*Articles from other media sources do not necessarily reflect the opinions or positions of NAMI Texas and its staff*
Good News for Mental Illness in Health Law
By RICHARD A. FRIEDMAN, M.D.
Published: July 9, 2012 in The New York Times
Americans with mental illness had good reason to celebrate when the Supreme Court upheld President Obama’s Affordable Care Act. The law promises to give them something they have never had before: near-universal health insurance, not just for their medical problems but for psychiatric disorders as well.
This was supposed to be fixed in part by the Mental Health Parity and Addiction Equity Act of 2008, which mandated that psychiatric illness be covered just the same as other medical illnesses. But the law applied only to larger employers (50 or more workers) that offered a health plan with benefits for mental health and substance abuse. Since it did not mandate universal psychiatric benefits, it had a limited effect on the disparity between the treatment of psychiatric and nonpsychiatric medical diseases.
Now comes the Affordable Care Act combining parity with the individual mandate for health insurance. As Dr. Dilip V. Jeste, president of the American Psychiatric Association, told me, “This law has the potential to change the course of life for psychiatric patients for the better, and in that sense it is both humane and right.”
To get a sense of the magnitude of the potential benefit, consider that about half of Americans will experience a major psychiatric or substance disorder at some point, according to an authoritative 2005 survey. Yet because of the stigma surrounding mental illness, poor access to care and inadequate insurance coverage, only a fraction of those with mental illness receive treatment.
For example, surveys show that only about 50 percent of Americans with a mood disorder had psychiatric treatment in the past year — leaving the rest at high risk of suicide, to say nothing of the high cost to society in absenteeism and lost productivity. The World Health Organization ranks major depression as the world’s leading cause of disability.
One of the health care act’s pillars is to forbid the exclusion of people with pre-existing illness from medical coverage. By definition, a vast majority of adult Americans with a mental illness have a pre-existing disorder. Half of all serious psychiatric illnesses — including major depression, anxiety disorders and substance abuse — start by 14 years of age, and three-fourths are present by 25, according to the National Comorbidity Survey. These people have specifically been denied medical coverage by most commercial insurance companies — until now.
From an epidemiologic and public health perspective, the provision that young people can remain on their parents’ insurance until they turn 26 is a no-brainer: By this age, the bulk of psychiatric illness has already developed, and there is solid evidence that we can positively change the course of psychiatric illness by early treatment.
Mental disorders are chronic lifelong diseases, characterized by remission and relapse for those who respond to treatment, or persistent symptoms for those who do not. Inschizophrenia, for example, relapse is common, even with the best treatment. It makes no sense to tell someone with this condition that his lifetime mental health benefit is just 60 days of inpatient hospitalization.
Psychiatric illness is treatable, but it is rarely curable; it may remit for a while, but it doesn’t go away. That is why the current limits on treatment are as irrational as they are cruel — the discriminatory hallmark of commercial medical insurance.
No more. The Affordable Care Act treats psychiatric illness like any other and removes obstacles to fair and rational treatment.
Older people with mental illness will also benefit, because the law will eventually fill in the notorious gap in Medicare drug coverage known as the “doughnut hole.” The law will immediately require drug companies to give a 50 percent discount on brand-name drugs and then gradually provide subsidies until the gap closes in 2020.
On the other hand, poor people with mental illness still have cause for concern. The new law would have expanded Medicaid to insure 17 million more Americans, but the Supreme Court ruled that states could decline to accept this expansion without losing their existing Medicaid funds. In states that opt out of the Medicaid expansion, poor people with mental illness may find themselves in a terrible predicament: They earn too much to qualify for Medicaid, yet not enough to get the federal subsidy to pay for insurance.
But on the whole, the Affordable Care Act is reason to cheer. Americans with mental illness finally have the prize that has eluded patients and clinicians for decades: the recognition that psychiatric illness should be on a par with all other medical disorders, and the near-universal mandate to make that happen.
Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.
Study: Texas Ranks Last in Mental Health Spending
By Claire Cardona, Texas Tribune
November 10, 2011
Despite an increase in state spending on mental health care, Texas still ranks last in per capita funding for people with mental illness, according to a report issued by the National Alliance of Mental Illness.
The report showed Texas increased its spending by 4.3 percent over the last three years — the 2012 budget is $964.1 million. But NAMI Texas Executive Director Robin Peyson said that’s not enough.
“I think that mental health stakeholders, NAMI and other partners, need to help our policymakers understand why it’s penny-wise and pound-foolish to not pay for mental health services,” Peyson said.
Although Texas was one of a handful of states that didn’t have its mental health budget cut over that time period, Peyson said the state has the largest uninsured population, one that’s only growing.
Some states made staggering cuts, such as California, which slashed $764.8 million between 2009 and 2012. But California’s per capita spending still remained higher than Texas’, which has been at the bottom of the list for the past few years.
Health funding for states became even more complicated in June with the expiration of the federal stimulus funds that temporarily boosted the federal match for Medicaid. Without the increased match, the heightened cost of Medicaid funding will fall largely on individual states: The report predicts an additional cost for Texas of $851 million in 2012.
The report recommends changes in policy to preserve mental health budgets, including protecting and strengthening mental health services and restoring spending cuts, and preserving access to acute care and long-term care services.
“If someone shows up with an acute mental health crisis, you get in the door but when your crisis is over you go on a waiting list,” Peyson said. “You wouldn’t put people with diabetes on a waiting list, they’ll die.”
NAMI Texas is hoping the report will encourage activism against cuts, since the state ranks so low on the list and the situation is urgent.
“I feel like a broken record but I’ll say it as many times as I need to, people with mental illness that aren’t treated show up in your emergency rooms and your jails,” Peyson said. “[Mental illness] one of the biggest health issues that has a measurable cost.”
US Judge Approves Deal in Miss. Youth Prison Suit
San Antonio Express-News
March 29, 2012
JACKSON, Miss. (AP) — A federal judge has approved an agreement that would move juvenile offenders out of a privately run prison that has been hounded by allegations of physical and sexual abuse.
The settlement was reached between civil rights advocates and the state of Mississippi in a 2010 lawsuit.
U.S. District Judge Carlton Reeves approved the agreement in a March 26 order made public Thursday.
Reeves had harsh words for the state in his order noting that officials “have been derelict in their duties and remain deliberately indifferent to the serious medical and mental health needs of the offenders.”
“The sum of these actions and inactions … paints a picture of such horror as should be unrealized anywhere in the civilized world,” Reeves wrote.
Walnut Grove opened in 2001 in Leake County and holds inmates ages 13-22 who were minors convicted as adults. It was run by the private prison firm Cornell Companies Inc. until Cornell was acquired by the GEO Group Inc. in a $730 million deal in 2010. GEO Group of Boca Raton, Fla., is now the nation’s second largest private prison company.
The company has declined to comment on the lawsuit.
Reeves said the misconduct was widespread. He said the facility was “deliberately indifferent to the serious and substantial risk of harm to which these youth are subjected.”
“And to add one final insult to these injuries, State officials repeatedly failed to monitor the contracts with GEO and simply rewarded the company by either extending or offering new contracts, or by not revoking the existing contract despite ‘systemic, egregious, and dangerous practices exacerbated by a lack of accountability and controls.'” Reeves said.
The Southern Poverty Law Center, the American Civil Liberties Union and Jackson attorney Robert McDuff sued the state over conditions at the facility in 2010. The class action suit claimed guards smuggled drugs to inmates, had sex with some of them and denied others medical treatment and basic educational services.
The sides reached a proposed settlement in February that would require youth to be moved to a facility governed by juvenile justice standards.
Mississippi Corrections Commissioner Chris Epps has said his plan is to send the 17-and-younger inmates to Central Mississippi Correctional Facility by Oct. 1. He said there are about 1,000 vacant beds at CMCF now, so there is no need for a new building.
Walnut Grove also houses adults. They would remain there under the deal.
Connecticut Moves Away from Medicaid Managed Care
BY: John Buntin | 2/28/2012
At a time when states across the country are turning to private health plans to provide Medicaid managed care, Connecticut is taking a different approach. This year, the state ended private insurer participation in the state Medicaid program. Mark Schaefer, Connecticut’s Medicaid director, told Kaiser Health News that “there has been a diminishing confidence in the value of what they are providing.” Instead, the state is taking responsibility for managing care for some half a million parents and children directly, using an administrative services organization (ASO) model. Heading the effort is Department of Social Services (DSS) Commissioner Roderick Bremby.Bremby’s career has run the gamut of state and local government. A former assistant city manager in Lawrence, Kan., he headed the Kansas Department of Health and Environment, under then-Gov. Kathleen Sebelius, who now serves as secretary for the U.S. Department of Health and Human Services. As Connecticut’s commissioner, he has sought to modernize and coordinate the state’s health and human services operation, while also executing the state’s closely-watched move away from private Medicaid managed care. I spoke to him about the state’s plans in this edited transcript.
Could you explain exactly what Connecticut is doing and why?
Roderick Bremby: The first thing is that we’re not demonizing private insurance companies as we move forward to acquire better health care for our clients. It’s just that we’ve used a model here in Connecticut for 15 years, and we believe it’s time to try something different. We hope to achieve greater transparency and accountability for the 600,000 people in our system, as well as cost savings through less administration.
What was the Medicaid managed care landscape like previously?
We spent about $860 million dollars on Medicaid managed care. It was primarily for our Medicaid program for children and their parents. We employed three plans to manage that program for us.
What the administration of Gov. Dannel Malloy and Lt. Gov. Nancy Wyman decided to do in this new construct is not only to bring our Medicaid program for kids and parents to the ASO model, but also our Medicaid for the aged, blind and disabled, and low-income, childless adults. Also included are the Children’s Health Insurance Program (CHIP) and the state-sponsored Charter Oak Health Plan for uninsured adults.
A primary goal is to bring people into this new arrangement who have not had intensive case management previously. In Connecticut, four percent of our population drives about 49 percent of our costs. Put another way, there are 28,000 people in the program that consume $2.3 billion of medical care every year. Trying to identify that four percent, those 28,000 people, across three capitated managed-care plans was not easily done. By aggregating everyone in a group or pool, we’ll be able to identify them. We’ll be able to assure that they get the continuity and type of service that they need at the right time.
A couple of questions about this ASO model: What’s the governance structure? Is this a new state entity? Is it something else?
Our model permitted us to go out into the marketplace and contract with a provider to be our ASO for medical services. [So the] new structural organization, if you will, is the state of Connecticut, DSS, interfacing with the ASO and our network of providers.
Are there models elsewhere for what Connecticut is trying to do here?
Yes. Oklahoma has been in this space for quite some time and has had pretty good outcomes. Oklahoma does this, though, through a different governing structure. They have an authority that runs their Medicaid program. But the model, the provision of care, is clearly one that’s been in operation for some time, and has had some success.
I ask everyone a question about the Affordable Care Act (ACA). What, in your opinion, did that legislation get right? What did it miss?
By and large, it got a great many things right. There are unique opportunities to drive down costs and improve health outcomes. There’s also a huge, historic allocation of money for prevention. The ACA also tied in with the [American Recovery and Reinvestment Act] legislation to provide the technical support for electronic health records and exchanges. There’s a major investment in developing and improving information systems that I believe is really essential to any real, meaningful improvement in health outcomes.
When you led the Kansas Department of Health & Environment, you were known for your work bringing Web-based services to the department. Technology and modernization have also been a focus for you in Connecticut. Can you talk about some of your efforts in that regard?
In Kansas, we worked on Web services, as well as trying to align systems such as county immunization registries. We also had a claims database that was available to apply analytics to the health-care experience.
Moving that forward here in Connecticut is a major goal. Our department has had a lack of investment over 20 years in the systems needed to support efficient and effective operations. At DSS, we receive 890,000 phone calls and process 3.7 million pieces of paper every month. Our regional offices are overwhelmed by the amount of work and effort that it takes to perform work manually.
We now have a modernization effort underway. We call it the ConneCT initiative. It will enable us to come up to current technological service standards. We’re going to move beyond that critical deployment and seek to replace the integrated eligibility management system, which is 22 years old. It’s fairly stable day to day, but any changes in the system create significant challenges. We’re working on those solutions internally. Lastly, we are planning to link our human services eligibility determination systems with the health insurance exchange eligibility platform. Those are the three fundamental areas of technology that we’re bringing resources to improve and modernize operations at DSS.
Some state officials I’ve spoken with, particularly in smaller states, have expressed anxiety about the technical challenges of developing eligibility determination systems. There’s a concern about whether the private sector resources will be there for everyone. Is that a concern for you?
No. Time is of the essence. States have to move, and they have to move quickly to take advantage of the opportunity that is out there. This is an unprecedented opportunity, fiscally as well as organizationally, to partner with the federal government to bring about change that we’ve all been talking about for a very long time. If states wait or are delayed in their deployment considerations, they may have difficulty finding the private-sector market solutions in a timely manner. We’re having no difficulties finding very capable and forward-leaning organizations to assist us in bringing solutions to bear. But you have to move, and you have to move fairly quickly.
States may want to look to partner with each other. Those are solutions that we really haven’t seriously entertained in the past. But given the requirements of the ACA and the opportunity for funding that’s available, it’s a great time to be creative.
There’s a widespread sense that care coordination, particularly for the dual eligibles, is a very promising area. However, evaluations of disease-management programs and other strategies have found only very modest improvements. Are hopes for dramatic improvements realistic?
I think that people may forget that the health-delivery system that we have today continues to evolve. It’s based on a system of care that is outdated. These innovations, by their very nature, are experimental. We’re trying to find the right model to solve this problem. I’m hopeful that we will find one or more successful care delivery models in the near term. But the very fact that the effort is being made, and the investment is being made, is essential to us getting there. The result is that it takes more than what we have been doing in the past.
We’ve focused almost exclusively on the medical intervention, and we haven’t been focused on all of those other life experiences that help maintain or restore health. We have to focus on the continuity of care in a much broader construct. We know that environmental factors drive a lot of the physical manifestations of health. We know that dental health is connected with cardiovascular health. We’re beginning to look at many relationships to determine better models to take care of the whole person. The long term potential is enormous.
Texas Lawmakers Working to Reform Medicaid
By Thanh Tan 2/29/2012
Regardless of how the Supreme Court rules on President Obama’s health care reforms next month, the state of Texas is pursuing plans to completely revamp the way it runs Medicaid. Of course, it must first get the federal government’s approval.
A joint oversight committee made up of House and Senate members met Wednesday morning to hear from the state’s top public health officials and stakeholders on the process they’ll pursue to cut as many strings as possible from federal funding for the entitlement program that serves the state’s poorest adults and children. The key operative word here: flexibility.
“This is an opportunity for us as a state to design a system that’s more efficient,” said state Sen. Jane Nelson, R-Flower Mound, the panel’s chairwoman. During the public hearing, she said the federal government should “allow us to do what we do best.”
The state is facing a problem much larger in scale compared with other states. Nearly 26 percent — or 6.5 million — of the state’s residents are uninsured. In 2014, the Affordable Care Act will require all Texans to sign up for health benefits (though the state estimates about 9 percent will still fall through the cracks and remain uninsured). Medicaid is expected to increase from 3.5 million to 5.7 million beneficiaries.
To deal with the increase in demand, the state is pursuing changes on two fronts. On the one hand, they are moving forward with the federal government’s recent approval of an 1115 waiver, which will allow the state to try proven or new approaches to delivering care. However, there are strict requirements that any plan the state presents be budget-neutral and maintain current coverage levels.
Health and Human Services Executive Commissioner Tom Suehs, Deputy Commissioner Billy Millwee and Department of Aging and Disability Commissioner Chris Traylor appeared before the panel to outline their agencies’ plans for reforming delivery of acute care, including changing Medicaid benefits, instituting copayments and incentivizing Texans to take better care of themselves.
The interim group is also figuring out ways to implement SB 7, a bill passed during last summer’s special session that directs the Health and Human Services Commission to pursue a waiver that would give the state more freedom to change Medicaid eligibility requirements, encourage the use of private benefits, establish co-payments and health-savings programs, offer vouchers and make patient care more cost-effective.
(View the full presentation offered to lawmakers at today’s hearing, including more details about the proposed rule changes, here.)
SB 7’s author, state Rep. Lois Kolkhorst, R-Brenham, said her legislation is intended to “create transparencies” and to lower costs while helping consumers take charge of their own health.
“As we innovate, we have to get to where the consumer understands what it costs,” she said.
State Sen. Dan Patrick, R-Houston, said he was concerned about the magnitude and long-term effects of the state’s struggle to contain health costs.
“In the past we did it more through family and not through government,” he said.
Patrick later emphasized he meant to say that government is more involved than it used to be in the care of the elderly and that the growth in the size of that population — it’s expected to double by 2040 — might cost more than the state can afford.
“It’s not 1950. … The world has changed a lot,” Coleman said.
State Rep. Brandon Creighton, R-Conroe, asked Suehs about the extent of the “unfunded mandate” related to Medicaid.
“We don’t have an unfunded mandate in Medicaid. I think what we have is more demand than we have resources,” Suehs responded.
The commission reports it is still early in the process. This spring, they will gather public input on the waivers before they deliver a concept to the federal government in the fall. It may take months for a plan to be approved.
Stakeholders include Medicaid’s current beneficiaries, nearly 2 million potential enrollees, and the medical sector Lawmakers acknowledged they would need to address the critical shortage of health care workers in the state, especially in the primary care field.
Texas Academy of Family Physicians CEO Tom Banning attended the hearing. He told The Texas Tribune that there is no “silver bullet” for solving the state’s pending crisis.
“The broad goals envisioned in the waiver are designed to ensure the state is getting higher quality care at lower costs, which is desperately needed,” Banning wrote in an email. “We’ve got a long way to go and change is hard. We are having a healthy dialogue on the changes that need to occur, which is long overdue and a positive step in the right direction.”
Anne Dunkelberg, associate director of the Center for Public Policy Priorities, testified before the committee. Like Banning, she said the terms of the waiver remain unclear.
“It could result in either really good innovations, or truly terrible cut-backs,” she warned. “The tone of today’s hearing was encouragingly thoughtful, but whether this effort leads to good news or bad news for Texas’ neediest will depend in large part on how high the bar is set for Texas by the Medicaid authorities in Washington.”
Calif. Medicaid case heads back to lower court
The U.S. Supreme Court sent a widely watched California Medicaid case back to a lower court, declining to rule whether providers can sue states to enforce the federal statute.
The California Medical Association, however, viewed the decision as a “win for physicians and their patients” because the opinion suggests that providers may have a mechanism to challenge Medicaid policies in the courts, according to a news release. California physicians, hospitals and other providers argued in five lawsuits that state amendments to the Medicaid program, including a 10% reimbursement cut, violated language in the federal law that payments are sufficient to sustain quality and access for beneficiaries. The 9th U.S. Court of Appeals agreed and issued injunctions blocking the state from making the changes.
Judge: Mentally incompetent state inmates being kept in jail too long
The White House
July 26, 2011
On Anniversary of the Americans with Disabilities Act, Obama Administration Recommits to Enforcing and Protecting the Civil Rights of All
On July 26, 1990, the Americans with Disabilities Act was signed into law. That landmark civil rights legislation reaffirmed the idea that all our citizens, regardless of disability, are entitled to the same privileges, pursuits, and opportunities as everyone else. As the Obama Administration marks that anniversary, there still remain many steps we must take together to ensure that the spirit and letter of that law are upheld.
At Texas Mental Health Center, Smaller Cuts Still Sting
The Texas Tribune
July 26, 2011
The Texas Legislature has cut $15 billion out of its budget for the next two years, affecting virtually every state agency and almost all state services. Bluebonnet Trails, a mental health services provider based in Williamson County, has lost more than a quarter of its funding. At the beginning of the legislative session, Andrea Richardson, Bluebonnet Trails’ executive director, was pleasantly surprised when the budget reductions she thought would force Bluebonnet to cut services to 2,000-plus individuals never materialized. But she was soon unpleasantly surprised by the dramatic cuts to programs serving people with developmental disabilities.
Perry’s Rainy Day Fund? Used Up, Say Some Republicans
June 24, 2011
The Last Seven Days: A Special Session Update
June 22, 2011
With the special session constitutionally limited to 30 days, lawmakers have just a week left to resolve the bills on the call – and a lot of loose ends to wrap up.
Texas Monthly Reveals Best and Worst List
Texas Tribune by Reeve Hamilton 6/15/2011
Texas Monthly‘s list of the Ten Best and Ten Worst Legislators in the 82nd session has finally been released. Who made the cut — and how did our Texas Tribune insiders do with their predictions?
Failed Budget Vote Threatens Senate Tradition
Texas Tribune by Ross Ramsey 5/3/11
Jails brace for influx of mentally ill
Health experts – along with already burdened sheriffs – decry lack of programs due to budget cuts
House OKs spending plan
April 3, 2011
House Bill 1, a spartan, $164.5 billion budget measure, sailed through the Texas House on Sunday night on a final vote that broke largely along party lines. The Republican majority rolled over the Democrats to approve the 2012-13 budget, which will spend $23 billion less than the current budget and institutes deep cuts to education, social services – and essentially every area of state government.
Senate Budget Gets Dose of Health Care Funds
March 25, 2011
Austin American Statesman
House Appropriations approves Rainy Day Fund use, supplemental bill
March 15, 2011
Well, today was the day Jim Pitts has been waiting for. It only took several weeks, a handful of canceled hearings, getting stood up by the governor’s office and presumably hours of negotiation for the House Appropriations Committee chair to get Gov. Rick Perry’s public blessing to tap the Rainy Day Fund for the current biennium.
Mental health cuts could cost taxpayers lots of money
News Channel 10
March 15, 2011
Amarillo, Texas – An influx of mentally ill inmates is expected in Potter County, as Texas lawmakers seriously consider making big cuts to the state’s mental health programs. Amarillo’s state-funded mental health care program directors expect their budgets to be slashed by more than 20%… Or roughly $5 to 6 million.
In San Antonio, Trying to Survive the Budget Cuts: Treatment works, but will the Legislature pay for it? Texas Observer: Dave Mann. March 9, 2011
Updated Analyses of County-By-County Effects of HB 1 State Budget Cuts. Center for Public Policy Priorities: Eva DeLuna Castro. March 10, 2011
Mentally ill defendant still deemed unfit to be tried 11 years later
Austin American Statesman: March 14, 2011
It’s been 11½ years since James McMeans was arrested on accusations that he fatally stabbed a woman in the neck at a South Austin gas station, and still he has not been to trial. McMeans, 41, has paranoid schizophrenia. He once told a state psychologist that stabbing people is the only way to tell if they are androids. He has spent most of the time since his 1999 murder arrest in state psychiatric hospitals after being found incompetent to stand trial.
Tx fund cuts force police to care for mentally ill
March 13, 2011
AUSTIN, Texas (AP) – In a state that offers meager funding for mental health, law enforcement officers across Texas have performed the duties of psychologists and social workers – roles they have neither the training nor the manpower to bear.
Report: Texas’ budget woes among the worst in nation – March 9, 2011