Why It's Time to Come Together

By: Paul Gionfriddo, president and CEO, MHA

I’ve now been at this job for about a year and a half, but I have to say, the last couple months has been the highlight to date. Because MHA and mental health advocates are at a pivotal moment. We could very well see major mental health reform—and for the first time in years there has been real, tangible progress on Capitol Hill. But not everyone in the mental health community has been supportive of the current legislation before Congress. There are legitimate concerns, but I want to speak directly to my fellow advocates right now, about why I think that mere opposition to legislation at this stage is short-sighted.  

I'll admit to my bias here—while as many of you know MHA has not endorsed a particular bill yet, we have taken a strong position that members of Congress should come together to pass something, we have actively offered our ideas (not all of which have been accepted), we have commended both sides for their efforts so far, and we believe that compromise from here is both possible and far preferable to the do-nothing alternative.

Here's why. Since the failure of the Murphy and Barber bills last year, we worked as hard as anyone to engage directly with members of Congress (including Tim Murphy) to create a bill that would (1) not mandate AOT in all states, (2) not cut existing grant programs to fund new ones, (3) not gut PAIMI, (4) not gut SAMHSA, and (5) not be so focused on public safety and deep-end considerations at the expense of screening, earlier intervention, and services integration. We also wanted the professionalism of peers who worked among other clinical providers to be acknowledged.

These things were not all that was in 3717 last year, but they were the major things that led us to oppose it.  

So we were pleased when Tim Murphy and Eddie Bernice Johnson introduced HR 2646 this year, because they listened to advocates and addressed all of these things.  But in our view, while the bill was a good start, it did not get all the way there:

• It restored the PAIMI funding, but not all the essential advocacy duties;
• It did not clarify that the most restrictive AOT programs would not be forced on states;
• It appeared to bring all peer-delivered services under the supervision of clinicians, to which many advocates strenuously objected;
• It populated all SAMHSA's advisory councils with people with clinical backgrounds and/or no history of work with SAMHSA;
• By not referring to SED in certain areas, it left children out of some services and programs;
• By not identifying authorization levels for programs, it left open the possibility that existing programs might still be cut to fund new ones; and
• It did not make it national policy to end incarceration of people with mental illness. 

So we (and others) asked for more changes to be made.

The result was an improved manager's amendment, which now includes:

• Clarity that there is no mandate for non-AOT states to adopt AOT;
• Clarity that the only peer services impacted by the best practices study - which we hope will lead to direct private insurance reimbursement of peer-delivered service - would be peers working formally in clinical care teams;
• Restoration of most if not all PAIMI functions;
• A plan to end incarceration of nonviolent offenders with MI within ten years;
• Continued support for early ID, intervention, and integration, with SED now added in several places;
• Loosening of 42 CFR pt. 2 to give individuals - not substance use providers - greater control over their full health records;
• Equal representation on the advisory councils between clinicians and non-clinicians;
• Continued support for innovation;
• Greater parity oversight;
• No cuts to existing programs; and
• Block grant flexibility (I do not know who proposed this; I imagine it could be dropped during the next round, but from the perspective of a mental health advocate, it is a good idea).

However, after getting the initial score, the subcommittee also removed some other provisions we liked that cost money, including HIT and Excellence in MH Act support.

I continue to believe that the current bill can be improved, if members of Congress work together and advocates push them to do so.  

If advocates speak with a consistent voice to policymakers, here are some of the things that I think are at least possible:

• The Open Dialogues concept could possibly be substituted to address the family/HIPAA issue.
• Some additional language that NDRN has identified could be added in the PAIMI section to clean it up (and remember, the current Senate bill does not include any PAIMI language at all).
• A financial incentive for states with ACT or other evidence-based programs, like the incentive for AOT, could be added.
• The future role of SAMHSA, and its relationship to the assistant secretary, could be better defined, ultimately clearly elevating the standing of mental health within the federal government (and we can all agree that this is needed, even if everyone can't agree on the route to getting there).

Others of you may feel that more good things are possible too, and if so, our pledge is to continue to work with any organization(s) that would like to try to get these and other things into the bill during the next mark-up.  Right now, all it would take is a few Congressional champions to emerge in each committee of jurisdiction who make inclusion of these things the centerpiece of their support of the legislation.

I recognize that I'm probably a policy incrementalist at heart, but it's hard not to be when you've been involved in the process for many years.  I understand that there are people or organizations who may still find all of these improvements inadequate and oppose any legislation that uses terms like "AOT" or "Assistant Secretary".  I would strongly encourage them to think about the implications of a "just say no" approach this year.  The risk is this: With lives at stake, we might get another opportunity next session or the one after to get a totally different bill, but we also might not get another opportunity to make this kind of a difference in our lifetimes - and history is littered with both public officials and advocates whose decisions not to take part of a loaf ultimately cost them the whole thing.

Paul