The History of U.S. Federal Mental Health Policy: Part II

In 1993, President Clinton presented the Health Security Act to congress, which provided universal coverage with a basic package of physical health care services (Coverage for mental health services was slated to be added at a later date.) The act also would have improved the integration of the public and private sectors of the health and mental-health care systems. The proposal failed. What occurred instead was a sharp acceleration of managed care‘s penetration into health insurance markets and care delivery systems.

By 1998, 902 Health Maintenance Organizations (HMOs) covered over 98 million citizens, or 36.4 percent of the nation’s population (Aventis, 2000). While the Health Maintenance Organization Act of 1973 obligates HMOs to accept prepayment; use specified, organized and accessible practitioners; ensure quality; and routinely collect data (P.L. 93-222), other insurance products co-opted some of these technologies over time. By the turn of the century, over 95 percent of the insured population was covered by a product that managed care in some form (Aventis, 2000).

Behavioral health care (the managed care industry’s moniker for mental health and chemical dependency care) was not immune to these changes. While it is true that the 1980's saw employers’ mental health insurance costs rise an average of 60% per year (England and Vaccaro, 1991; Washington Business Group on Health, 1996), the resulting typical benefit design--matching the minimums set fourth in the federal HMO Act and its amendments--was patently discriminatory. 

Compared to benefits for physical health therapies, benefits for behavioral health therapies typically had higher deductible, copayment and coinsurance requirements; lower limits on the number of outpatient visits and hospital days covered in a given year; and more austere care management guidelines. This remained the case even though it has never been clear whether managed behavioral health care produces more savings than is created by the initial expense reduction from imposing managed care on a system or population anew. (See Goldman et al. 1998, for example.) 

The Mental Health Parity Act of 1996 (P.L. 104-204), which was signed by President Bill Clinton, began to correct these inequities by prohibiting disparate annual or lifetime limits on coverage for mental health and general health care. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which was signed by President George W. Bush and included in the Emergency Economic Stabilization Act of 2008 (PL 110-343), took this even farther.

Primarily, it prohibits the discriminatory practices noted above. Moreover, in contrast to most state parity regimes, the Act extends parity requirements to all conditions in the latest issue of the DSM, including addiction. Additionally, out of network parity is made compulsory.

Importantly, the Mental Health Parity and Addiction Equity Act (or MHPAEA) does not mandate mental health coverage. Instead it sets benefit parameters which are only in force IF mental health coverage is offered. Also worthy of note are two categories of exemptions. The first is of businesses with fewer than fifty employees. The second exemption applies to business that can show an actuarially certified 2 percent increase in healthcare costs in the first year, or a 1 percent annual increase thereafter (P.L. 110-343).

One of the explicit objectives of managed care is seamless patient transition between levels of care. (The levels of care in the United States’ mental health system are: institutional, residential, hospital, partial hospital, intensive outpatient, and outpatient.) While this is a natural conceptual extension of the one-stop-shopping afforded by staff model HMOs, especially those sponsored by hospitals, vertical integration proved to be challenging. 

In response, 1997 saw the industry’s primary regulatory body, the National Committee on Quality Assurance (NCQA), begin to require compliance with post-psychiatric discharge follow-up standards. The data do show improvement. However, taken as a whole and assuming perfection to be impossible, they still fall short of proving true seamlessness and vertical integration. Such is the case in community mental health care, as well.

Linkages across types of systems are even more fractured. Although there are higher rates of mental illness in incarcerated populations than in the general population (Rouse, 1995), the low rates of follow up for mental health services after release from correctional facilities continue. 

This has prompted court challenges in some states. In 1999 for example, Brad H. filed a negligence suit against the City of New York for its failure to provide discharge planning services for mentally ill persons released from the City’s jail. The case was settled in 2003 through an agreement that the City would provide people who have received mental health treatment, or have taken medication for a mental health condition while in jail, with discharge plans. Also included in the settlement were requirements for active Medicaid benefits upon release and housing support for the homeless.

More vexing are areas where coverage is inadequate or simply does not exist. The situation in rural regions, which comprise 90 percent of the nation’s land mass and contain 25 percent of the nation’s population (Bureau of the Census, 2001), clearly illustrates this problem. Sawyer, Gale and Lambert (2003) note (paraphrasing the related section of the report issued by George W. Bush’s President’s New Freedom Commission on Mental Health) that “the vast majority of Americans living in underserved, rural and remote areas experience disparities in mental health services”. They also identify four key barriers, many of which were cited in the President’s 2003 report, as well. They are, stigma and cultural issues; financing and reimbursement challenges; structural and organizational concerns; as well as access and workforce problems. 

Inadequate financing remains a major underlying obstacle to building comprehensive mental health systems in rural areas, but has a similar effect in suburban and cosmopolitan areas. The recent economic downturn has deepened the problem. This growing resource shortage has caused many states and localities to slash their mental health budgets, shuttering countless programs. 

Torrey (1997) notes that many with mental illness are incarcerated instead of treated. Moreover, many state mental health systems have begun to limit their services to individuals who are severely ill, while some others only provide services for those meeting its statutorily determined criteria for involuntary treatment. In both scenarios, those who request mental health services, but do not meet a predetermined clinical threshold, are not able to access treatment. 

The staffing reductions resulting from the system’s fiscal problems have direct effects on patient care and recovery. Without programs for prevention-typically the first type of program to be slashed in lean economies-opportunities for early identification and care linkages are lost. For those in treatment, insufficient continuity of clinical contact inhibits the development of trust in the therapeutic relationship. Here, the primary vehicle for the delivery of care is impaired. Furthermore, medication may be prescribed without sufficient monitoring or follow-up. Lastly, decompensation, as well as problems with relationships, housing, schooling and employment, may be obfuscated by inadequate contact. The related service delays increase both acuity and, paradoxically, medical and mental health care costs in the long run (See Pallak et al., 1994; Cummings, 1994; Friedman et al., 1995; Olfson et al., 1999; Chiles, 1999; Simon et al., 2001; Katon et al., 2003; and others). 

Conversely, and even in times of austerity, instances of violent behavior on the part of individuals with mental disorders—be they random acts, shootings, suicides-by-cop, or hate crimes—typically evoke knee-jerk reactions and increased pressure to use mental health interventions, albeit for social control. This often takes the form of calls for statutory modification to create (or tighten) outpatient commitment standards, and/or loosen inpatient commitment standards. Extending periods of commitment and simplifying procedures (including those for the involuntary administration of medication) are typically seen in the resulting statutes, as well. 

All of the foregoing increase service use. Apologists for such laws explain that both increase the amount of treatment delivered, making the recurrence of violence less likely. Opponents decry the inherent governmental intrusion and lack of self-determination that these laws create.

Compared to involuntary inpatient hospitalization, compulsory outpatient treatment is a relatively new phenomenon. “Assisted”, or court-ordered, outpatient treatment was born in 1999 with the passage of an amendment to New York State’s Mental Hygiene Law. “Kendra’s Law” (named after Kendra Webdale, who lost her life after being pushed off of a subway platform by a mentally ill man who was untreated at the time), sets forth the following criteria. 

The individual must be assessed to be unlikely to live safely without supervision. In addition, he or she must 1) have a history of treatment noncompliance related to psychiatric hospitalization and/or incarceration, or 2) have committed serious acts-or threats-of violence to self or others. Forty-four states have enacted similar legislation over the last decade, with Maine’s 2010 statute being the most recent addition.

KENDRA WEBDALE

There have been three empirical studies of the effectiveness of Kendra’s Law. The conclusions of the New York State Office of Mental Health’s 2005 study mirror those found in the research conducted by Swartz, Swanson, Steadman, Robbins and Monahan (2009), and Phelan Sinkewicz, Castille, Huz, and Link (2010). In summary, they found dramatically lower rates of homelessness, psychiatric hospitalization, arrest and incarceration. Costs varied directly with these reductions. Moreover, rates of substance abuse, victimization, and harm to self, other or property, all plummeted, while illness-related social functioning improved.

Enter Barak Obama's Affordable Care Act...

 

Stay tuned for an update on federal mental health policy changes resulting from the Trump administration's efforts to "repeal and replace" the ACA, otherwise known as ObamaCare.