Slow economy, tight state budgets allowing mental health system to slowly disintegrate
Slow economy, tight state budgets allowing mental health system to slowly disintegrate
In a starkly worded report on the country’s mental health system, which advocates had hoped was finally due for a major overhaul, the Bazelon Center for Mental Health Law in Washington, DC, warns that most public mental health systems "have all but disintegrated."
Even worse, the center sees little immediate opportunity to reverse the situation given tight state budgets as result of the nation’s slowed economy and changing budget priorities caused by the terrorist attacks of last September.
Chris Koyanagi, Bazelon Center policy director, who wrote the report, tells State Health Watch that while the country has not had a particularly sound mental health system for some time, we seemed to have a more coordinated approach in the 1970s, although we knew less scientifically at that time about effective mental health treatment. "The system has deteriorated due to neglect," she says bluntly. "We haven’t invested enough resources in mental health. For instances, those who are working on the front lines receive very little pay. We’ve ignored the need to modernize services and treatment and make different policy changes to phase out less-effective services and bring new services on-line."
States generally, she says, have not given sufficient priority to mental health care and services. "There’s not enough money allocated and not enough attention paid to whether the system is operating as it should. And the move to managed care has just accelerated the view of mental health as a footnote to the health managed care system." Actual state spending on mental health has declined from 1955 to 1997. (See graph, below.)
State Spending on Mental Health
1955 & 1997 (in billions of dollars)
"We stand on the verge of a big black hole," Ms. Koyanagi warns. "The system is getting to a high level of crisis. Community clinics are closing. People can’t be admitted to hospitals in a time of major crisis. When you have people in the communities who are in really bad shape, things happen. It’s hard to attract good staff and administrators to deliver services. It’s frightening where we are headed, especially when you realize that this is a time when states are retrenching ever further. No one calculates where the costs go when you cut the mental health budget. You’re not dealing with people who can just pick up and go on. Many of them will move into the criminal justice system and start showing up all kinds of places."
Increases in overall state spending and spending on corrections has far outstripped the percentage growth in spending on mental health services. (See graph, below.)
Percentage Growth in State Spending on
Corrections & Mental Health (1990-1997)
To prepare the report, Ms. Koyanagi and Robert Bernstein, Bazelon executive director, reviewed materials from 35 states, produced primarily by independent commissions or task forces, but also by investigative journalists, advocacy organizations, and states’ mental health authorities. Consistent themes, they say, were found in many of the items. For instance:
- A 2001 action agenda by the Ohio Mental Health Commission says that statewide the supply of mental health services does not meet current demand and will not meet increasing demand in the future.
- Louisiana’s 2002 mental health services plan says, "There is simply not enough money invested for acceptable mental health services in Louisiana."
- "California explicitly rations care to only those with the most extreme needs, and even then we turn people away," according to a report commissioned by the state.
Ms. Koyanagi and Mr. Bernstein say that since their research was done before the economic downturn, things are even more difficult today, and states are poised to make decisions that would all but destroy their capacity to address the needs of children and adults with serious mental illnesses.
Some of the states planning cuts in their mental health budgets already are having significant problems, according to the Bazelon staff:
- In New York, funds for the community reinvestment program will end and overall mental health funding may be cut by $26 million.
- Massachusetts is considering $20 million in cuts for the Department of Mental Health.
- Georgia has reduced payments for community services by $50 million and expectation that the cuts can be restored through increased Medicaid billings have not been realized.
- Many Maryland outpatient clinics have closed due to a lack of resources.
- Large cuts in the Michigan health budget will lead to cuts in programs for people with mental illnesses.
- Oregon’s governor has proposed cuts that would eliminate mental health services to 1,000 uninsured children who are not eligible for Medicaid, drop 50 clinical therapist slots from schools, and reduce spending for juvenile offenders with mental disorders.
Illustrating the problems, the Washington Post reported that three mental health clinics in wealthy Montgomery County, MD, are about to close, putting 3,400 patients at risk. Four clinics closed last year, and eight remaining providers say they are unable to cover their expenses because the state underestimated the need for mental health care.
Douglas Duncan, Montgomery County executive, told the Post that the state "needs to meet its financial obligation to provide mental health services. They’ve underfunded that dramatically. If that continues, we’re going to see more and more mental health services shut down."
Maryland’s mental health patients are covered by a combination of state and federal programs. Those whose conditions are so serious that they are considered disabled can be covered by Medicare, although there is no reimbursement for drugs and Medicare pays only 50% of psychiatrist bills, compared to 80% of doctor charges for physical ailments.
Impoverished patients are eligible for Medicaid, which covers all medical care and drugs. Everyone else either has private coverage or is uninsured. Observers say the problem has been building since a 1996 state decision to stop paying the remaining 50% of bills for Medicare patients who also qualify for Medicaid. Without those state payments, most patients were unable to pay their share.
In 1997, they say, the state began an ambitious program to cover more people at lower cost, but officials greatly underestimated the number of people needing mental health services. Instead of the projected 40,000, 80,000 people sought treatment. "The demand was greater than our resources," Oscar Morgan, administration director for Mental Hygiene, told the Post.
Ms. Koyanagi says similar stories are and will continue to appear around the country until it is recognized that in the long run, it is more cost-effective to treat people. "It’s hard to find a state that’s doing well," she says. "You can find programs and special initiatives that are doing well, but not a full state system. We need a more coherent national policy, but I don’t see that emerging at the moment. It never seems to be the right moment for mental health."
[Contact Ms. Koyanagi at (202) 467-5730, ext. 118.]
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