent psychiatrist of up to $35,000 per year, for up to two years, for those who work in medically underserved areas. This promises to positively impact the shortage of child and adolescent psychiatrists.
Not Amending the HIPAA Privacy Rule to Create a Special Exception for Reporting of Mental Health Records to the National Instant Criminal Background Check System (NICS)
NAMI shares the goal of reducing gun violence in America and believes that firearms and ammunition should not be easier to obtain than mental health care. At the same time, NAMI strongly advocates that people should not be treated differently with respect to firearms regulations based on stereotypical assumptions about mental illness and its relationship to violence. We believe that the current NICS law is based on faulty assumptions about the relationships between mental illness and violence, not grounded in science. We therefore do not support amending the HIPAA Privacy Rule to create a special exception for reporting of mental health records to the NICS database.