“If the new federal law equalizing coverage for mental conditions with that for medical–surgical care works as hoped, there may no longer be a need for a public system to handle mental health in the long run,’ says Michael Hogan, New York State’s mental health commissioner.”
This was the headline and lead on the Wall Street Journal health blog’s April 16 story, by Shirley Wang, following my comments at a New York City mental health conference (sometimes you know there’s a reporter in the crowd, and sometimes you don’t.) In this case, however, I won’t claim I was misquoted. Rather, given the history of behavioral healthcare and the road ahead, it’s a good time for serious thinking about the future.
The theme is not new. In 1993, in an earlier era of (anticipated) healthcare reform, a group of state mental health commissioners met with the mental health task force of the Clinton health reform effort, chaired by Tipper Gore. We had lots to talk about. The Clinton reform proposal was to recommend universal health coverage, with mental health parity. Surely part of the conversation had to consider the role of the states’ public mental health systems.
The commissioner’s group, meeting as an ad hoc task force of the National Association of State Mental Health Program Directors, had already considered this issue. So when the question came ⎯“If health reform includes universal coverage and full parity, are you willing to discuss folding state resources into the larger system?”⎯ we were prepared. Our answer was “Yes, we have lots to discuss. State responsibilities extend beyond healthcare. Obligations such as forensic services and housing need to be fulfilled. And we’ll need a careful transition. But we should not maintain state systems if the alternative is being part of the mainstream.”
Almost two decades later, the seemingly impossible future has been promised to the American people, with the combination of national healthcare reform, parity for both mental health and addiction treatment, and aggressive parity regulations that raise the bar on acceptable treatment. What can we expect in this new environment?
My crystal ball predicts a paradox in the future of separate public systems. First, in the next couple of years, little will seem to change. The combination of uncertainty, phased-in implementation of the federal legislation, and the “boiled frog effect” mean that little will change — or, rather, that few changes are apparent. The second prediction I am pretty certain about is that in 45 years, distinct public mental health systems with state-operated and state-funded specialty services will no longer exist in anything like their current form.
Actually, I think the change will happen more quickly. But it’s been 45 years since Medicaid and Medicare were created, so the frog is a useful analogue. Recall that, when enacted, Medicaid had no specialty mental health benefit, and state (and private) psychiatric hospitals (Institutions for Mental Diseases) weren’t covered. And then consider how things have changed in the past four decades. Acute care was moved to newly covered units in general hospitals, so that there are only a few thousand “state beds” still devoted to acute care in the entire country. Nursing homes were covered for intermediate care, whereas state hospitals were not, so by the mid 1980s several hundred thousand older patients (and some not so old — in an unfortunate lesson about the power of financial incentives) had been moved to nursing homes. By 1985, Gronfein had demonstrated that the Medicaid program’s (indirect) impact on mental health policy was already greater than the impact of the Community Mental Health Centers program. And that was before things really ramped up; you know the rest of the story. Medicaid benefits for community care (clinic, case management, and rehabilitation) were in place. Special services, such as Assertive Community Treatment, were covered. “Medicaid it” became a cry of cashstrapped budget offices and an army of consultants. Today, Medicaid’s funding levels, policy influence, and — in many states — impact on mental healthcare are greater than those of the state mental health agency (if one still exists).
Moreover, the changes since 1965 were not explicitly called for. Now parity is the law, and the administration proposes rules for parity that do not allow different approaches for managing overall health benefits. So think about it again. Will we need a separate mental health system in the future?
The long term, I admit, is all speculation. The question before us now is what mental health managers, providers, and advocates should be seeking and acting on as we move forward. We know what consumers will be seeking. The evidence is before us, in data showing that behavioral issues are the number one cause of pediatric visits and also that the treated prevalence of depression doubled after the introduction of the selective serotonin reuptake inhibitors — although most care in general medical settings is not up to recommended standards. People want care in the mainstream, for complex reasons that no doubt include stigma, convenience, and coverage.
I believe our challenge is at the heart of healthcare reform. It is also evident in the statistics above. Although people want care in the mainstream, the general health sector, without our help, is incapable of reliably delivering good behavioral healthcare.
We see this across the life span in care for depression (a prevalent disorder that is reliably diagnosed and usually well treated by specialists). In the general medical sector, depression is often undiagnosed, and, when diagnosed, it is usually undertreated — from peri- and postnatal depression to adolescence to middle age to late-life chronic illness. Keep in mind that depression is usually simpler to diagnose and treat than other disorders. The research and demonstration programs yield clear results.
With a mental health depression specialist on the team — not across town, not in another agency, not available by referral, but on the floor — along with screening, treatment protocols, and measurement, good care can be reliably delivered. Our mission, in the first few years, is clear. We must lead to achieve integration of care, everywhere. We also have to integrate medical care into our specialty settings, because without it our clients will never get decent medical care, and the rates of premature death will not improve.
In addition, we must work to integrate mental health competencies into all clinical general medical settings — because emerging standards of care will demand it. We have to help craft health plans that pay attention to behavioral health beyond inadequate measures (e.g., whether a discharged psychiatric patient made a single timely follow-up visit) to fully integrated care expectations and outcomes. At the national level, we need leadership to increase access to appropriate psychotherapies, now that we have overcorrected to a dominance of medication treatment.
I believe that a few entrepreneurial leaders will embrace the challenge of achieving true integration at every level, from policy to plan to practice. These entrepreneurs will also succeed in business, because the game will come to them. Most of us will stumble along the road that we are on. For many, this road will turn out to be a dead end, because someone else got to the integration mandate first. In some circumstances, we will have no leadership and no mission except cost control — which will lead to a kind of deinstitutionalization revisited. In the next round of state budget cuts, in fact, we may see some early evidence of this unfortunate trend.
Other challenges will certainly continue to require state, federal, and local mental health leadership. Key supports such as housing and employment are outside of healthcare. Special responsibilities, such as forensics, are in statute. More must be done to support prevention and early intervention services that now have the force of evidence behind them. But the topic of the day and the biggest area of federal reform are in the area mentioned in our association’s name: health.
What’s your vision of the road ahead? Does it depend on specialty state agency leadership? Does it rely on protected status for particular providers? Or do you have a business plan for success, in an integrated health and behavioral health environment?
Michael Hogan is the New York State Commissioner of Mental Health. His experience in mental health administration and research is unparalleled and includes leadership roles with the President’s New Freedom Commission on Mental Health, the Joint Commission, the National Institute of Mental Health’s National Advisory Mental Health Council, and the National Association of State Mental Health Program Directors. He has coauthored a book and several national reports, written more than 50 journal articles and book chapters, and received numerous awards for his service and leadership.