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/

President Kennedy's Unrealized Promise

Exactly a half century ago, in October, 1963, President John F. Kennedy signed the Community Mental Health Centers Act into law.  It affected two very different classes of people - people with mental illness and people with developmental disabilities.

In many ways, it was a civil rights act, promising to replace large, segregated institutions with integrated, community-based services.

It made a huge difference for people with developmental disabilities. 

But for people with mental illnesses, its promise is unfulfilled and the dream sometimes feels like it is dying.

When President Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Acton October 31st, he did so with optimism. The law specified that the new community mental health centers would offer four services – prevention, diagnosis, treatment, and rehabilitation or recovery – to people with mental illness.  And the result would be that all people, no matter what their disability, would live freely and comfortably in their home communities.

Had he lived to today – into his late 90s – President Kennedy would be appalled at what became of this vision.

He would have witnessed in 1981 the replacement of direct federal funding for community mental health services with an inadequately-funded mental health block grant to the states.  And he would have seen the result.  Chronic homelessness grew, and jails and prisons became the new warehouses for adults with mental illness.  Here is a statistic that would have stunned President Kennedy – women in prison today are twice as likely to have serious mental illnesses as are men.

President Kennedy would also be dismayed that his vision for community-based special education for children with emotional disturbances became so clouded, and with such tragic consequences.  The Act provided for demonstration grants to improve special education services.  He never could have imagined that fifty years later, only 389,000 children would be receiving special education services because of emotional disturbances.  And if one in five school-aged childrenactually has a mental disorder, then this means that we are identifying only one in every 28 for special education services.

And, notwithstanding the promise of the Affordable Care Act, President Kennedy would also be far from satisfied with some recent federal foot-dragging.  In 2008, the Mental Health Parity and Addiction Equity Act passed with the help of his brother and nephew.  It guaranteed equitable insurance coverage for mental health and health conditions.  But it has taken five years for a final rule to implement that law (a rule now promised within days or weeks).  And at the same time funding for SAMHSA – through which federal block grant dollars flow – has declined.

He would have seen states do no better.

I was in the Connecticut State Legislature when we received our first block grants in the early 1980s.  There was zero interest in using state funds to continue building the community mental health center program. 

That was long ago.  So let’s look at today. 

In the five years between 2008 and 2013, states cut $4.6 billion from mental health services, often citing an unwillingness to burden state taxpayers with these services. 

But even when states were offered a free ride, many still refused to authorize additional spending on mental health services.  This year, twenty-two states refused to expand their Medicaid programs, even though the federal government agreed to pay 100 percent of the cost for three years and told states that they could contract the programs again as the federal share went down.  No surprise – many of the 5 million left behind will be people with mental illnesses.

If we wanted to realize the vision of President Kennedy, it would not be hard.

We could offer all children mental health screening as part of well-child exams, and admit more children with mental illnesses to special education services.

We could provide insurance coverage to more people with mental illness, and appropriate more funding to community mental health services. 

And we could opt not to send adults with mental illness to prison, at least until we have guaranteed them access to care and worked with them to develop a meaningful recovery plan that might help them avoid hospitalizations, homelessness, and imprisonment in the future.

If we did these five things, we could give vigor to the dream and honor the promise President Kennedy made when he signed the Community Mental Health Centers Act into law:

“It was said in an earlier age that the mind of a man is a far country which can neither be approached nor explored.  But today… it will be possible for a nation as rich in human and material resources as ours to make the remote regions of the mind accessible.  [People with mental illness]… need no longer be alien to our affections nor beyond the help of our communities.”   

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

Suicide and Obamacare

In 2009, there were 36,891 suicides in the United States, according to the CDC.  This translates to a rate of 11.9 for every 100,000 people.

And rates among certain groups were even higher.  For example, the suicide rate among veterans, according to the Veterans Administration, was three times higher – or 35.9 per 100,000 veterans.

Suicide is a problem that ought to command our attention.

And it does.  For many years we have used suicide data as surrogates for documenting the consequences of serious mental illness.  We all know that the “danger to self” standard we use for determining when people with mental illness qualify for emergency care is, in effect, a “suicide may be imminent” standard.

As a result, for many years community mental health organizations have also been asked to track suicides as a measure of the effectiveness of their programming. 

But there are reasons why focusing on suicide rates too closely leads to inadequate public policy.

Suicides are just the tip of the iceberg.

Many more people consider or attempt suicide than die from it.  If you really want to be staggered by a national statistic, CDC reported that in 2011 7.8 percent of the teenage population had attempted suicide.  That is one thousand times as many as had died from it.

Also, the overwhelming majority of people with serious mental illness who die early do so not because of suicide, but because they are undertreated for other chronic conditions (such nicotine addiction, diabetes, and cardiovascular problems).  Some of these are linked to treatments they receive for their mental illnesses.

Finally, at the community level the number of suicides is usually so small that it is nearly impossible for any single organization to affect the rate more than anecdotally.  The agency may be able to point to individual cases where its intervention made a difference, but it will probably never be able to move the rate on its own.

And when the suicide rates don’t move, policy makers use this to justify decisions to reduce or eliminate program funding. 

So what does Obamacare have to do with suicide?

Many other provisions of the law have been lost in the din surrounding the most visible parts of the Affordable Care Act.

One of these was a mandate that the Department of Health and Human Services focus on the quality of our health care.  Since 2012, it has been doing this, along with a number of agencies in the Department, including the Substance Abuse and Mental Health Services Administration (SAMHSA). 

SAMHSA has just invested over two years in developing a National Behavioral Health Quality Framework (NBHQF). 

When the NBHQF is finalized, it will open the door to the use of new standard outcome indicators in determining the effectiveness of health and behavioral healthcare in our communities. 

We will be able to add these indicators to suicide rates, giving state and local officials much more powerful tools in judging the effectiveness of community mental health programs.

For example, suicide risk assessments (NQF #0104) will become a standard diagnostic tool in provider settings.  Providers will also be expected to use depression screening tools such as the PHQ-9 at six and twelve month intervals to monitor patients consistently over time (NQF #0710-0712).  And risky behavior assessment and counseling for children under the age of 13 will become a standard of practice (NQF #1406), as will diagnostic evaluation of children with major depressive disorder (NQF #1364-1365).

These all focus our attention on the 999 in every 1000 who consider and attempt suicide in addition to the one who tragically commits it.

We can also expect the integration of health and behavioral healthcare to become more systematic. 

Cardiovascular and diabetes monitoring of people who are prescribed antipsychotics (NQF #1933-1934) will become a standard of practice, as will management of ADHD in children in primary care settings (NQF #0107-0108). 

These indicators focus our attention on some of the other reasons people with mental illness die so young.

We all have an opportunity to say how we feel about these indicators. 

SAMHSA has released the NBHQFin draft form, and is accepting public comments on it until September 17, 2013.  Comments can be submitted using an online form, and don’t have to be formal or comprehensive.

The NBHQF will be finalized after the public comment period.  Then it will begin to guide the funding and delivery of mental health services. 

But for the next week, we all can say how we think the government should measure the quality of our behavioral healthcare services.

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

The Ten Best and Ten Worst States for Your Mental Health

Connecticut spends four times more per capita on state mental health services than Texas.  In Florida, 25 percent fewer people report having mental illnesses than in Washington.

Across the nation, there are significant differences in the amounts states spend on mental health services.  Connecticut spends $189 per capita, while Texas spends only $39.

But there are also significant differences in the reported prevalence of mental illnesses.  For example, fewer than 18 percent of Floridians report having a mental illness during the past year, but in Washington almost 24 percent do.

But what happens when you put spending and prevalence together?  Some new rankings emerge that give you a measure of each state’s real commitment to protecting mental health – and treating mental illness – in their population. 

This week, I have ranked all fifty states using both spending and prevalence data.      

I have taken per capita mental health spending from Kaiser Family Foundation’s State Health Facts data, and prevalence data from SAMHSA’s Summary of the National Survey on Drug Use and Health (NSDUH).  Both data sets are from the 2010-2011 time period.

It turns out that some states spend more than ten times as much as others on behalf of people with mental illness.

You can review the full list of the states along with the full set of the data I used here. 

But for now, if the commitment of state government is your measure, here are the ten best and ten worst states for your mental health.

The Best:

1. Maine.  Maine spends almost $1,900 per person with mental illness – 25 percent more than the next closest state.  It is tops in spending per capita, and but also 7^th best in percentage in percentage of people reporting mental illnesses.

2. Alaska.  Alaska is middle-of-the-pack in prevalence, but it is second in spending per capita.  The result?  Alaska spends just under $1,500 per person with mental illness.

3. Pennsylvania.  Pennsylvania is 3^rd overall in spending, but only 16^thbest in prevalence.  That still results in spending of over $1,400 per person with mental illness.

4. New York.  New York is 4^th in spending, and middle-of-the-pack in prevalence.  It spends over $1,200 per person with mental illness.

5. Vermont.  Like New York, Vermont is 23 places higher in spending than in prevalence.

6. New Jersey.  New Jersey is 3^rd best in prevalence, but still spends over $1,100 per person with mental illness.

7. Arizona.  Arizona is only 36^th best in prevalence, but it invests well in mental health services, spending $1,044 per person with mental illness.

8. Connecticut.  Connecticut is one of eight states that spend at least $1,000 per person with mental illness.  It pays off for a state that is tied with Georgia for 9^th best in prevalence.

9. North Carolina.  North Carolina’s high ranking is driven by a 4^th best ranking in prevalence, and top twelve spending per capita.

10. Hawaii.  Balance is the key to Hawaii’s ranking – 15^th in prevalence and 10^thin spending.

And the worst:

41. South Carolina. South Carolina ranks 23^rdbest in prevalence, but is 43^rd in spending.

42. Louisiana.  Louisiana is 35^th in prevalence, but it is not enough to nudge up its overall ranking.

43. Utah. Utah is 49^th in reported prevalence of mental illness – a surprise for a state that regularly ranks near the top in other health categories.  It spends only $263 per person with mental illness.

44. Kentucky.  Kentucky is middle-of-the-pack in prevalence, but spends only $259 per person with mental illness.

45. Georgia.  Georgia is tied with Connecticut for 9^th best in prevalence, but it by spends only one-quarter as much per person with mental illness.

46. Oklahoma.  Oklahoma earns its ranking by placing 40^th in prevalence and 45^th in spending.

47. Florida.  Florida ranks second in prevalence, but only 48^th position in spending per capita.  As a result, it spends just $222 per person with mental illness.

48. Texas.  Texas – which has the lowest prevalence of mental illness – still spends only $221 for each person with mental illness.

49. Arkansas.  Arkansas is one of only two states spending less than $200 per person with mental illness.  It is among the worst in both spending and prevalence.

50. Idaho.  Idaho is far and away the worst state for your mental health.  It is worst in reported prevalence and worst in reported spending.  How bad is Idaho?  At $143 per person, it spends less than one-tenth as much per person with mental illness as do Maine, Alaska, and Pennsylvania.

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

For the 37 Percent, Stigma Trumps Acceptance

In November, 2012, a fourteen-year-old Utah boy named David Q. Phan committed suicide by shooting himself on a pedestrian bridge near his junior high school.  It was reported that he had been the victim of bullying.

In June, 2013, the New York Times published a story about three students who committed suicide at East Hampton High School during the past three years.  All three students were Hispanic.

Sam Harris, who is half-Native American and half-African American, has writtena first-person account of his own experience with mental illness that has been published on SAMHSA’s “Promote Acceptance” web site.  In his account, he reports that he lived for years with symptoms of mental illness without seeking help in part because he believed that he would be stigmatized by “going to the white man” for help.

And in a case which has attracted recent national attention in the aftermath of the Zimmerman verdict, 32-year-old Marissa Alexander – an African American and a past victim of domestic abuse – received a 20 year sentence in Florida after she fired a bullet in the direction of her estranged husband during a domestic altercation.

These diverse individuals all have had something in common. 

They all have lived in America.  They all have been among the 37 percent of Americans who are considered minorities.  And they all are or were among the 6 percent of Americans who have had a mental illness – such as PTSD, depression, or psychosis – which is considered to be serious. 

They –and others like them – are the reason that July was designated National Minority Mental Health Awareness Month.

Because while all forms of serious mental illness touch all races and ethnicities, all ages, and all socioeconomic groups, they do not touch them equally. 

For example: 

• Suicide is the second leading cause of death for Native Americans between the ages of 10 and 34.
• Hispanics living below the poverty level are three times more likely to report experiencing psychological distress than are Hispanics living above 200 percent of the poverty level.
• Up to 70 percent of Southeast Asian refugees receiving mental health care have been reported to have PTSD, and Asian American women have the highest suicide rate of women over the age of 65.
• African Americans are 20 percent more likely to report having serious psychological distress than are white Americans.

These are some of the realities Americans deal with every day, and they have been a special focus of the Department of Health and Human Services’ Office of Minority Health.

Serious mental illness is a threat to both life and liberty.

According to the Office of Minority Health, Black students are 30 percent more likely than white students to attempt suicide during high school. Hispanic students are 60 percent more likely than white students to attempt suicide. Asian American students are 70 percent more likely.  And Native Americans are an astounding 140 percent more likely to attempt suicide.

And SAMHSA has noted that over 26 percent of people who are chronically homeless have serious mental illnesses.  SAMHSA also notes that our sheltered population is disproportionately minority (only 42 percent of those sheltered are white) – and in some of our largest cities people of color comprise nearly the entire chronically homeless population.

Our jails and prisons have also become our de facto mental health facilities in recent times.  And, according to 2012 data from the Center for American Progress, 60 percent of our prisoners are people of color.  Male prisoners are 2.5 times more likely to have serious mental illness than are people in the general population.  Female prisoners are five times more likely!

We can learn a great deal by understanding the realities of mental illnesses among minorities in America.

We can learn, as a matter of fact, that mental illness often seeks its victims from among those who least able to defend themselves.

We can observe, as a matter of perspective, that the stigma associated with mental illness is harder to overcome when it is coupled with de facto discrimination.

And we can remind ourselves, as a matter of public policy, that the experiences of white males in our society are clearly not representative of the experiences of everyone in our society.

This all hits especially close to home for me.  My son is among the 37 percent, the 6 percent, those who have had suicidal ideation, those who have been imprisoned, and those who have been homeless. 

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

Why Are We Afraid of Mental Health Screening?

Should all school children be screened for mental health?

The evidence suggests that if we do not screen them, then we will be continuing a persistent and historical pattern of neglecting the mental health needs of our children.  But why let evidence get in the way of fear?

Over the past several months, legislators in a number of states have considering mandating – or at least offering – mental health screening for all children, either in the schools or in pediatricians’ offices. 

But when the Connecticut Legislature had a public hearing on a mental health screening bill recently, opponents came out in force. 

One parent called mandatory screening an “unnecessary invasion.”  The Connecticut Civil Liberties Union argued that mental health screenings should be optional.  A treatment provider asserted that the problem wasn’t with a lack of assessment, but the lack of treatment options.

And in recent days, a Palm Beach Post writer in Florida joined the chorus when he claimed that mental health screening is less “straightforward” than vision and hearing screening in an editorial entitled “Florida Should Not Require Mental Health Screenings in Schools.”

The truth is that if we don’t at least screen, then we don’t know what it is we’re supposed to treat.  And this “head in the sand” approach is what has gotten us into trouble in the first place.

The extent of our neglect of our children’s mental health needs is staggering.  

In 1999, the U.S. Surgeon General estimated that 10 percent of children had mental illnesses serious enough to disrupt their home life or schooling.  That percentage is still cited today, but we have more recent data, too.

For example, the Substance Abuse and Mental Health Services Administration noted that in 2009 two million children between the ages of 12 and 17, or 8.1 percent of the population, had a major depressive episode.

In the same report, SAMHSA also disclosed that 2.9 million children that year, or 12.1 percent of the population, received at least some mental health services in a school setting.

But here’s where the neglect comes in.  Only 407,000 children in 2009 received special education services because of their mental illness – just a fraction of those who needed them.

And this neglect is getting worse.  According to the most recent data from the U.S. Department of Education, only 389,000 children were offered special education services in 2011 as a result of their mental illness.  To put this number in context, this was:

• The smallest number in 20 years;
• A drop of over 20 percent in just six years; and
• Only 8 tenths of one percent of the entire school-age population.

In other words, less than one in every ten children with a serious mental illness is even identified as emotionally disturbed by our special education system.

As for the other nine in ten, their time bombs just tick silently.

Perhaps this could be justified if the stakes were low.  But they are not.  We all know the results of neglect.  We see them every day in our homes and neighborhoods, and, most tragically, on the news.

And what is most frustrating is that the “controversial” screening that could save lives is both simple and non-invasive – and straightforward. 

More often than not, mental health screening consists of a few questions that can be answered and scored in minutes. 

Here is a link to a commonly-used tool, called the PHQ-9.

It asks nine questions about how a person has felt in the last two weeks, with one follow-up question at the end.  Has the person been having trouble falling asleep or staying asleep, or sleeping too much? Been feeling tired? Experienced a poor appetite or overeating? Had trouble concentrating?

These are hardly the kinds of questions that probe so deeply into the psyche of the individual as to scar or stigmatize them for life. 

But, ironically, when we refuse to ask these questions we do end up stigmatizing people for life – if not costing them their lives.

It may seem hard to believe that there could be any fuss about using such screening tools universally when you consider the alternative.  Or that the tools can reasonably accurately identify an emerging mental illness.  But they can, and do.  And the more we use them, the better off we will be.

So what are our schools afraid of?  And, more importantly, what are we all afraid of? 

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

The Chain of Neglect: The Real Link Between Violence and Mental Illness

More than 11 million American adults with mental illnesses – 4.5 million of them with serious mental illnesses – are not receiving care today.  So it may not be unreasonable to conclude that the history of public mental health services over the last century can be summed up in a single brief sentence. 

We replaced the chains of institutions with a chain of neglect.

I have argued that this chain of neglect typically begins when children with mental health needs are still young, and continues throughout their lives.  And that it often has tragic consequences.

Why is it so important that we talk about breaking it now, the month after Sandy Hook and almost exactly two years since the mass shooting in Tucson?

It is because tragedies like those in Sandy Hook and Tucson remind us that it is wrong to balance budgets on the backs of children and young adults with mental illness and expect that there will be no consequences.

This is a sensitive, and even complicated, issue to discuss, because mental illness doesn’t cause violence.  Violence causes mental illness.

Violence and mental illness also share some of the same risk factors, such as trauma and abuse.

They have something else in common, too.  They often appear together in times of tragedy.  And this may be the result of conscious policy decisions we have made.  

It is hard to exaggerate the enormity of the problem that we have created by chopping away at mental health services. 

In 1970, according to a 2009 articleby Steven Sharfstein and Faith Dickerson in Health Affairs, there were 525,000 psychiatric beds in American hospitals.  Eighty percent were in public institutions.  By 2002, the number had dwindled to 212,000.  Only 27% (or approximately 57,000) were in public institutions. 

In the last ten years, things have gotten much worse.  Between 2002 and 2010, states cut even more beds, reducing the number of public hospital psychiatric beds from 57,000 to just over 43,000.  By 2009, according to SAMHSA Administrator Pamela Hyde, over 10 million people were reporting that they had unmet mental health needs.

What did states do after cutting inpatient beds?  They cut community services, too.  Since 2008, according to the National Association of State Mental Health Budget Directors, states have cut mental health budgets by $4.6 billion.

It doesn’t take a policy expert to conclude that when 4.5 million people with serious mental illness are receiving no mental health services, this is neglect.

And this neglect is the real link between mental illness and violence.  Because while mental illnesses may not lead to violence, neglecting them assuredly will.

We can fix this. 

After the Sandy Hook tragedy, the Hartford Courant invited me to make some suggestions about how. 

I offered three.  Because mental illnesses typically begin in childhood, the first is intervening early, by making mental health screening a part of regular well-child and, later, well-care exams.  The second is intervening in the schools, by adding new special education services – paid for by states, not local education authorities – as symptoms of mental illness begin to affect school performance.  The third is intervening when young adults need services, by re-directing dollars from jails and prisons to community mental health programs.

The resulting Op Edit, Breaking the Chain of Neglect, was published by the Courant on December 28^thand appeared in print on December 30^th.  I hoped that it would add to a Connecticut dialogue about improving mental health services – one that has been ongoing for at least thirty-five years, when I first served in the State Legislature.

But perhaps we can all hope for something more in the aftermath of so many potentially avoidable tragedies – thoughtful new policies, instead of neglect.

In the past week, the column has been reprinted by a dozen others, including the Arizona Daily Star, the Dallas Morning News, the Tulsa World, the Las Vegas Sun, the Milwaukee Journal Sentinel, the Lawrence Journal World, the Chattanooga Times Free Press, the Kansas City Star, and the Youngstown Vindicator.

If policymakers in just those areas were to decide to work together to improve mental health services for children and young adults, then the prevention, early intervention, and treatment improvements we need so badly might finally come.

And those policymakers could leave a lasting legacy for their own children – who, I can attest, may someday need the services themselves.  

Follow Paul Gionfriddo on Twitter @pgionfriddo.  Find Paul Gionfriddo on Facebook at http://www.facebook.com/paul.gionfriddo.  Email Paul Gionfriddo at gionfriddopaul@gmail.com.

Making Health Services Our Priority

Are essential health and behavioral health services a priority for our elected officials?  We got a clear picture when House leaders offered their 2011 continuing resolution and President Obama proposed his 2012 budget this past week.   

Both the continuing resolution to fund federal agencies for the current fiscal year and the President’s budget proposal for next year cut billions of dollars from the federal budget.  Some essential health services are surprising targets.

Cost Per Person to Restore Proposed Health Cuts

For a total savings of $2 billion, or just over six dollars a person, would we choose to slice what they chose to slice, or would we make health services a bigger priority?

The continuing resolution proposed to cut $1.3 billion from community health centers.  These centers are located in every state.  They provide comprehensive primary care to everyone, regardless of their ability to pay.  They employ doctors, dentists, nurses, counselors, and other health professionals. 

They treat a lot of elders, people with disabilities, and lower income working families because they accept Medicare and Medicaid in addition to private insurance.  They provide high quality services, and meet a significant consumer demand.  According to the National Association of Community Health Centers (NACHC), they served 20 million Americans in all income ranges last year. 

NACHC responded that the proposed cut would cost 3.3 million Americans their care during the next few months, worsening the health care crisis in our country and driving up costs for everyone.

The continuing resolution also proposed a $500 million cut to mental health and substance abuse services, reducing the federal Substance Abuse and Mental Health Services Administration (SAMHSA) budget from $3.7 billion to $3.2 billion.  This is a 10% reduction from actual FY2010 funding.  It affects hundreds of thousands of children and adults with serious behavioral health problems. 

Elected leaders are betting that reducing services won’t backfire and leave more people with behavioral health problems without any treatment.  However, in providing the justification for her budget request, SAMHSA Administrator Pamela Hyde noted that over 10 million Americans already have unmet mental health needs and mental illnesses cost our economy over $100 billion per year, making this at best a risky, pound-foolish bet. 

Essential health services weren’t spared by President Obama in his proposed 2012 budget either.   

The President proposed taking $133 million from prevention by eliminating funding for the Preventive Health and Health Services Block Grant and halving funding for the Healthy Environment program aimed at preventing asthma and other chronic conditions. 

Though asthma has become one of the most common chronic conditions in our country, the President’s budget seems to be throwing in the towel on asthma prevention.  In justifying the cut in his proposed budget, his budget office writes “there are currently limited proven means of asthma prevention. In asthma care, the key intervention is to increase use of inhaled corticosteroids...” This is an uncharacteristic and remarkably one-sided rationale for emphasizing treatment at the expense of – instead of in concert with – prevention.

Each state decides how to allocate the prevention dollars it receives through the Preventive Health Block Grant, choosing 265 programs of local importance to support. 

In Florida, for example, the block grant has been used for chronic disease prevention programs, water fluoridation activities, and services for victims of sexual violence.  In Connecticut, it has funded childhood lead poisoning prevention, youth violence prevention programs, older adult fall-related injury prevention, and cardiovascular disease prevention.  In Texas, it has been used for sanitation services in rural border counties, support for a trauma registry, and support for local public health services.

While the President argues that there are other prevention services available, the long-standing problem in this country is not that we fund too many prevention services, but too few.    

Funding for this block grant is already $50 million less than it was in 1994, and it should come as no surprise that our health status as a nation has declined across a number of indicators since that time. 

What if we said no to cuts to these community health centers, behavioral health services, and prevention programs?  The $2 billion this would cost would add up to approximately $6.19 per person for the year.  Spending this $6.19 would result in the retention of hundreds of prevention programs across the country, up to 11 million physician visits, and services to over 200,000 adults and children with behavioral health problems. 

Have our nation’s resources really become so scarce that we can’t afford $6.19 a person to buy all this?

Maybe so, but I suspect the real answer lies in our priorities.  They spend this much every week on the war in Afghanistan, and both the President and Congressional leaders have made Afghanistan their continuing priority.  It’s past time for some new ones.