Did We Turn the Corner on Mental Health in 2013?

At least thirty-six states increased funding for mental health services during 2013, according to a recent report by the National Alliance on Mental Illness.  And last week, Vice President Biden announced that the federal government was adding $100 million in new funding for mental health services.

So have we turned the corner on our nation’s mental health funding crisis, as many of the accompanying news headlines seemed to imply?  Or are these initiatives more a token gesture aimed at mollifying the mental health advocacy community in the aftermath of the Sandy Hook massacre, as others have suggested? 

I think that – with a couple of notable exceptions in Connecticut and Texas – the initiatives tend more toward tokenism than real change.

Consider the national initiative.  On the face of it, $100 million sounds like a lot of money.  But it still represents only around 3 percent of the Substance Abuse and Mental Health Services Administration (SAMHSA) budget, the agency which provides most of the direct federal funding to state and local mental health programs.

If the $100 million were distributed equally throughout the country through SAMHSA, it would provide for only a modest increase in community mental health budgets.  But this is not what the Administration has in mind. 

Instead, half of the money has been promised to community health centers through the Affordable Care Act to help them support the mental health services they have been required by law to provide for the past generation.  And the other half will be given to the Department of Agriculture (yes, Agriculture) to provide loans to rural community mental health centers and for telemedicine and other programs through the USDA community facilities direct loan program.

So the “$100 million for mental health” doesn’t look quite so impressive anymore.

But the truth is that funding mental health services has always been more the responsibility of the states than the federal government.  In fact, the total SAMHSA budget is still one-third less than the amount states cut from mental health services - $4.6 billion – between 2009 and 2013.   

So did the state increases this year actually restore the dollars that were cut?

Not exactly.

First of all, there are the fourteen states – including Florida (48th in spending coming into the year), which has developed an unflattering reputation in recent years for both vigilante violence and lack of compassion toward people with behavioral health needs – that either reduced mental health funding or held it level, in spite of overwhelming popular support for better mental health services.  And of the states that did increase funding, the increases were often modest ones. 

For example, Ohio cut $93 million over four years, and then added back only $50 million this year.  The $50 million made for a good headline, but Ohio’s funding is still far behind where it was five years ago.  And in Idaho – the lowest per capita spending state – Governor Butch Otter promised millions in new funding for mental health in early 2013.  But when the legislative dust settled, the increase was only 3.6 percent for community mental health services and 2.3 percent for psychiatric hospital services. There was no change in the funding for community psychiatric hospitalization. 

And looking forward, some lower-spending states are still not looking to do too much.  Utah, for example, has always put a premium on health, but does not spend highly on mental health. Utah’s Governor is recommending only a one-time, $1.5 million increase in FY2015 for mental health promotion and mental illness prevention.  This is better than nothing, but not enough to make a significant difference – especially if the commitment lasts for only one year.

And as NAMI noted in its report, when the issues became a little more controversial or complicated, fewer and fewer states took them on.

Only twenty-five states plus the District of Columbia decided to move forward with Medicaid expansion this year – an expansion that will help adults with mental illnesses in particular.  Only thirteen states made significant improvements to their mental health systems.  Just ten improved school-based mental health training and/or services.  And only five enacted legislation to improve early identification and childhood mental health screening. 

On the plus side, there are the two exceptions.  Connecticut – which felt most keenly the impact of the Sandy Hook shooting – led the way in passing comprehensive legislation to improve mental health service systems.  And Texas – which has long been near the bottom of states in funding mental health services – led the way in providing new funding for mental health services.

But we still have such a long way to go.  And for most of us around the country, we have not really made much progress in the past year.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Mental Health Cuts Will Lead to Increased Health Costs

On December 8, 2010, Jack Dalrymple, a Republican Governor in the safely Republican state of North Dakota, sent a budget to the state Legislative Assembly calling for an $8 million increase in funding for mental health services.

His transmittal message accompanying his FY2011-2013 proposed budget was simple. “We… need to make investments that help take care of people.  We have all been alarmed recently about teen suicide rates, especially on our Native American reservations.  These highlight the need to make more resources available for critical mental health services for our citizens.”

So, in a $3.3 billion general fund budget, he proposed over $6 million for new inpatient services, community crisis stabilization, and drug dependency treatment.  He also proposed $1 million for suicide prevention, another million dollars for mental health services on college and high school campuses, and a rate increase for mental health providers. 

He summed up these requests by saying that “the physical and mental health of our citizens is always a top priority.”

The North Dakota Legislature apparently agrees.  According to a recent report of the National Alliance on Mental Illness, the state has made up for historically low spending on mental health services over the past three years by topping the nation in increasing spending for mental health. 

As overall state mental health spending in the nation declined by $1.6 billion, North Dakota increased spending for mental health by 48.1%.

In the same time frame, South Carolina, Alabama, Alaska, and Illinois all cut mental health spending by over 30%, and Nevada, the District of Columbia, and California all cut it by over 20%.  In fact, most of the rest of the country is clearly out of step with North Dakota.

A Bloomberg News article headline this past week made clear what cuts to mental health mean: “Mental Health Cuts by U.S. States Risk Boosting Health Costs.”  The reason, as one Illinois emergency room physician pointed out, is that sick patients don’t just disappear when they are denied one set of services.  They seek out another, often more costly, alternative.

In the case of people denied mental health care, it is usually the hospital.

According to the Centers for Disease Control and Prevention (CDC), there were 2.4 million primary diagnoses of mental illness in general hospitals in 2006. In the same year, state mental health spending totaled $104 per capita, according to Kaiser Family Foundation State Health Facts data. 

CDC recently released new data for 2009.  In that year, the number of primary mental illness diagnoses decreased to under 1.6 million.  But the State Health facts data reported that state mental health spending had increased by then to $123 per capita.

In other words, during a time frame when state mental health agency funding increased by 18%, mental health diagnoses in general hospitals decreasedby 35%.

These are the facts, and there is an association here, at least for the most recent three-year period for which we have data. When states spend more on mental health as they did in 2009, fewer people with mental illness need hospitals for care.  And when states spend less on mental health, as they did in 2006, hospital use goes up.

Now that they have the facts, what are states proposing this year?

• The Florida Senate has proposed to reduce adult mental health services funding by 34%.  The House saved Florida from such a spending disaster last year; it will have to do so again this year.
• Connecticut’s Governor has proposed a $12 million cut to the Department of Mental Health and Addiction Services from the state’s already-approved FY2013 budget.
• Alabama last week announced plans to close 4 psychiatric hospitals.
• Illinois has proposed cuttingtwo psychiatric hospitals and a host of community health centers throughout Chicago.
• Mississippi is proposing a 5% cut to mental health that could result in the closing of six mental health facilities throughout the state.
• The Pennsylvania Governor’s newly proposed budget will cut Philadelphia by $42 million in mostly mental health and addiction services funding, according to information provided by the Mental Health Association in Pennsylvania.

Do you detect a pattern here?

Proponents argue that these cuts are being made in the name of fiscal responsibility, but they don't have the vision to see the forest beyond the trees.  Every one of them will make people sicker, state costs higher, and an already bad situation worse.

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Making People with Mental Illness Pay the Price

Isn’t it worth a few dollars to preserve essential mental health services?  It would appear that many state legislators would say no.

According to the National Alliance on Mental Illness, states have cut a total of $1.6 billion for mental health services over the past three years.

That was just the teaser. 

This year, states around the country are making people with mental illness pay the price for tax cuts and deficits.

NAMI state-by-state data show that the State of Florida spends no more for mental health services than it did in 2009.  But Health News Florida reports that the Florida Senate has proposed millions of dollars of cuts to mental health. 

Next week, its Appropriations Committee will vote whether to cut $137 million from adult mental health services, 57% of the total outpatient budget.  Anyone who thinks these services aren’t essential should think again.

On a single day this spring, in addition to offering its full array of group counseling, AA, NA, and individual support services, the only full-time peer drop-in center operated by MHA of Palm Beach County dealt with the death from natural causes of a middle-aged client (people with mental illness die 25 years earlier than normal), a former client’s suicide, a hospital patient discharged to the center for follow-up services, and a person with a traumatic brain injury who had no other place to go.

“Days like this are now common,” commented MHAPBC CEO Pam Gionfriddo, “and will become even more so if policymakers keep cutting.”

 Over 5,300 people in central Texas alone will lose services, according to the Austin American Statesman, if a proposed 20% cut in outpatient mental health services goes through.  The CEO of Austin’s major service provider said this would add to the suffering of families, and Lynn Lasky Clark, President of Mental Health America of Texas added that those affected would be “devastated.”

Texas already spends 3% less on mental health services than it did in 2009. 

Nevada spends 17% less on mental health services than it did in 2009.

But, according to the Las Vegas Sun, the Governor’s proposed budget includes millions of dollars of additional service cuts, including cuts to triage centers in Las Vegas and Reno and to outpatient counseling services.

Sen. Sheila Leslie termed the cuts “a mental health catastrophe.”

Tennessee already spends 10% less on mental health services than it did in 2009.

Now, Tennessee is proposing to cut $31 million more from mental health services, affecting all areas of the state.

The northeast is not immune.  New Hampshire has cut mental health funding by 8% in the last two years.  This year, the state is considering eliminating all services for two-thirds of the 20,000 people for whom it has responsibility. 

Ditto the northwest.  Oregon actually added 23% to its state mental health budget the past two years.  However, Disability Rights Oregon reports that the state is now proposing cutting mental health services by 30%, costing 45,000 Oregonians access to care.

Let’s call this exactly what it is – public officials across the country pummeling people who are the least able to defend themselves.

The bad economy is a phony excuse. 

Even in the Great Depression, state policy makers increased mental health services to meet increased needs.  The census of patients served in mental hospitals – the only care option available at the time – grew from 272,252 on January 1, 1929 in 1929 to 321,824 on January 1, 1934, and the number of first admissions – a signal that new needs were being met – rose from 60,500 on January 1, 1929 to 69,368 on January 1, 1933.

Do policymakers really think times are tougher today than they were then?

Most legislators pray to God for enlightenment and compassion at the opening of each session.  Here is an excerpt from a Florida Senate prayer this year, offered on March 16^th by Monsignor Thomas Skindeleski of Delray Beach:

“Open our minds to better understand the needs of those who have chosen us to serve them. Teach us how to craft laws that will better the lives of millions of people who are counting on our efforts to serve them well.  Let justice and peace be foremost in our minds as we endeavor to legislate in ways that will benefit the lives of our people. Direct our efforts to preserve the life and liberty of the most vulnerable members of our society.”

It’s a powerful prayer.  I hope our leaders listened. 

Don’t smirk.  When was the last time we told our own elected officials that we willing to pay taxes to provide services to people with mental illness?  Today – before it’s too late – is the day to call, email, or forward this column to a policy leader.

We must add our voices to those of the mental health advocates speaking up for some of the most vulnerable members of our society.

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