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/

How Increasing Our Obesity Rate is Becoming Federal Policy

Obesity rates in America are higher than ever.

This is the conclusion in a new Robert Wood Johnson Foundation report entitled F as in Fat: How Obesity Threatens America’s Future.   Released last week, the document notes that one-third of children and two-thirds of adults are now obese or overweight. 

Obesity is no minor health matter.  It is linked to disease, disability, and premature death.

The report received some media attention for a couple of days, but then we had our fill of it.  It faded into the news background largely because we’ve heard the story before. 

No one disputes the two major causes of obesity in America.  Americans take in too many calories, and work off too few.

If we accept these causes at face value, the story ends as we decide that weight is a matter of individual – not governmental – responsibility. 

The individual choice argument is a powerful one for those who do not think that the government needs to “interfere” with people’s food and exercise choices.  But it’s wrong.

The forces of governmental inaction regarding the food we eat are powerful. 

First, the “freedom to choose” argument is the same argument the Tobacco Institute used successfully against governmental regulation of smoking for many years.  Smoking was “an adult custom,” the argument went.  Two-thirds of people chose not to smoke, and those who did should be left alone.

Despite overwhelming evidence about the harmful effects of smoking, it took almost thirty years to overcome most of the prejudice against governmental regulation of smoking in public places.

Second, there is an even stronger prejudice against governmental action regarding weight, because weight doesn’t have second hand effects like smoking.  On the contrary, the weight debate often devolves into an argument about the extremes.  Isn’t it worse to be morbidly underweight than it is to be morbidly overweight?  Many people think so.  Morbid underweight even carries a diagnostic label, anorexia, with no real counterpart on the opposite end of the scale.

When former Surgeon General David Satcher issued a call to action against obesity in 2001, the nation responded by grabbing a snack, taking a seat, and tuning him out.  In a Forward to the RWJF report, he writes that 12% of children were overweight in 2001.  The percentage tripled over the next decade.  Three out of every five adults were overweight in 2001.  Two out of three are today.

So why are we so bad at exercising our individual responsibility to eat well? 

Governmental action, or in this case, inaction, may have something to do with it.  As individuals, we are doing some things right, like eating more fruits, vegetables, and milk products today than we did a generation ago.

But the biggest weight culprit may have nothing to do with individual choice.  It appears to be the sugars added during processing to the foods we eat, and the government’s failure to use its own data to regulate this added sugar effectively.

A recent USDA report notes that Americans now consume 30 teaspoons of added sugars every day.  These are often added to our foods during manufacturing, long before we reach for our own sugar bowls.  They add the equivalent of 477 total calories to our daily diet.  We’re hooked on added sugars, which may well be the nicotine of the 21^st century.

Food manufacturers start spooning added sugars into our mouths early in our lives.  Baby foods need no added sugars.  According to another  USDA report published in 2006, however, more than half of the sugars in babies’ teething biscuits were added sugars, as were two-thirds in a “fruit supreme” baby dessert.

We expect sweet desserts, but some non-dessert products have even more added sugars.  Frozen lemonade from concentrate had more added sugar per 100 grams of carbohydrates than cinnamon raisin sweet rolls or chocolate glazed donuts.  A “low calorie” Caesar dressing had almost as much added sugar as a jelly donut.

Telling us to eat less is just background noise when we’re pumping empty calories into our manufactured foods.

Our government should report on, and regulate, the sugars and other substances that are added to our foods.  But the USDA agency program that produced the two reports lost 10% of its funding in 2010.  It will suffer much deeper cuts if the USDA budget passed by the House in June is approved as part of the deficit reduction deal.

This program area accounts for 2% of USDA spending, and 8/100ths of one percent of the US Federal budget.  Eliminating the program area entirely would close the deficit by two-tenths of 1%.

Without information or regulation, the sugars will keep coming whether we want them or not.  And we’ll continue to get fat.

If you have questions about this column or wish to be added to an email list notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.