B4Stage4

For the past several months, I've been traveling around the country for Mental Health America.

I have been delivering two messages.  The first is that it was a mistake to use a "danger to self or others" standard as a trigger to treatment for people with serious mental illnesses.  Because this has made mental illnesses the only chronic diseases we wait until Stage 4 to treat, and then often only through incarceration.

The second is that if we are to treat people with mental illnesses the same way we treat people with other chronic conditions, we have to act before Stage 4.  We have to start with prevention and then invest in early identification and intervention.  We have to integrate health, behavioral health, and other services.  And we have to give people an opportunity to recover at all stages in the disease process.

May is Mental Health Month. Since 1949, it has been a signature program of Mental Health America, formerly known as the National Mental Health Association.

This year's theme is B4Stage4.  It succinctly gets the message across that we need to turn our attention upstream if we're going to prevent tragic outcomes, and if we're going to change the trajectories of people's lives for the better.

By May 1, more than 3,500 organizations had downloaded MHA's materials to share with others - and many more have downloaded them since.  That's no surprise.  We've had millions of social media impressions with #B4Stage4, and advocates around the country are rallying to its simple and straightforward message.

Mental Health Month materials are available free of charge here, and help explain the importance of B4Stage4 thinking - and action.  They are available in English and Spanish, and there are videos and infographics that go along with them.

It's no secret why this matters to me.  I've had too many all-too-personal experiences with Stage 4 thinking.  It has cost a lot of people like my son Tim the opportunity to lead happy and productive lives.

And we can do a whole lot better than we have in the past - if we're willing to try.

Order a copy of Paul's book, Losing Tim, from your local or online bookstore or directly from Mental Health America.  Read more of Paul's occasional blogs at the MHA website, at Health Affairs, or at Psychology Today.

We've Grown Accustomed to Disgrace

It sometimes seems like policymakers go out of their way these days to pick on people with mental illness.

According to a report released last week by the American Mental Health Counselors Association, 3.7 million people with mental illness will remain uninsured because of the decisions of states not to expand Medicaid. 

And if you believe some earlier data from the Kaiser Family Foundation about the total number of people who will be left uninsured because of states' failures to expand Medicaid, then you can only conclude people with mental illnesses account for nearly 80 percent of all those who are being denied insurance coverage in non-expanding states.

This includes 652,000 in Texas and 535,000 in Florida, and around 200,000 each in Pennsylvania, Indiana, Georgia, North Carolina, South Carolina, Tennessee, and Louisiana.

The association characterizes this as “dashed hopes” and “broken promises.”

You might also call it a national disgrace.

For those of us who live in one of the non-expanding states, we’ve grown accustomed to disgrace.  Our states are often held up as examples of what not to do.  We have poorer health status, and usually spend less on mental health services.   We also have the life expectancies of Libyans.

Our policymakers often blame Washington for all of our troubles.  But Washington isn’t to blame for this one. Washington’s recent decisions on health policy did not contribute to our current staggering debt.  Fighting two interminable wars on a credit card at the same time our banking industry nearly collapsed took care of that. 

No, these decisions reflect a lack of understanding and empathy on the part of elected officials.   Their decisions have consequences, and cannot always be blamed on someone else.

Perhaps those who live in more progressive states are feeling a little superior right now.  But they should not be.  Legislators in those states also didn’t clamor to expand Medicaid for all these people with mental illness before the federal government stepped in and offered to pay for it. 

So we are really all in this together.

We are all pushing nearly 4 million people even farther out on the fringes of our health care delivery system. 

These are people living with at least one serious, often life-threatening, illness.  They are living near or below the poverty line.   They cannot afford to pay for health care.  And to top it off they are often subjected to stigma and discrimination. 

This is a group of people who are frequently homeless or incarcerated. 

And when they do need medical care, this is what we say to their providers.  Treat them for free.

We ask hospitals to care for them in their emergency rooms for free.  We ask community mental health centers to provide inpatient and outpatient services for nothing.  And we ask clinicians to donate their care.

The solution for this is simple and involves us all.  If we want to do so, we can bypass those non-expanding states entirely.

All we need to do is to ask Congress to amend the Affordable Care Act to allow people living below the poverty level the option of purchasing insurance on the exchanges at the same price as those living at the poverty level. 

Right now, they cannot.  The reason is that the price of insurance for someone living below the poverty level isn’t subsidized.  But it is for everyone between the poverty level and 400 percent of poverty – over $90,000 per year for a family of four. 

There are plenty of people who think we treat people below the poverty level like millionaires with our entitlement programs.  Ironically, in this one instance they happen to be right. 

If Congress were to make this change, the immediate result would be that 3.7 million people living with mental illness could get decent basic health insurance for little or no cost. 

Of course, it would cost the rest of us something.  But Medicaid expansion costs all of us something, too – even those of us living in non-expanding states. 

And the money would be put to good use. It would reimburse providers of necessary health care, stimulating the sector of the economy that accounts for one-sixth of our GDP (and a similar percentage of our jobs).

So everyone would win if we did this.

Who could object to that?

My guess?  Many of the same politicians who don’t favor Medicaid expansion.  Because when you get right down to it, where people with mental illness are concerned, some of these politicians may in fact be our biggest national disgrace.

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

Myth and Miriam Carey

This is Mental Illness Awareness Week. But the sad tragedy of Miriam Carey is another reminder of how deeply unaware we are about mental illness in general and its relationship to violent behavior in particular.

And how much we rely on myths to fill in the gaps in our knowledge.

We all heard the news about Ms. Carey last week.  But we were not exactly informed by it. 

Ms. Carey drove her car onto a White House driveway, hit some temporary fencing, backed up, and then pulled away. She was pursued toward the Capitol by law enforcement officers in what became a high-speed chase.  Ms. Carey was eventually cornered near Garfield Circle.  Six officers, with guns pulled, approached her car there.  She apparently panicked, scattering the officers as she drove away.  At least nine shots were fired at her as the chase began again.  She eventually got stuck on a median near a Capitol guard station, where she was shot to death by an officer.

As I watched the unfolding news that afternoon, the story was embellished, to say the least.  There were reports of a possible terrorist attack on the White House and the breaching of a White House barrier.  And gunfire had been “exchanged” in an apparent attack on the grounds of the U.S. Capitol, as Senators cowered in their offices.

But then the real story began to emerge.

Ms. Carey hadn’t breached a White House barrier; she had hit a fence or a gate.  No gunfire was exchanged, because Ms. Carey was unarmed.  And Ms. Carey wasn’t attacking the Capitol; she had fled in her car in that direction.

So the narrative changed.  Now Ms. Carey – suffering from mental illness – had “rammed” a barrier at the White House.  She was “obsessed” with President Obama.  She used her car as a 1300 pound “weapon” to mow down law enforcement personnel as she continued on her “rampage.”

And she “chose” to ignore officers who tried to subdue and pursue her.

Words themselves are powerful weapons.  And these new words helped paint the mythical picture of the seriously mentally ill person who stalks, snaps, and kills without warning. 

But this narrative proved to be wrong, too.

We later learned that Ms. Carey apparently drove all the way from Connecticut to Washington with her one year old baby in the car.  So she didn’t “snap.”  And there was no evidence in her home that she had been plotting against the President with whom she was “obsessed.”  And she wasn’t on a “rampage.” Not only was she unarmed, but she apparently managed to avoid pedestrians and other motor vehicles as she raced down Pennsylvania Avenue at speeds up to 80 miles per hour.

But because she is dead the pieces missing from her story – like what she was actually thinking at the time – will probably remain missing. 

And the myth-makers will have another field day at the expense of people with mental illnesses.  Because the facts about mental illnesses don’t fit the narrative.

These are the facts.

People do not acquire mental illnesses by choice.  They can’t turn them off like a faucet.  The people who knew her best said Miriam Carey was not out to harm anyone last week, and that her mental illness was being treated successfully.  But if she was suffering from a mental illness-induced panic in the final minutes of her life as she was chased and under fire, she would have been no more able to turn that off when the police yelled stop than to will herself to stop bleeding from her gunshot wound. 

All mental illnesses are not the same, but none is a very strong predictor of violence.  Postpartum depression – for which she had been treated – is not the same as schizophrenia or bipolar disorder.  But if you believe the myth that any of these conditions by themselves leads to violence, then take a look at the chart accompanying this column about the low lifetime prevalence of violence among people with serious mental illnesses, from an article published almost a decade ago in the New England Journal of Medicine.

And people with mental illness do not “snap” without warning.  There are often years of warnings that go unheeded by payers looking to save a dollar.  And by public officials who cut mental health budgets and deem mental health agencies and services as “non-essential.” And then cower in their offices at the first sign of trouble – the one part of the initial reporting that was, apparently, accurate.

Let’s deal with facts, not myths.  After all, this is Mental Illness Awareness Week.

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/

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/

Veterans and Mental Illness: A 2013 Update

Fifty-four percent of Iraq and Afghanistan war veterans who have sought treatment in the VA system since 2001 have been treated for mental disorders.

This is the second most-frequent diagnosis among these veterans.  It is an indicator of the profound effect recent war service is having on the mental health and well-being of our veterans.

The data come from a March, 2013, report entitled Analysis of VA Healthcare Utilization Among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) Veterans.  

Here are some numbers that reflect how extensive the use of VA services has been during the last decade.

As of the end of 2012, 2.5 million troops had served since the beginning of the Iraq and Afghanistan wars.  Just over 1.6 million had become eligible for VA healthcare.  Of that group, almost 900,000 had used VA healthcare services by the end of 2012.

These 900,000 veterans most often sought treatment in VA centers in the south or in the west.  More than 85,000 sought treatment in the VA South Central Healthcare Network, while more than 80,000 sought treatment in the VA Desert Pacific Healthcare Network.  By contrast, less than 39,000 sought treatment in the VA New England Healthcare System.

Of those seeking treatment, 88 percent were male, and 12 percent were female.  93 percent had been seen on an outpatient basis only, while 7 percent had been hospitalized in a VA hospital on at least one occasion. 

Almost half were under the age of 30.

And the 550,000 who accessed care during 2012 alone represented 9 percent of the total number of veterans receiving VA care during the 2012 fiscal year.

And while – as might be expected – musculoskeletal system conditions were the most frequent diagnosis (58 percent) over the entire decade, nearly as many veterans (54 percent, or over 486,000) were diagnosed with mental disorders.

Many had two or more disorders.

Post-traumatic Stress Disorder, or PTSD, was the most frequent mental disorder treated in VA settings.  Over a quarter million OEF/OIF/OND veterans were treated for PTSD by the end of 2012.  But depressive disorders were nearly as prevalent, with more than 200,000 veterans being diagnosed with those.  Also, nearly 200,000 veterans were treated for neurotic disorders.

Together, these numbers provide strong statistical evidence that repeated exposure to environmental risk factors, including violence, are factors in multiple mental health conditions.

On the other hand, only 59,000 were diagnosed with alcohol dependence and only 32,000 with drug dependence.  These numbers suggest just as strongly that the mental disorders among returning veterans were not caused by risk factors within the control of the veterans themselves.

On Memorial Day, all of these data should give us pause to think about the inadequate federal and services and systems to which our OEF/OIF/OND veterans are returning. 

While the VA has taken steps in recent years to extend additional services to returning veterans, including allowing veterans to enroll in VA health services for up to five years after service and waiving co-pays for health problems related to military service, a significant number of veterans have not yet entered – or will never enter – the VA system.  

In addition, as a number of news outlets, including the Daily Beast, reported in March 2013, 245,000 veterans had been waiting for more than a year for disability benefits as of December 2012.  The average wait time for Iraq and Afghanistan veterans was between 316 and 327 days.

The federal government could be doing more for these men and women, but so could our states.

Funding for mental health services were cut by $4.6 billion by states between 2009 and 2012, and the unwillingness of many states to expand Medicaid benefits this year is certain to take a toll on many of our returning veterans and their families.   

We all know that this is no way to treat our returning veterans.

So as we raise our flags on another Memorial Day, we should never forget that our responsibility to those who serve our country extends over 365 days. 

Now is the time to pay back those for the sacrifices they have made.  Or are we so cold as to expect these mostly young veterans to have made this sacrifice – along with the toll it took on their health and mental health – all by themselves?   

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

As a Medicaid Expansion Tool, Premium Support Leaves Neediest People Sitting on the Sidelines Again

It is way too early to break out the champagne over the latest Medicaid expansion initiatives bubbling up around the nation. 

States that have been reluctant to expand traditional Medicaid are ablaze with proposals to offer “premium support” to expansion populations. 

Premium support programs may differ in their details, but they have one thing in common.  Instead of offering regular Medicaid to an expansion population, the state pays the cost of their private insurance premiums.

Kaiser Health News reported last week that the Department of Health and Human Services is encouraging states to explore this approach.  MSN featured some “let’s make a deal” offers on expansion by a number of GOP legislators.  And Health News Florida reported a wave of bipartisan enthusiasm for a Florida premium support proposal that was unveiled after support for traditional Medicaid expansion collapsed.

For policymakers who don’t like Medicaid but want the federal expansion dollars, the benefits are clear.  They can prop up the private insurance market as an alternative.  They can allow children and parents in Medicaid-eligible families to be covered by the same insurance.  And they can make the Medicaid program appear smaller to the naked eye.

But based on expert evaluations, the benefits of premium support may not be so clear for today’s expansion populations.

By the early part of the last decade, at least seventeen states had premium support programs in some form, according to a 2005 report of the State Health Access Data Assistance Center.    

And from the perspectives of the states running them, the programs had some problems.

There were significant upfront costs and administrative burdens, difficulties in enrolling families, and challenges in defining the roles of employers.  And they often had to be supplemented by regular Medicaid, in which “wrap-around” Medicaid benefits were offered to close the coverage gaps in traditional insurance products.

From the perspective of potential Medicaid recipients, there were also some significant challenges. 

Writing in Health Affairs in September 2005, Janet Mitchell, Susan Haber, and Sonja Hoover compared the regular Medicaid program in Oregon with a premium assistance program also offered by the state.

They found that the families enrolling in the premium assistance program:

• Were less likely to be of Hispanic origin;
• Were more likely to have at least one parent employed;
• Had higher levels of educational attainment;
• Had better health status;
• Were more likely to have had experience with private insurance programs; and
• Were more likely to receive care in a doctor’s office, as opposed to a community health center.

We can divide today’s expansion population into three groups – better educated parents of SCHIP children who have a medical home and place a premium on staying well; parents who use safety net services episodically only when they are sick; and childless, mostly single, adults with chronic conditions.

Based on the evaluations, only the first group is clearly helped by premium support – provided enrollment is encouraged and simplified.

The second group may be helped, but only if the states put additional resources into education and outreach.

As the Health Affairs authors put it:

“If premium subsidy programs are to be successful in enrolling low-income families, the results of our study suggest that these programs may need to be accompanied by efforts to educate these families about the importance of health insurance and how it works.”

The third group is one for whom premium support may be no answer at all – low-income, uninsured childless adults who have chronic conditions.  Up to 6.6 million people in the Medicaid expansion population have mental illnesses or addiction disorders.

They already often have so many strikes against them – no medical home, underemployment, no children receiving Medicaid or SCHIP benefits, and stigmatization by policymakers who equate illness with entitlement.

They don’t need insurance with all of its profit motives, administrative costs, and bureaucratic tangles.  Their providers just need someone to help pay the bills.

And states need the $20 to $40 billion Medicaid expansion would add to their revenues over the next five years if people with behavioral illnesses were added to the regular Medicaid program.

Premium support is better than nothing. 

It may ultimately win the blessing of HHS, and in some states premium support may be the only path to expansion. 

But premium support is only a partial expansion of the Medicaid program – a concept rejected by HHS just months ago. 

And this partial expansion will leave some of those most in need sitting on the sidelines again.  

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

Mental Illnesses a Leading Cause of Hospital Admissions, But Treatment Lags Behind

Would you send your mother to a pediatrician for her arthritis, or your child to a geriatrician for his well-baby exam?

Probably not – unless there were no other provider in town.

But some new reports from the Agency for Healthcare Research and Quality (AHRQ) suggest that something akin to that is happening every day to people with mental illnesses.

Two reports – Costs for Hospital Stays in the United States, 2010 and Most Frequent Conditions in U.S. Hospitals, 2010 – were released in January 2013.  The third, Most Frequent Procedures Performed in U.S. Hospitals, 2010, was released in February.

They make for fascinating reading, with an unexpected twist at the end. 

Spoiler alert – mood disorders are among the most common reasons for hospitalizations for people under 65.  But mood disorders aren’t driving the increase in hospital costs, because the procedures hospitals most often perform have nothing to do with treating people with mood disorders.

Mood disorders accounted for 877,000 hospital inpatient stays during 2010.  Apart from being born, they were the #1 reason that children under the age of 18 were admitted to hospitals, ahead of pneumonia, asthma, and appendicitis.

Mood disorders were also the 3^rd most common primary diagnosis among all people between the ages of 18 and 44.  The other four in the top five all related to childbirth and delivery.

And among adults between the ages of 45 and 64, mood disorders ranked 5^th as a reason for inpatient hospitalization, behind four conditions closely related to aging – osteoarthritis, back pain, chest pain, and coronary artery disease.

Mood disorders may be common reasons for hospitalization, but they have nothing to do with the recent increase in health care costs.

The mean cost of a hospital stay was $9,700 in 2010, up from $6,700 (in 2010 dollars) in 1997.  That represents a 45% increase over a thirteen year period. 

But the mean cost for mood disorders was less than half of that – just $4,800.  And what’s even more interesting is this.  That represented a 6% decrease from the $5,100 cost per stay in 1997.

On the other end of the scale, the most expensive hospital stay was for adult respiratory arrest, at $22,300.  In other words, we pay almost five times more for people to die in a hospital than to be treated for mental illness in a hospital. 

We also pay $18,000 to diagnose and treat an acute brain injury – four times than what we pay to diagnose and treat a chronic brain disease.

And in every age group, the most common procedures hospitals perform have nothing to do with mood disorders. 

Among children, hospitals most frequently offer vaccinations, circumcisions, respiratory intubations, and appendectomies.  Among younger adults, the most frequent procedures include those related to child birth and delivery – such as Caesarian sections and repairs of obstetric lacerations, and blood transfusions.  And among older adults, blood transfusions, cardiac catheterization, respiratory intubation, and upper GI endoscopy are most common, along with knee and hip procedures for the very old.

So what do we need to do to respond to the needs of people with mood disorders who are entering our hospitals?

The answer isn’t to deny or restrict care to patients with mental illnesses who show up at hospitals because they have no other place to go, or to force hospitals to discharge patients with mood disorders before they are ready to go, or to wait for jails to pick up the slack – as we do in so many places today.

We have choices.

One is to fund more community treatment programs – to replace those we lost to massive budget cuts – so that thousands of people can avoid hospitalizations in the first place.

And another is to insist that when patients are admitted to hospitals, our new mental health parity rules and regulations mandate payment for hospitals to use new procedures like functional MRIs (fMRIs) to diagnose more accurately – and therefore to treat more effectively – mental illness in their patients. FMRIs are brain scans that can show differences in brain activity that are correlated with specific mood and anxiety disorders. 

FMRIs aren’t exotic – they have already been used in consumer studies to measure consumer preferences for brand names. If we can use fMRIs to help sell cola or political candidates, why can’t we use them in hospitals to help treat mental illness?

We always have choices.

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

Let's Treat Mental Illness Before It's Too Late

Why is mental illness the only chronic disease we don't begin to treat until Stage 4?

I posed that question in a presentation for over 400 attendees at last week’s winter meeting of the North Carolina Hospital Association.  For an audience that witnesses first-hand the crowding of patients with mental illnesses into general hospital beds and emergency rooms, the question resonated.

Stage 4 of a chronic disease is associated with the imminent threat of death – a widely metastasized cancer, for example, or kidney disease so advanced that only dialysis or a transplant keeps the person alive.

The odds of recovery are long.

It is the same with mental illness.  Either the patient's life or someone else's needs to be at stake before we guarantee access to treatment.  That's Stage 4.

Diagnosing and treating a disease at Stage 1, 2, or 3, always improves the odds of survival and recovery.

Why not apply that standard to mental illness, too?  In Stage 1, people show early signs of the disease – sleeplessness, anxiety, and fatigue, for example.  These are signs that can be readily identified using common mental health screening tools, and symptoms that can be managed through the use of medications, counseling, or even healthy living.

In Stage 2, the disease is more advanced and the symptoms more pronounced.  Depression may affect performance at school or work for example, or “command voices” (sometimes known as auditory hallucinations) may become louder and more pronounced.  This is a stage at which – if we act aggressively and provide the proper supports – we can help patients maintain an independent life, even though they may require an occasional hospitalization. 

People in Stage 3 are in need of ongoing treatment and support, which is often expensive – like chemotherapy in the case of cancer.  But with mental illness, people in Stage 3 are far more likely to be in jails than in treatment beds, and among the homeless population instead of the general population. 

While 6 percent of the general population has serious mental illness, that description applies to an estimated 15 percent of male prisoners, 31 percent of female prisoners, and one-quarter of all people who are homeless.

Intervening effectively during Stage 1, 2, or 3 can save lives and change the trajectories of those lives for literally millions of people.

But that isn’t what we usually do.  According to the National Institute of Mental Health, just over half of adults with serious mental illness receive any treatment at all.

That finally may be about to change. 

Last week, Florida’s Governor Rick Scott and the Federal Department of Health and Human Services came to a compromise.  HHS is going to permit Florida to transition nearly all Medicaid patients into private managed care plans, including for those needing long term care.  In return, the Governor dropped his opposition to Medicaid expansion.  If the Legislature agrees, Medicaid will be available for many more adults with chronic diseases – especially for people with mental illnesses.

And this will make a huge difference.  

If Florida implements Medicaid expansion, other states - like North Carolina - that are still on the fence are more likely to follow suit.  And its managed care program may also offer cost-saving lessons to states that have already braced expansion.  

Policymakers will have a new source of revenue to intervene more effectively to treat mental illness at every stage.

This means more screening and early intervention at Stage 1, more integration of behavioral health, education, and primary care services at Stage 2, and more emphasis on treatment as opposed to incarceration or neglect at Stage 3.

The best part is that states can pick and choose from a long menu those strategies that suit them the best. 

And this means that patients in general hospitals throughout the country – where mood disorders are the 5^th most common diagnosis – will finally get some relief.    

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.

The Tragedy of Sandy Hook

The entire world is in mourning over the senseless and horrifying massacre of innocent children and adults in Sandy Hook, Connecticut. 

This hit so close to home for me, about forty miles from where I grew up.  So many of my former legislative colleagues are among those trying to help the state through it. 

I can’t even pretend to imagine what this must be like for the families of Sandy Hook. 

On the first day of the tragedy, too many politicians trotted out their tired old line that “today is not the day to have the debate” about gun control.  Thank God their tone-deaf voices were silenced by the outcry of reasonable people.

Connecticut Congressman John Larson (D-1) said that “Congress should be prepared to vote on requiring background checks for all gun sales, closing the terrorist watch list loopholes, and banning assault weapons and high capacity clips. Those measures don’t solve all our problems, but they’re a start.”

Senator Joseph Lieberman (I-CT) and Senator Richard Blumenthal (D-CT) also called for an assault weapons ban.  

But does our nation have the will to do this and more?

I hope so, because if the images of six and seven year olds staring down the barrel of an assault weapon in their last split seconds of life do not motivate us, then nothing will.

And there are two big things that it is past time to do. 

This first is to get lethal firearms out of the hands of people who are not defending us.  The second is to reverse the damage we’ve caused by neglecting and discriminating against people with mental illness because we mistakenly think that they are the cause of all the violence.

According to data reported in July by the Manchester Guardian, we are by far the most gun-toting of all of the most civilized nations in the world.  If the population of Newtown, Connecticut, is just average, then among them they already own 24,513 firearms. 

Adam Lanza’s mother owned the three of them used in the Sandy Hook massacre.  A self-described gun enthusiast, she was reported to feel she needed all this weaponry for safety and self-defense.  In the moment before her life was taken, did she feel safer, or better defended?

A member of Congress from Texas, Rep. Louie Gohmert (R-1), thinks we need even more. Does he really believe that the other 24,510 Newtown firearms made the children of Sandy Hook any safer that day?

Perhaps the horror of this massacre might open our eyes to something else – every day, an equal number of our sons and daughters die in our towns and cities because someone shoots them to death.

In 2007 alone, over 9,000 people in our country died because of gun violence, far more than the 6,656 Americans who have died in both the Iraq and Afghanistan wars since their beginning. 

We can do much better than this.  And, as President Obama declared in Newtown, “we will have to change.”

But making real change is not just finding someone to blame.

After tragedies, we often find at least hints of mental illness in the people using the guns.  But when we do, we miss the point. Violence is not a mental health problem, it is a public health problem.

Today, we are too quick to equate violence with mental illness, too quick to send people with serious mental illnesses to jail, and too quick to balance our state budgets by neglecting the people with the greatest service needs.

Connecticut’s Governor, Dannel Malloy, has shown leadership in his response to the massacre.  But another test of that leadership will come soon.  He recently ordered the rescission of up to $9.5 million in mental health services funding in Connecticut.  This funding is desperately needed to prevent and mitigate mental illnesses.  Governor Malloy is not alone in this regard – in all fifty states $4.6 billion has been cut from state mental health services during the last four years. 

Will Governor Malloy rescind that rescission now, and call on his colleagues around the country to do the same, so we can re-build our nation’s mental health services infrastructure, and better detect and treat mental illnesses early?  Will he help de-stigmatize those with mental illness, who are more often the victims of violence than its perpetrators?

Will the nation have the will to raise the money we need for prevention?

Because only if we do will we be able to say that protecting all of our children from harm is our highest priority.

Addendum:  There are news reports that Adam Lanza’s mother may have, for behavioral reasons, removed him from school at some point for home schooling.  I believe that voluntary or involuntary removal from school is often one step in a years-long chain of events that leads to bad outcomes. 

This time might therefore become a critical intervention point to change a bad trajectory and prevent future tragedies of all sorts – if we were to change our special education policy as follows:

Whenever a parent or a school believes that a special education student needs to be removed from his school for behavioral reasons, either via suspension, expulsion, or voluntary removal, for at least five consecutive days or for at least ten days in the course of a school year, there must be a mediation scheduled within 10 days with the school district, the parents, and the state education department as a mandatory third party.  The purpose would be to develop a new IEP with additional services.  The new IEP must have the input of a child’s regular health and mental health providers, if there are any.  If not, health and behavioral evaluations should be done to inform the mediation, with the state picking up the cost.  If any two parties agree to the additional services, then the services must become an immediate part of the IEP, with the state picking up the additional cost.  If the parents are not one of the parties in agreement, they still reserve their right to go to due process.  If the student is not yet admitted to special education, then the same event should trigger an immediate outside evaluation for eligibility for special education services.

Let’s assume that all parties would act in good faith.  But just in case one were concerned that a local district would low-ball a set of services from the start to shift more costs to the state, then a district could be made responsible for the costs of either its existing plan or the average cost of plans for comparable students in other districts, whichever is greater.

We’re all searching for answers.  This is just one suggestion.

Note: This column was published early this week because of the timeliness of the issue.  My prayers are with the people of Newtown.  Our Health Policy Matters will be return to its regular publication on December 26 and January 2.

When George McGovern Made Mental Health A Campaign Issue

When Senator George McGovern, who died this past weekend, decided to run for President, he did so as a World War II hero who opposed the Vietnam War. 

A respected South Dakota senator, he helped galvanize anti-war sentiment among young people and ride it to the Democratic Party’s nomination in the summer of 1972.

His election prospects that year were as remote as Senator Goldwater’s had been just eight years earlier.  From opposite ends of the philosophical spectrum, there was much to admire about both of them.  But they were also both too removed from the center of the political spectrum to be electable in the moderate America of those times.

As a vocal McGovern supporter back in 1972, I have long wondered how he felt about the one thing I admired least about his political career – the moment when he let fear about mental illness alter the course of our public policy history.

There is an excellent and recent brief story about this on the National Public Radio website, summarizing a book written by Joshua Glasser entitled The Eighteen Day Running Mate.

Despite growing opposition to the war, Senator McGovern’s path to the Democratic Presidential nomination was far from easy.  By the time he won his nomination, he was a polarizing figure who was behind in the national polls. 

President Nixon’s campaign machinery was also in full swing at the time, doing its damage just after the Watergate break-in.  Had people known at the time all there was to know about the Nixon Administration, any viable Democrat probably could have beaten him.

But it was still a full year before the full nature of that Presidency would come to light in the Watergate hearings.  It was more than a year before Spiro Agnew would resign the Vice-Presidency over corruption, and two years before Nixon would resign the Presidency in disgrace.

So the focus was on McGovern, who was on the defensive politically.  “A” list politicians wanted to stay off of the McGovern ticket.  At the last minute, McGovern finally settled on Senator Thomas Eagleton – a respected Senator from Missouri.  When McGovern asked him if he had any skeletons in his closet, Eagleton answered “no” and accepted the nomination for vice-president.

Within days, there were rumors that Eagleton had a “complicated” medical history.  People didn’t talk much about “complicated” medical histories in those days, but the story bled out over the next two weeks. 

Several years earlier, on three occasions, Eagleton had been treated – ultimately successfully – for depression.

That was the sum total of Eagleton’s “complicated” medical history.

McGovern initially responded by supporting Eagleton – I remember when he declared that he was behind him “1,000 percent.”  But within days, fears began to grow in the media and among the public about whether Eagleton, with a history of mental illness, could be trusted with his “finger on the button.”  Bowing to this fear and prejudice, McGovern backed away from Eagleton’s candidacy, and Eagleton gave up the nomination just eighteen days after accepting it.

How might the course of our public policy history have changed if McGovern had kept Eagleton on the ticket?

Certainly, the discourse of the 1972 campaign would have been different.  Eagleton’s continued presence on the ticket might have stripped away at least some of our prejudices.  We all would have been educated about the nature of treatable mental illness.

And it would have shown an entire nation that mental illnesses were not to be feared, and did not need to prevent people from lives of amazing accomplishment.

It might have changed the course of actual public policy, too. 

If Senator Eagleton were more than just a quiet footnote to Presidential campaign history, would the Community Mental Health Centers Act still have been repealed back in 1981 and replaced with a block grant?

Would fewer people with serious mental illness today be in jail – a percentage that is three times greater than the prevalence in the general population and also three times greater than the prevalence among those incarcerated at the time of the 1972 campaign – and more have access to treatment?

I don’t know the answer to these questions, but I do know this.  Senator McGovern – whom I otherwise admired until his death – had just a moment on the stage when as a candidate for President he could have permanently altered the way we think about illness and disease.

And he squandered that opportunity.  

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

Our Mental Health Policy Mistakes and the Sons and Daughters Who Pay For Them

We have made some big mental health policy mistakes in my lifetime.  And my son Tim is among the millions of our sons and daughters who have paid for them.

This is because he happens to be among the 6% of sons and daughters with serious mental illness.

We fail to see mental illnesses as often preventable and always treatable diseases.  And although half of us will be diagnosed with one during our lifetime and mental illnesses cost as much to treat as cancers, we more readily send people with mental illness to jails and prisons than we do to hospitals and health centers.  Meanwhile, we underfund mental health care, special education, and social services systems.

I explain what this has meant for my son in an essay just published by Health Affairs, the nation’s leading health policy journal. 

How I Helped Create a Flawed Mental Health System That’s Failed Millions – And My Soncovers over twenty years of Tim’s life in Connecticut, Texas, and California – a life now lived mostly in jail, in hospitals, or on the streets.  This isn’t because of his mental illness.  It is because of the way we treat his mental illness.

The article appears in the September 2012 issue of the print journal, but Health Affairs has also made it available free of charge online and via podcast.  There is a link at the end of this column.

In the essay, you will see that we former policymakers – along with educators and service providers – made a lot of mistakes that resulted in the isolation of people like Tim. 

And today’s policymakers aren’t just repeating the mistakes we made.  They are piling new ones on top of them.

As a Connecticut state legislator in the 1980s, I thought we had the right idea.  Close the archaic state psychiatric hospitals, and move people with chronic mental illnesses back to their homes, schools, and communities. 

There was a problem.  Closing the institutions was popular, but returning people with mental illness to communities wasn’t.  So we directed only some of the dollars we saved into services.  The rest we used to lower taxes.

We justified this because we made taxpayers happy and because we believed that whatever happened in the community would be better than the underfunded services in the institutions.

We were wrong.  Sometimes no services are worse.

Today, Americans with serious mental illnesses have life expectancies that are diminished by as many as 25 years.  They die from violence and suicide, and from ineffectively treated chronic illness.

Those who survive suffer from stigma and neglect.  This is because they often act differently from the rest of us, sometimes because of disease, sometimes because of the medications they take to manage disease, and sometimes because of the drugs they use when the medications don’t work. 

We are afraid of them. 

To make them less frightening, we use the term “behavioral illnesses” to describe what they have.  But this in turn feeds a fantasy to which unsophisticated people (some of whom serve as policymakers) cling – that mental illnesses are the same as bad behaviors, and people with mental illnesses could choose to will away their diseases if only they’d try.  As if someone with cancer or heart disease could will those away.

They can’t. 

I can’t defend what we did in the 1980s to shackle people with mental illness with neglect.  But it seems to me that today’s policymakers are doing worse.

They can see with their own eyes the results of neglect – people sleeping in our parks, lying on our sidewalks, and standing on our street corners begging.  So how can they possibly defend the $3.4 billion in cuts they’ve made to state mental health services in the last three years, or some of the other horrible policy decisions I write about in the essay?

Maybe they just choose to look the other way.

That’s what most people do who see my son Tim – and all our sons and daughters who are like him. 

And when they do, they miss seeing a gentle soul with an easy smile, a good heart, and an imperfect history who has accepted humbly the hand he has been dealt and graciously consented to me writing about it.

But what they miss most isn’t who they choose not to see, but an essential part of what makes us human – empathy.  We were made to do better than this.

To read the full Health Affairs Narrative Matters essay, click here.

For links to the sources of data cited in this column, please see the mental health section of my data links page.

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

Mental Illness, Aging, and the Failure of Public Policy

In the next twenty years, more than 3 million people over the age of 65 will likely experience serious mental illness.  Are we prepared to treat them?

The answer is no, according to a new Institute of Medicine report. 

The report was released in July, and it contains some striking evidence of the challenges we face as we confront the growing behavioral health care needs of our aging population.  We don’t have nearly enough trained providers.

And when states cut their existing state Medicaid programs or refuse to adopt the ACA Medicaid expansion, these decisions have devastating consequences for the providers we do have – and, of course, their patients. 

Today, between 5.6 and 8 million adults over the age of 65 are believed to have mental illnesses.  These numbers could nearly double over the next twenty years. 

There’s a reason that the range is so big.  We’ve given so little attention to this challenge in the past that we don’t even have an accurate count.

We do know a lot, however.  As the IOM report documents:

• At least 14-20% of the elderly population has a mental illness.
• Up to 1.9 million have a mental illness described as “serious” – a number that could grow to over 3 million by 2030.
• 57% of nursing home residents, or 675,000 people, have one or more mental health conditions.
• Dementia is not the same as mental illness.  However, 57% of adults with dementia, or approximately 2.5 million people, also have symptoms of mental illness.
• Older women are more likely than older men to have every type of behavioral health condition except two – alcohol abuse and drug abuse.  In fact, the prevalence rates of mental illnesses among elderly women are 50% higher than they are among elderly men.

Publicly funded programs – like Medicare and Medicaid – are essential to treating all these people. 

The 2009 AHRQ MEPS data determined that the cost of the mental health services alone for the over-65 population exceeded $17 billion.  Affecting 7.4 million individuals, behavioral illness was the 8^th most costly condition for the over-65 group. 

Medicare paid just over half the bill all by itself and the combined Medicare, Medicaid, and other public share was 70%.  Private insurance, on the other hand, paid under 12%, far less than patients paid out-of-pocket.

These costs don’t occur in isolation from other health care costs.

This is because elders with mental illness are also likely to have chronic physical conditions.

In one representative study cited in the IOM report, this group had an average of 3.8 co-occurring physical conditions:

• 58% had hypertension
• 57% had chronic pain
• 56% had arthritis
• 55% had hearing or vision loss
• 39% had urinary tract or prostate disease
• 28% had heart disease
• 23% had chronic lung disease
• 23% had diabetes
• 21% had gastrointestinal disease
• 11% had cancer  
• 8% had neurological disease

This puts pressure on providers, who must manage multiple chronic conditions at the same time. 

What’s the most cost-effective way to do this?  We already know the answer.

“What works for many older adults who need MH/SU services is a patient centered, team-based, primary care-centered model that is proactive and employs a coordinated team of personnel with specific roles and special training,” the IOM report concludes.

In other words, the same primary and behavioral health care integration initiatives that work for the non-elderly population work for elders, too.

But unless policymakers change the course of their current thinking dramatically, we may not get close to what we need.

• The report identified “a conspicuous lack of national attention” to developing an appropriate workforce – including mental health counselors, primary care providers, care coordinators, and others – to give this care.
• It also described “a fundamental mismatch” between the need for coordinated care and Medicare’s refusal to pay for the services of trained care managers and psychiatric consultations.

We could add a third.  State cutbacks to existing Medicaid programs and states’ refusals to implement the ACA Medicaid expansion compromise our most vulnerable aging adults.  Those with mental illness and other chronic conditions usually have few resources of their own to pay for their care.

The question raised by the way we treat elders with mental illness is an important one.  Do federal and state policymakers mean to throw the neediest of us out into the cold as we age?

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.  For more columns about mental health policy, click on the “Mental Health” tab at the top of the page.