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Views on how mental health policy is likely to develop over the next five to 10 years vary depending on the perspective of who is doing the predicting. From dramatic change to calm waters, predictions and their responses are as unpredictable as political change.
Chris Koyanagi, an analyst with the Bazelon Center for Mental Health Law in Washington, DC, tells State Health Watch that she expects current policy trends to continue without any dramatic changes.
"We’ll certainly continue action regarding mental health parity, but I don’t foresee anything like a sweeping parity bill for the entire country. If anything, there will be only small gains," she says.
However, Mary Graham, senior policy advisor for the National Mental Health Association in Alexandria, VA, says she is hopeful that work on parity will be completed in the next several years and "we will have met our goals." Ms. Graham says she is particularly hopeful that action will move more quickly on the federal side.
Another issue on Ms. Koyanagi’s radar screen is managed behavioral health care. She sees a trend toward a managed care approach in public
programs, but generally not through for-profit companies. She also sees more capitation in public programs and adds that she would like to see managed care reforms so better data will become available and there is more accountability.
Tom Bryant, MD, secretary of the National Association of County Behavioral Health Directors in Washington, DC, points out that most of the seriously mentally ill patients in the United States are in the public systems operated either by counties or states.
"Treating the seriously mental ill and drug addicts isn’t a profit center, so there’s very little for-profit competition. Three to five years ago, the main issue was managed behavioral health care. People were trying to cope," he points out. "That wave has passed, and people have pretty much figured out how to cope, although that doesn’t necessarily mean it’s a good system."
Ms. Koyanagi says that while services for adults are in bad shape, those for children are even worse. "There are small islands of innovation and hope, but I think things are going to gradually get worse, especially involving people in contact with the justice system. There are some demonstration projects going on, but no systematized change."
Mr. Bryant also expresses concern about the "interface between mental health/substance abuse and the justice system" but sees more hope. "There are a lot of people who have been inappropriately placed in the justice system. I expect to see a lot of progress in this area in five years."
The analysts sometimes have difficulty seeing how things may change in 10 years. "A lot depends on when the slide in our mental health system hits the public between the eyes," Ms. Koyanagi says.
"Right now, we’re keeping a lid on the crisis, but at some point, it has to burst into public consciousness. Right now, we’re at the bottom of the heap in human services programs. It’s going to implode eventually if we don’t deal with mental health services," she adds.
The problem is not only a lack of resources, she says, because what money there is often goes to "old ideas that have their own constituencies," meaning that groups that want to innovate have to find new resources each time.
While states had hoped that managed care organizations could help them cut through political problems, they can’t fund innovation, Ms. Koyanagi says.
Ms. Graham also points to the problem of a dearth of adequate resources. "There are a lot of states with funding problems, and we may see more lawsuits over states not meeting their obligations for the welfare of their citizens."
She expresses concern that because of the lack of adequate funding, managed care payments to clinicians are too low and "we are losing some of the best people from the system." Mr. Bryant predicts funding changes to more block grants covering mental health and substance programs together.
Ms. Koyanagi cites 24-hours-a-day programs and those providing long inpatient stays and residential placements for children as only a couple of examples of old ideas that still receive significant funding.
"In the 1970s and ’80s, there was a lot of enthusiasm for partial hospitalization," she says, "but we’ve learned that rehabilitation programs work better and cost less. I don’t know if we’ll be able to deal with these issues in 10 years. It’s more likely that by then we’ll be forced to grapple with them."
Ms. Koyanagi says there are many clinical services in different types of settings as well as less traditional approaches that can provide good value.
"Things like peer support groups work very well but don’t get funding. And solid, evidence-based treatments don’t exist in almost any community.," she says. "We keep following established patterns of practice because the people who work in them understandably want to keep on making a living."
An issue that Ms. Koyanagi predicts is going to emerge over the next few years is how the nation will deal with women who are going to work as a result of welfare-to-work activities but have children with serious disabilities.
"It’s hard to find specialized care for these children, and this issue is going to become more apparent as welfare-to-work moves on to people who will have a harder time getting back to work," she says.
Ms. Graham says she would like to see more integration of mental health and substance abuse systems.
"The public and policy-makers need to be more educated that these things are treatable and the cost to society is great," she says. "People bounce between the two systems and get worse care. Clinicians should be cross-trained so they can deal with both."
While dual-disorder (mental health and substance abuse) diagnoses are very common, Mr. Bryant says, a block grant approach makes it all but impossible to comingle funds and provide an integrated service.
"Research shows that integrated services work best. The federal officials aren’t malevolent when they raise funding issues. The law has established differences in accounting at the federal level," he explains. "You can find good treatment programs for co-dependent disorders funded at the local and state levels, but not at the federal level."
Mr. Bryant says one bright spot, although it has its own problems, is the development of new antipsychotic drugs that have fewer negative side effects, meaning that patients who are treated with them can be placed in work or educational situations that are more appropriate for them. The problem is that these new-generation drugs cost a lot more in a system that is already short on funds.
A problem for providers arises through the Balanced Budget Act of 1997 that requires a choice of providers in any plan submitted. "Lots of rural areas are lucky if they have one provider," Bryant explains. While Medicaid has been allowing waivers to get around this requirement, such waivers don’t continue, and agencies must reapply each time.
Electoral politics also plays a part in what decisions will be made. "A lot will ride on what happens in the next congressional election in two years, the next presidential election, and state elections," Koyanagi says. "If the political winds are against us, if people continue to bury their heads in the sand, we’ll have more simplistic solutions that sound good in sound bites."
[Contact Ms. Koyanagi at (202) 467-5730, ext. 18, Ms. Graham at (480) 513-4540, and Mr. Bryant at (202) 234-7543.]