Position Statement 14: The Federal Government's Responsibilities for Mental Health Services

Policy

The federal government and state governments have complementary roles in funding and regulating mental health and substance use treatment. Since the deinstitutionalization movement began in the 1960s, mental health and substance use treatment systems have undergone profound change with an evolving federal-state partnership that has promoted the development of community-based care, but they remain as a whole siloed, fragmented, and inadequate. Access to effective community-based services and supports is extremely limited for many people, and despite some progress, people with lived experience of mental health and substance use conditions still face discrimination in education, employment, health care, and many other areas of community life. Mental Health America (MHA) believes that both the federal and the state governments must rededicate themselves to strengthening the partnership that is essential to building out and sustaining the comprehensive system of care that is needed to ensure that Americans have access to the kinds of mental health and substance use treatment services and supports they need to develop valuable and meaningful roles in the community.

Background

The states retain important responsibilities for treatment in jails, prisons and involuntary mental health and substance use treatment facilities, provide subsidized community-based treatment, and license treatment providers, but greater federal government involvement has become indispensable to address the inadequacies of an incomplete and inadequate system of care. The federal role includes partnering with the states, providers, advocates, families, and people in treatment in funding and regulating treatment systems, insurers, and providers, protecting the rights of people in treatment, and supporting research and innovation. As a major funding source for mental health services, the federal government establishes and enforces minimum standards in partnership with the states, but greater efforts are needed to improve care. In particular, implementation of mental health parity[1] and the Patient Protection and Affordable Care Act (ACA)[2] require a vigorous federal initiative to assure effective promotion, prevention, screening, and treatment of mental health and substance use conditions.[3]

In many places in America, a person still cannot access any effective mental health and substance use services, let alone receive community-based supports, prevention, and early intervention. States also vary significantly in protecting individual rights or establishing and implementing basic rules to prevent discrimination. While some of the solutions have been developed by states and localities, it is the responsibility of the federal government to identify and reduce disparities and gaps.

Mental Health America embraces the view articulated in 2002 by the New Freedom Commission on Mental Health that the federal government’s failure to make mental health a priority is a national tragedy, and applauds the efforts of Congress in 2015 and 2016 to embark on major mental health reform.  That tragedy manifests itself in many ways, of which the following data are illustrative:

• Mental disorders are implicated in 90 percent of the 30,000 suicides and 650,000 suicide attempts in this country each year;[4]
• 50-80 percent of the youth entering the juvenile justice system have a mental disorder;[5]
• Untreated and mistreated mental illness cost American business, government and taxpayers an estimated $113 billion annually in 1997, more than $200 billion in 2016.[6]

Americans have a stake, individually and collectively, in making effective prevention, screening and treatment of mental health and substance use conditions more of a priority.  Communities across the country have taken steps to advance that goal, working to improve individual and family well-being and mental health, and reducing substance use in schools and health systems. Too often, however, communities have embraced that goal only partially, after experiencing a wrenching tragedy such as a youth’s suicide.  Too often, the system failures and inadequacies that leave people without access to needed care are not perceived as critical public health issues. And too often, well-intentioned efforts fail to employ effective, state-of-the-art services and fail to provide culturally and linguistically competent services.

The impact of mental illness and addiction on individuals, families, communities, businesses, and taxpayers across the country is enormous, and poses public-health challenges beyond the capacities of individual communities.  As the 2002 New Freedom Commission’s report makes clear, and the Congressional hearing in 2015 and 2016 reaffirm, governmental mental health and substance abuse systems and other "systems" that serve people affected by mental health and substance use conditions are badly fragmented. Focusing primarily on the needs of those with the most severe disabilities and more generally on illness, rather than on wellness, these systems have failed to keep pace with expanding needs and capacities for treatment.  They have failed to serve the great majority of individuals who suffer significant but not catastrophic disorders. These failures have many causes and explanations.  Among them are a lack of understanding that mental health is integral to all health; the widespread ignorance, fear, and stigma surrounding mental illness and addiction; and a legacy of laws and policies that discriminate against coverage of mental health and substance use conditions.    

Roles for the Federal Government in Behavioral Health

Many considerations – ranging from social justice to economic self-interest -- make it imperative that the federal government assume a major, focused, and coordinated role in mental health and substance use disorder policy, a role both different and larger than it currently plays.  Among the many factors dictating a robust federal role is the extraordinary toll – in disability, productivity, and premature death – that mental illness and substance use disorders take in this country.  Time after time, the federal government, armed with scientific tools, has responded aggressively to looming risks of disease endangering its citizens. In the 1960s, the federal government founded community mental health centers to begin to make community-based mental health treatment a reality. Community-based addiction recovery centers have performed much the same role for substance use disorders. Expansion of Medicare and Medicaid coverage increased coverage of some community services. But those initiatives are spent, the federal role in Medicaid expansion is in jeopardy, and with the advent of the Affordable Care Act, a new federal role is needed.

Advances in evidence-based treatment now make it possible to offer people with mental health and substance use conditions a vision of recovery and to offer children a pathway to thrive in school and in their communities.  These visions are the origin of federal advocacy of what has come to be called "transformation." But true transformation requires more than rhetoric. We must improve people’s access to a choice of treatments responsive to their needs.  Ensuring a path to recovery and increased resiliency will also require provision of a broad, comprehensive range of services and supports for individuals with more severe illnesses or disabilities, ranging from supportive housing to psychosocial rehabilitation to supportive employment.

Our federal government has a rich history of ensuring its citizens equality of opportunity to achieve their potential, particularly in the face of discrimination or other societal barriers.  We should not shrink from pressing the federal government to play that same critical role in fostering the recovery of those with serious mental illnesses and serious substance use disorders, as well as in promoting wellness, fostering resiliency, and minimizing and containing the risk factors associated with the development of mental health and substance use disorders through mental health promotion and mental illness prevention programs.[7]

A robust federal role is needed to reform and transform our behavioral health systems for many reasons:

Protecting individual rights. Individuals with mental health and substance use conditions have suffered horrible abuses, involving neglect, abuse, and sometimes even death, especially in jails and prisons and in the former drunk tanks and mental hospitals. Today, these abuses continue with the routine shackling of people in custody, notwithstanding great psychological distress to people in crisis, the rationing of care to children in schools and the over-incarceration and over-seclusion of people with mental health conditions, not to speak of the lack of effective treatment inherent in an underfunded system of care. Since Americans care deeply about individual rights, both the states and the federal government have a responsibility to serve and protect vulnerable individuals to the fullest extent possible. The federal government should put new efforts into enforcing laws that response to the abuses of today and make available private rights of action so individuals and protection and advocacy organizations can sue to enforce individual rights as well.

Repairing the holes in the safety net. People with any chronic condition should have the chance to recover as best they can, get their lives back on track, and be independent and productive. That is why our federal and state governments provide some safety net services – such as food, housing, job training, and health care. A key part of health care includes mental health and substance use treatment services and related supports, which help people rebuild and maintain their lives in the community while confronting a serious mental illness. With ongoing gaps in access to effective mental health services and supports, the federal government’s continuing engagement is indispensable, in partnership with the states, to keep up the effort to ensure that the safety net adequately protects all citizens.

Stopping discrimination. All American citizens, no matter which state they live in, should have a fair chance to participate in social and economic life. This allows everyone to benefit because it creates more opportunities for innovation and economic and social progress. Discrimination and unfair treatment can stop some people from being able to participate, and both the individual and society as a whole bear the costs. People with mental health and substance use conditions are discriminated against in a number of ways, including through increased suspension and expulsion from school, increased likelihood of incarceration, limited access to housing and employment, especially after incarceration, limited access to comprehensive health care, more barriers to obtaining their health records and managing their own care, and some coercion in medical settings. The federal and the state governments must step in when necessary to level the playing field and protect and serve vulnerable people. Federal laws like the Americans with Disabilities Act (ADA) and the Individuals with Disabilities Education Act (IDEA) have made great progress in enabling individuals with mental health or substance use challenges to participate more equally in a variety of settings. But these laws are far from being fully implemented. The federal and state governments should continue to build on and enforce laws that protect individuals from discrimination based on their mental health or substance use conditions.

Ensuring a Fair Distribution of Resources. Mental health and substance use treatment resources are very unevenly distributed in America, and inner cities and rural areas are particularly lacking in adequate facilities and professionals.  MHA believes that where you are born and live should not determine how long you live, but right now, it does. The life expectancy can differ by over a decade for babies born just one mile apart. While states can help with this to some extent, the federal government needs to support efforts to lay a common foundation of community-based care for health and mental health.

Addressing a public health crisis. Large health crises require national coordination and resources. We see this with outbreaks of Ebola and massive lead exposure. The crisis of our mental health and substance use treatment systems is caused in part by a number of social, economic, and environmental factors, which can be most effectively addressed with a coordinated national response – just like any other major public health crisis. The federal government will need to thoughtfully work to solve the different issues that contribute to mental health and substance use challenges across the country.

Empowering people with information. Sometimes competition in health care can lead to better services at lower prices. But in order for competition to work, people need to understand what they’re buying. With mental health and substance use services, this can be more complicated – if you are not a behavioral health provider, how do you know if you’re getting what you need? The federal government can intervene to ensure that large, complex health care systems provide people the information they need to make informed choices about what they want. Quality reporting systems can help individuals decide which provider they want to see and what treatments they want to discuss. The federal government should continuously improve these efforts to ensure that people are equipped with the information they need, based on what they value.

Focusing on prevention and early intervention. People get mental health treatment because they are feeling sick. Prevention and early intervention often must be provided before a given individual even knows that he or she needs services, so these services must be “population-based,” i.e., made available to everyone. This does not fit into our current healthcare financing system, so prevention and early intervention are often short-changed. The result is that people get sicker and society ends up paying more overall. The federal and state governments have a critical role in making sure that health care systems provide the prevention and early intervention services that people don’t always know they need. The federal government currently works to make sure that health care addresses risk factors and screens for some mental health conditions (and recommends mental health screening for everyone), but all governments and providers need to do more to make sure that everyone has access to routine mental health screening and to deliver the most recovery-oriented, consumer-friendly, and cost-effective prevention and early intervention services.

Improving competition. The federal government should structure incentives to favor more comprehensive insurance coverage, so that health care insurers are competing on quality as well as on price, and people get the most cost-effective services rather than the cheapest services for their healthcare dollars. Regulations that balance the needs of insurers to make money and the needs of people to get care are the answer. Because health insurance is a massive industry that spans all fifty states, the federal government has to develop these regulations in partnership with the states under the ACA. Our country has made progress by requiring healthcare insurers to accept everyone, so they can’t just pick the healthiest people, and helping those insurance companies that end up taking on a lot of very sick people. But America still has a long way to go before healthcare insurers and other health care stakeholders address all of the healthcare needs of everyone, and the federal government will need to lead in making sure this happens.

Funding research. Research can take decades before it leads to effective treatments – but all Americans want the research to happen so that they have access to the treatments. The federal government makes sure the research is properly funded, so we can get the benefits it brings. In mental health, this includes research on how the brain works, how different factors impact our behavioral health, new types of treatments, and how our behavioral and emotional health affects other areas of our lives. The research has the potential to more effectively prevent and treat mental health and substance use conditions, but the federal government will need to increase the funding and coordination offered to mental health and substance use research to realize these benefits.

Translating innovation. Justice Brandeis popularized the important concept that the states should serve as “laboratories of democracy,” because each state has the freedom in our federal system to innovate based on the needs and interests of the people in that state. However, once a state innovates and finds something really impactful, it should be efficiently disseminated to the other states to move from evidence to action. This is a major problem in mental health, where pockets of excellence have been developed throughout the country with well-designed policies and effective services, but there is no clear path to give the rest of the country a chance to learn about them. The federal government needs to raise awareness of innovations in mental health policy and programming, and provide more assistance to the states in implementing them.

It is the job of federal and state legislators and regulators to institute mental health policies under each of these rationales as they carry out their responsibilities. By stepping up into its proper role, the federal government can support states in meaningful transformation of our mental health systems, and make sure people get the services they need.

Call to Action

Mental Health America urges the federal government to fulfill its crucial role, and advocates for the following policies:

• In general. The federal government should take a strong leadership role in health care reform and behavioral health, and prioritize interdepartmental collaboration among federal agencies to increase effective, efficient services, including promotion of shared outcomes and shared finances. One example of how it can do this is by convening health, education, and other stakeholders from the public and private sectors to agree on shared metrics to promote cross-sector alignment. By using common metrics, different groups work together toward the same goal. Thus, for example, the federal government has recently convened groups like the AHIP-CMS Core Measures Collaborative, which brings together private health insurance and Medicare and Medicaid to agree on common measures, but has not brought together non-health sectors;

• Protecting individual rights. The federal government should strengthen federal laws to protect individual rights in ways that respond to the abuses of today – including basic standards of care – and provide adequate funding for oversight and enforcement with a person-centered process of remediation, as well as private rights of action so that individuals may enforce their rights, increased support for the Protection and Advocacy for Individuals with Mental Illness (PAIMI) program, and increased focus by the Health and Human Services, Education and Labor Offices of Civil Rights on issues of discrimination in mental health and substance use;

• Repairing the Safety net. The federal government should increase funding for safety net services so that providers are adequately reimbursed to keep pace with inflation, and that enough quality providers are available to serve those that need help;

• Stopping discrimination. The federal government should strengthen federal laws to address emerging forms of discrimination and provide adequate funding for oversight and enforcement with a person-centered process of remediation, as well as private rights of action so that individuals may enforce their rights; provide greater clarity on the requirements of the Mental Health Parity and Addiction Equity Act, and audit private and public insurance to ensure compliance with parity, network adequacy, and other federal standards;

• Ensuring a Fair Distribution of Resources. The federal government should continue to fully fund the federal contribution to Medicaid expansion so that every state has a fair opportunity to offer coverage for mental health and substance use services for individuals who would not otherwise be able to pay; and increase funding for SAMHSA block grants so that states have more opportunity to offer gap-filling mental health and substance use services;

• Addressing a public health crisis. With the recent passage of groundbreaking federal legislation by the House of Representatives, the federal government is poised to reaffirm its commitment to dealing with the crisis in behavioral health care. As recognized by the Congress itself, the 2016 legislation is only a starting point. The federal government should build on this initiative and the Prevention and Public Health Fund that the Affordable Care Act created to pay for large prevention efforts, and prioritize grants that help states and counties address social determinants of health that impact mental health;

• Empowering people with information. The federal government should improve quality reporting systems for providers, health care systems, and health insurance plans to include accessible and concise information about the outcomes that they achieve for individuals like themselves; See MHA Position Statements 71 and 16 for more recommendations on healthcare reform, the ACA, and parity;

• Focusing on prevention and early intervention. As stated in MHA Position Statement 48 on prevention: the child welfare, education, and juvenile justice systems, as well as medical, mental health, and substance abuse providers and community organizations must cooperate for prevention to work. Yet resources within these agencies are scattered, not coordinated, and often do not effectively support prevention programs or policies. No public system is formally charged with the responsibility of carrying out the critically important work of promoting health by fostering resilience and promoting well-being. The result is a patchwork that does not perform as an integrated system and fails to serve the needs of many young people and their families. Leadership is necessary to make systematic prevention efforts a high priority in the health care system as well as an integral aspect of the network of local, state, and federal programs and systems that serve young people and families. Specifically, the federal government should promote interagency cooperation and expand the U.S. Preventive Services Task Force, which currently only looks at prevention that can be done during short clinical visits, to include broader non-clinical intervention;

• Improving competition. Continue to lead with initiatives like the Health Care Payment Learning and Action Network, which allows health care stakeholders to decide what they think the future of health care should look like, and then support this with regulations that ensure that health care systems are rewarded for serving people well;

• Funding research. Fund research in mental health including research through the National Institutes of Health, National Institute of Mental Health, or SAMHSA; Ramp up requirements mandating screening, electronic record usage, interoperability, and public availability of de-identified data to support further research and innovation; and data analysis

• Translating innovation. Coordinate between different programs that the federal government funds to note effective innovations and provide technical assistance to other states in implementing aspects of the innovation.