Ev­ery­one agrees men­tal health re­form is es­sen­tial, but will last year’s prom­ises be ful­filled?

Modern Healthcare - - NEWS - By Har­ris Meyer

Judge Steven Leif­man re­cently had a fe­male de­fen­dant in his Mi­ami court­room who faced a mi­nor crim­i­nal charge. He dis­cov­ered she had ex­pe­ri­enced sex­ual trauma as a child and suf­fered from a schizoaf­fec­tive men­tal dis­or­der.

She ini­tially was re­sis­tant to par­tic­i­pat­ing in the court’s di­ver­sion pro­gram and get­ting men­tal health­care. Leif­man knew if he re­leased her, she would be ar­rested and jailed again, lead­ing to more trauma—and higher costs for tax­pay­ers and the health­care sys­tem. He talked her into par­tic­i­pat­ing in the court’s res­i­den­tial treat­ment pro­gram fol­lowed by com­pre­hen­sive out­pa­tient re­cov­ery ser­vices.

“We need sup­port­ive hous­ing and a case man­ager who can work with these in­di­vid­u­als,” said Leif­man, who is na­tion­ally rec­og­nized for his work in im­prov­ing Mi­ami-Dade County’s men­tal health sys­tem. “Most of the sys­tem­atic change has to be done in each com­mu­nity, with the fed­eral gov­ern­ment pro­vid­ing the fi­nanc­ing. There’s not a sil­ver bul­let.”

Pol­i­cy­mak­ers and health­care providers widely agree that the U.S. has lots of hard work ahead to im­prove its sys­tem for serv­ing the mil­lions of Amer­i­cans suf­fer­ing from se­ri­ous men­tal ill­ness and sub­stance abuse. They cur­rently are crowd­ing the na­tion’s streets, jails, pris­ons and hos­pi­tal emer­gency de­part­ments, largely go­ing with­out ef­fec­tive treat­ment and so­cial ser-

“Most of the sys­tem­atic change has to be done in each com­mu­nity, with the fed­eral gov­ern­ment pro­vid­ing the fi­nanc­ing. There’s not a sil­ver bul­let.” Judge Steven Leif­man Mi­ami

vices to en­able them to live health­ier, more pro­duc­tive lives. Re­search has shown that they die, on aver­age, 25 years younger than other Amer­i­cans due to un­treated chronic med­i­cal con­di­tions.

There’s bi­par­ti­san sup­port for steppedup fed­eral co­or­di­na­tion and fund­ing. The land­mark 21st Cen­tury Cures Act, en­acted last De­cem­ber, in­cludes a pack­age of re­forms and grants. The law also cre­ated a first-ever HHS as­sis­tant sec­re­tary po­si­tion to quar­ter­back fed­eral pro­grams for men­tal health and sub­stance abuse treat­ment. Pres­i­dent Don­ald Trump has nom­i­nated Dr. Eli­nore McCance-Katz, an ad­dic­tion psy­chi­a­trist and for­mer med­i­cal di­rec­tor of the Sub­stance Abuse and Men­tal Health Ser­vices Ad­min­is­tra­tion, for that po­si­tion. At dead­line, her nom­i­na­tion was await­ing ac­tion by the Se­nate Heath, Ed­u­ca­tion, La­bor and Pen­sions Com­mit­tee.

In an­other sign of bi­par­ti­san sup­port for ex­panded men­tal health pro­grams, con­gres­sional lead­ers in May reached a com­pro­mise on a fis­cal 2017 ap­pro­pri­a­tions bill, re­ject­ing a num­ber of Trump’s pro­posed cuts to health and so­cial ser­vices pro­grams. The bill, which will fund gov­ern­ment op­er­a­tions through Septem­ber, al­lo­cates nearly $800 mil­lion to fund a num­ber of pro­grams aimed at curb­ing the opi­oid epi­demic. The deal also in­creases fund­ing for men­tal health block grants by $30 mil­lion this year; the pres­i­dent had sought a 20% cut. Ten per­cent of that block grant is set aside for early in­ter­ven­tion pro­grams on se­ri­ous men­tal ill­ness. Re­search has shown that peo­ple with se­ri­ous men­tal ill­ness fare much bet­ter over their life­time if their dis­ease is de­tected and treated early.

‘We have to treat it’

De­spite the pro­tec­tion of fund­ing for 2017, the out­look for fis­cal 2018 is un­cer­tain. There are wor­ries about full fund­ing of the nu­mer­ous men­tal health and sub­stance abuse ini­tia­tives for which the Cures Act au­tho­rized fund­ing, in­clud­ing $500 mil­lion for opi­oid ad­dic­tion treat­ment and $51.9 mil­lion to pro­mote in­te­gra­tion of pri­mary and be­hav­ioral health­care. Beyond that, the Repub­li­can drive to re­peal and re­place the Af­ford­able Care Act could roll back the Med­i­caid ex­pan­sion that has en­abled mil­lions of low-in­come peo­ple with men­tal ill­ness and ad­dic­tion prob­lems to re­ceive treat­ment.

“If the pro­posed cuts end up im­pact­ing the cur­rent fund­ing for men­tal health, we could be in a sit­u­a­tion where there is a sin­cere in­ten­tion to give and an equally sin­cere ef­fort to take away,” said Paul Gion­friddo, CEO of Men­tal Health Amer­ica, an ad­vo­cacy group.

Rep. Tim Mur­phy (R-Pa.), chief spon­sor of the Cures Act’s men­tal health pro­vi­sions, vowed to keep up the pres­sure for full fund­ing. “Men­tal health and sub­stance abuse are a mas­sive prob­lem and we have to treat it,” he said in an in­ter­view. “It will be a chal­lenge be­cause of tight bud­gets, but we will con­tinue to push hard.”

Ex­perts say even if the Cures Act re­forms and grants are fully funded, the neg­a­tive im­pact on the men­tal health sys­tem of re­peal­ing the ACA would swamp those ad­vances. “It would be one step for­ward and 10 steps back,” said Ron Hon­berg, a se­nior pol­icy ad­viser at the Na­tional Al­liance on Men­tal Ill­ness.

The GOP re­place­ment bill that nar­rowly passed the House in early May would ef­fec­tively end the law’s Med­i­caid ex­pan­sion to low-in­come adults, and threaten its man­dated ben­e­fits and pre-ex­ist­ing con­di­tion pro­tec-

In an­other sign of bi­par­ti­san sup­port for ex­panded men­tal health pro­grams, con­gres­sional lead­ers in May reached a com­pro­mise on a fis­cal 2017 ap­pro­pri­a­tions bill.

tions for pri­vately in­sured peo­ple with men­tal health and sub­stance abuse prob­lems. In ad­di­tion, state Med­i­caid man­aged-care pro­grams would have the op­tion to stop cov­er­ing treat­ment for men­tal health and sub­stance abuse. Those pro­vi­sions could neuter a sep­a­rate fed­eral law re­quir­ing in­sur­ers to cover be­hav­ioral care on par­ity with phys­i­cal care.

On top of that, the House GOP bill would cut over­all Med­i­caid fund­ing by $839 bil­lion, or about 25%, over 10 years. Med­i­caid pays for about 25% of all men­tal health­care in the U.S.

An es­ti­mated 30% of adults who have re­ceived cov­er­age un­der the ACA’s Med­i­caid ex­pan­sion have a se­ri­ous men­tal ill­ness and/or sub­stance abuse prob­lems, and about 1.3 mil­lion peo­ple re­ceive treat­ment for those dis­or­ders through that cov­er­age.

Ohio Gov. John Ka­sich and other Repub­li­can gov­er­nors have stressed that the Med­i­caid ex­pan­sion has been key in en­abling many peo­ple with opi­oid ad­dic­tion to re­ceive treat­ment. Med­i­caid pays for nearly half of all med­ica- tion-as­sisted treat­ment for opi­oid ad­dicts in Ken­tucky, Ohio and West Vir­ginia, and 20% of ad­dic­tion care na­tion­ally.

Mur­phy, who has faced crit­i­cism from men­tal health ad­vo­cates for back­ing the ACA re­peal-and-re­place leg­is­la­tion, ar­gues the House GOP bill would en­hance be­hav­ioral care. The GOP bill, he noted, would of­fer states tens of bil­lions of dol­lars through 2026 that could be used for men­tal health and sub­stance abuse treat­ment.

That fund­ing, he said, would do more than Med­i­caid ex­pan­sion to en­cour­age states to de­velop ef­fec­tive sys­tems of care.

Rep. Joe Kennedy (D-Mass.), a strong pro­po­nent of im­proved cov­er­age for men­tal health­care, re­jected that claim. “The ad­di­tional fund­ing doesn’t come close to off­set­ting the dam­age of re­peal­ing the Af­ford­able Care Act,” he said in an in­ter­view. “Our (Repub­li­can) col­leagues have got­ten com­mit­ted to re­peal­ing the law with­out ac­knowl­edg­ing the mil­lions of peo­ple suf­fer­ing from men­tal ill­ness who will be sac­ri­ficed.”

Va­can­cies im­ped­ing progress

Be­sides the fund­ing un­cer­tain­ties, a ma­jor con­cern for men­tal health providers and ad­vo­cates is SAMHSA’s pace in im­ple­ment­ing the am­bi­tious men­tal health agenda laid out by the Cures Act. That im­ple­men­ta­tion has been slowed by the Trump ad­min­is­tra­tion’s de­lay in fill­ing key posts at the agency.

Among other things, the leg­is­la­tion cre­ates a fed­eral in­ter-agency com­mit­tee to make rec­om­men­da­tions to Congress for bet­ter co­or­di­na­tion of ser­vices for adults and chil­dren with a se­ri­ous men­tal ill­ness; es­tab­lishes a Na­tional Men­tal Health and Sub­stance Use Pol­icy Lab­o­ra­tory to pro­mote ev­i­dence-based ser­vice de­liv­ery mod­els; and strength­ens fed­eral en­force­ment of in­sur­ers’ com­pli­ance with men­tal health par­ity rules.

The law also calls for clar­i­fy­ing pol­icy and of­fer­ing train­ing on when providers may dis­close health in­for­ma­tion re­lated to treat­ment of an adult with a men­tal health or sub­stance abuse dis­or­der, a press­ing is­sue for providers. In ad­di­tion, it es­tab­lishes a pi­lot pro­gram to award grants for med­i­cal res­i­dents, fel­lows, nurse prac­ti­tion­ers, psy­chol­o­gists and other pro­fes­sion­als to pro­vide men­tal health and sub­stance abuse ser­vices in un­der­served com­mu­ni­ties. The short­age of men­tal health pro­fes­sion­als is one of the big­gest prob­lems in the field.

Ad­di­tion­ally, Trump didn’t nom­i­nate McCance-Katz un­til late April. Her se­lec­tion re­ceived harsh crit­i­cism from Mur­phy. He ar­gued that she is too closely as­so­ci­ated with the agency’s pre­vi­ous prob­lems— even though she pub­licly blasted the agency when she re­signed in 2015 for not ad­e­quately ad­dress­ing the treat­ment needs of peo­ple with se­ri­ous men­tal ill­ness.

“She was a lit­tle too silent when all those prob­lems were oc­cur­ring,” Mur­phy said. “That con­cerns me.”

Leif­man, who re­port­edly was HHS Sec­re­tary Dr. Tom Price’s top pick for the as­sis­tant sec­re­tary po­si­tion, has a dif­fer­ent view of McCance-Katz, who’s cur­rently chief med­i­cal of­fi­cer in Rhode Is­land’s of­fice of be­hav­ioral health­care. “I think it’s a very good pick,” he said. “She’s very smart, she’s very knowl­edge­able, and she has a re­ally great back­ground on ad­dic­tion medicine.”

Still, key Cures Act re­forms likely will lan­guish un­til McCance-Katz is con­firmed by the Se­nate and other ad­min­is­tra­tive posts at SAMHSA are filled.

“It’s a lit­tle frus­trat­ing,” Hon­berg said. “We have this new law and new op­por­tu­ni­ties. Some work is be­gin­ning on im­ple­men­ta­tion, but cre­at­ing the in­ter­de­part­men­tal co­or­di­nat­ing com­mit­tee and es­tab­lish­ing the sub­stance abuse pol­icy lab­o­ra­tory will re­quire some­one at the helm in the as­sis­tant sec­re­tary po­si­tion.”

SAMHSA says it’s mov­ing for­ward with the in­ter­de­part­ment co­or­di­nat­ing com­mit­tee. The agency cur­rently is seek­ing rep­re­sen­ta­tives from var­i­ous fed­eral agen­cies and set­ting up a process for nom­i­nat­ing pub­lic mem­bers, said Brian Alt­man, the act­ing di­rec­tor of leg­is­la­tion.

Ther­apy vs. pun­ish­ment

An­other ma­jor pol­icy ques­tion is whether the Trump ad­min­is­tra­tion will fo­cus on a ther­a­peu­tic or puni­tive ap­proach to­ward peo­ple with sub­stance abuse prob­lems. So far it’s sent mixed sig­nals.

To head a new Pres­i­dent’s Com­mis­sion on Com­bat­ing Drug Ad­dic­tion and the Opi­oid Cri­sis, Trump ap­pointed New Jersey Gov. Chris Christie, who has stressed re­ha­bil­i­ta­tion dur­ing his gov­er­nor­ship. Trump or­dered the com­mis­sion to pro­duce fi­nal rec­om­men­da­tions by Oc­to­ber on im­prov­ing the fed­eral re­sponse to the drug ad­dic­tion cri­sis. Many won­der whether the com­mis­sion is even nec­es­sary. “It seems to be re­vis­it­ing a lot of ter­ri­tory that’s al­ready been covered by Congress and the pre­vi­ous ad­min­is­tra­tion,” said Richard Frank, a pro­fes­sor of health eco­nomics at Har­vard Uni­ver­sity who served in a top HHS post in the Obama ad­min­is­tra­tion. “The an­swer is to get money out the door and get pro­grams up and run­ning.”

On the other hand, At­tor­ney Gen­eral Jeff Ses­sions has sig­naled a get­tough ap­proach to­ward peo­ple who use or sell drugs. “We have too much of a tol­er­ance for drug use,” he said in a re­cent speech. “We need to say, as Nancy Rea­gan said, ‘Just say no.’ ”

Ex­perts are wary. “I’m hope­ful they’ll treat this pri­mar­ily as a med­i­cal is­sue, which it is,” Leif­man said. “For some peo­ple, the crim­i­nal jus­tice sys­tem does play a role to en­cour­age them to get the ser­vices they need. How­ever, if you set up sys­tems ap­pro­pri­ately, most in­di­vid­u­als can and should be treated with­out ever com­ing into the crim­i­nal jus­tice sys­tem.”

De­spite these con­cerns, providers and ad­vo­cates fer­vently hope the Trump ad­min­is­tra­tion and the new as­sis­tant sec­re­tary suc­ceed in be­gin­ning to trans­form the na­tion’s bro­ken sys­tem of men­tal health and ad­dic­tion care. They hope the Cures Act pro­vi­sions will be just the first of many re­forms and new fund­ing mea­sures.

Kennedy ar­gues Congress needs to boost Med­i­caid pay­ment rates to per­suade more men­tal health and sub­stance abuse treat­ment providers to serve Med­i­caid pa­tients. In ad­di­tion, he said, law­mak­ers need to toughen en­force­ment of in­sur­ance par­ity re­quire­ments to en­sure ad­e­quate cov­er­age of men­tal and sub­stance abuse dis­or­ders.

The end goal, many be­lieve, is to stream­line the labyrinth of pro­grams at the fed­eral, state and lo­cal lev­els to pro­vide much eas­ier ac­cess to com­pre­hen­sive treat­ment and re­cov­ery ser­vices.

“One of the most im­por­tant jobs for the new as­sis­tant sec­re­tary is that when peo­ple show up for ser­vices, they can get ev­ery­thing they need in one place,” Leif­man said. “Oth­er­wise we’re go­ing to waste a lot of money, and peo­ple are go­ing to con­tinue to die.”

“For some peo­ple, the crim­i­nal jus­tice sys­tem does play a role to en­cour­age them to get the ser­vices they need. How­ever, if you set up sys­tems ap­pro­pri­ately, most in­di­vid­u­als can and should be treated with­out ever com­ing into the crim­i­nal jus­tice sys­tem.” Judge Steven Leif­man

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