Advocates to reform America’s struggling mental health care system got a major advance Wednesday when Congress approved a huge, bipartisan healthcare package.
The $6.3 billion 21st Century Cures Act includes the first major mental health care and substance-abuse legislation to be passed in 20 years.
The mental health portion of the bill doesn’t include much extra funding, but advocates say it lays the groundwork for putting resources in the right programs.
“Hopefully there’s a foundation that’s been laid for mental health and substance abuse to continue to be a top priority issues on health care moving forward,” says Ron Honberg, the national director of policy and legal affairs at the National Alliance on Mental Illness. “A better mental health system that’s more focused on early intervention and continuity of care could save this country billions of dollars and save people a whole lot of suffering."
"Is this bill going to solve all these problems? No, but it’s a good first step,” he adds.
In a year of extreme political polarization, the bill has been one of the few bipartisan achievements, passing in the House by a vote of 392 to 26 and in the Senate by a vote of 94 to 5. President Obama is expected to sign it.
"This represents the first significant reform of our mental health delivery system in perhaps 20 to 25 years and I believe it will provide families with the tools they need to protect loved ones who are suffering from mental illness and who may be refusing to follow their doctor's orders," said Sen. John Cornyn (R) of Texas, a champion of the bill. "So this is a very significant bipartisan development."
Mental health provisions
Among other provisions, the mental health portion of the bill includes:
• Creates a new position of Assistant Secretary for Mental Health and Substance Abuse;
• Establishes new grant programs for early intervention;
• Directs states to only fund evidence-based mental health initiatives with a proven track record;
• Removes barriers to individuals accessing mental-health care and services;
• Promotes jail diversion initiatives and other programs to keep the mentally ill from being incarcerated;
• Expands access to mental healthcare providers and beds for patients;
• Requires health insurance companies to cover more mental health treatments;
• Requires substantial new data collection around mental illness and the criminal justice system.
“It’s a landmark piece of legislation for severe mental illness,” says John Snook, executive director of the Treatment Advocacy Center.
The other, more prominent pieces of the 21st Century Cures Act deal with drug development and biomedical research, including $4.8 billion toward research for cancer and neuroscience. Some lawmakers, including Sen. Elizabeth Warren (D) of Massachusetts have criticized the bill as a handout to the pharmaceutical industry, and have warned of the dangers of reduced pharmaceutical regulation in the bill.
Mental health advocates have long sought to draw attention to an issue that they say affects 1 in 5 Americans, but that lags far behind traditional medicine in terms of access to treatment.
In too many cases, they say, the mentally ill only access treatment when they hit a crisis, often requiring expensive hospitalization. In other cases, their illness results in tragedy, sometimes with violence toward themselves or others, and they can end up cycling between homelessness and prison.
Assertive Community Treatment (ACT), highlighted in this legislation as a strategy that should be implemented more, provides teams of mobile professionals, on call 24 hours a day, to help patients with the most severe forms of mental illness with wraparound services like housing and employment, along with treatment.
“These are some of the key things we know work for people who have a severe mental illness,” says Mr. Snook, speaking of both ACT and Assisted Outpatient Treatment, a form of court-ordered treatment for those with serious illness who won’t voluntarily comply. “This is the first time we’ve seen the federal government say we want those programs funded and encouraged.”
Shootings highlighted mental illness
Recent tragedies, including the 2012 shooting at Sandy Hook elementary school, have helped draw attention to mental illness. Some of the bill’s authors – particularly Republican Congressman Tim Murphy (R) of Pennsylvania, a practicing psychologist – have been working on the issue of untreated mental illness for several years.
“’Treatment before tragedy.’ That became our mantra,” said Representative Murphy in a press conference Monday, pointing to a button he was wearing with that slogan. The final bill isn’t perfect, he noted, saying several times that “we didn’t get everything we needed, but we needed everything we got.”
In an interview with the Monitor, Murphy said there is a lot of work remaining to be done, including on issues like removing limits to the number of days per month Medicaid will pay for a patient to be in a psychiatric bed. He says that real changes to the mental health system will require funding and accountability.
But Murphy says the bill goes a long way toward improving the system, including: measures that could lead to more access to care in mental health “deserts"; improving integration and accountability under the new assistant secretary; and providing for better data collection that can allow advocates to make the case for mental health to Congress in the future.
And on the financial front, it shows that even seemingly expensive programs can be a lot less expensive compared with costs of incarceration, emergency room care, and homelessness.
“By having a more comprehensive approach to review this, we can come back to Congress and say, 'This is effective, it saves money, it keeps people out of jail, gets people back in the workforce, and that’s something that was never there,” says Murphy. “That will have an impact.”
Significant shift in approach?
Some of the more controversial measures in the bill, including one that would have reduced privacy protections for patients in certain circumstances, were left out of the final version.
“The final bill has a better set of provisions around privacy,” says Jennifer Mathis, director of policy and legal advocacy for the Bazelon Center for Mental Health Law, which advocates for the civil rights of the mentally ill and which fought the measure that would have reduced protections under the Health Information Portability and Accountability Act (HIPAA).
Ms. Mathis says she was concerned about many of the provisions in the original bill, which she saw as heavily pushing a model of involuntary treatment and institutionalization and reducing the legal rights of the mentally ill, rather than expanding access to services.
“We were really looking at this largely from a damage-control perspective,” says Mathis. “We never felt any of these bills were going to be the key steps that were needed to really shift mental health services in significantly better directions.”
But other mental health advocates say that the bill could represent a significant shift in the government's approach. Even seemingly small things, like reducing barriers to how federal grants can be used and integrating mental and physical healthcare, can have a big impact.
In the past, many states didn’t realize they could use Byrne grants – a major source of criminal-justice funding – for mental health issues, like jail diversion programs or police training, says Mr. Honberg. “Now it’s clearly written into the law that these are priority areas for funding…. That’s not inconsequential.”
Similarly, the law establishes that there is nothing in Medicaid that prohibits the program paying for both mental and physical health treatment in the same day, something Medicaid frequently argued in the past. “Will it immediately translate into more integrated supports? No, but it removes impediments, and that’s not unimportant,” says Honberg.
A big section of the law deals with criminal justice issues.
"For too long we've left mentally ill people warehoused in our jails and on our streets without access to the treatment they need, not only to not be a danger to themselves but to potentially be a danger to others," said Sen. Cornyn.
The law promotes law enforcement training, mental-health courts, and other jail diversion programs, many of which have been effectively used in San Antonio.
“If you were to design a wish list of what the federal government is allowing you to do on the criminal justice side, it’s all there,” says Snook.
Mental health advocates like Honberg say they’ll be watching closely during the appropriations process to ensure that the new initiatives are funded, and emphasize that there remains a lot to be done to improve America’s mental health system.
But he is incredibly encouraged.
“I hope this bill will transform a system that has historically been focused only on crisis intervention, and only as long as needed to alleviate the crisis, to one that is more focused on early identification and intervention and continuity of care.”