Budget cutting has become a top priority for virtually all political leaders from the President on down to every Governor, County Executive, and Mayor in the land. As a result, health care reform and the effort to transform America’s behavioral health systems to promote recovery (both of which offer great promise for improved care) are being compromised by the demand to save money. No one can predict how all of this will affect the people we serve—today and for years to come.
I can’t help but recall the promise of the “community mental health” movement of the 1960s and 1970s which (rightly) moved to eradicate the deplorable conditions at most state hospitals for people with mental illness. The plan called for treating people in local communities rather than warehouse them in hospitals. State hospitals were emptied except for the most seriously ill. Tens of thousands of people with serious mental illnesses across the country were released from or denied admission to state hospitals. Care of this population became the responsibility of local communities rather than of institutions. The Community Mental Health Act called for funding of community mental health centers to carry the load. On paper the idea seemed to herald a more therapeutic and humane system of care. Sadly, the community mental health centers were never fully funded and expansion of services in the community did not keep pace with the need created by de-institutionalization. There were a few genuine community success stories, but many patients fell through the cracks. Over time they became the nation’s new homeless population and the now skyrocketing and disturbing prison psychiatric system population.
Will this happen again? There are reasons for concern. In order to hold down Medicaid expenditures for behavioral health services, New York and other states are expanding the use of managed care. In his article, Whatever Happened to Community Mental Health? (Psychiatric Services, May 2000), Steven S. Sharfstein, MD stated: “In the cost-driven medical marketplace, psychiatry and, more broadly, mental health have suffered more than the rest of medicine. Private health insurance benefits have been cut significantly, and the public mental health system is in a state of collapse that varies only by degree from state to state. Two sectors of care in particular have been under attack in the managed care revolution: hospitals and physicians. Managed care has taken on many of the rhetorical flourishes but none of the substance of the community mental health revolution of the 1960s and 1970s. Managed care emphasizes lower levels of care and lower-cost professionals as a way of saving money and enhancing stockholder value, which has led to an increasingly consolidated behavioral health industry. But in the face of cost cutting, what about access and quality?” Dr. Sharfstein concludes his article saying, “Community mental health battles for survival in the rapidly changing public and private marketplace. Many of the old federally initiated community mental health centers are now called community behavioral health care organizations, or CBHOs, with a principal function of coordinating and integrating aspects of mental health treatment, addiction treatment, and primary care. The success of psychosocial rehabilitation approaches coupled with supervised housing stands in contrast to the continuing public health disaster of seriously mentally ill persons who are homeless or in prison. Dorothea Dix would be shocked if she revisited America today. As Geller (Geller JL: The last half-century of psychiatric services as reflected in Psychiatric Services. Psychiatric Services 51:41–67, 2000) understates, “We remain entrenched in our concerns about locus of care, confusing it with the humaneness, effectiveness, and quality of care.” Because most care will take place in the outpatient arena, a great challenge for community mental health in the 21st century is to address the issue of people who are not in treatment, who resist treatment, and who become marginalized and destitute. Without reinventing asylums or discovering a magic bullet or cure for schizophrenia and other serious mental illnesses, we must rely on mental health policies and services with adequate financial support for community care. Barton’s “service follows the dollar” maxim is important if managed care is a temporary aberration in mental health policy, as I believe it to be. We still must find a way to set priorities, allocate resources, and ensure delivery of high quality scientific and humane care to people in need.”
Sharfstein wrote the above 11 years ago, yet much of his analysis still applies today. However, managed care for people with mental illness is not a temporary aberration as he thought it would be, but a present-day reality which holds the promise or the doom for the people we serve.
In addition to managed care, major changes to our healthcare systems are coming into being at a fevered pace. As Barry B. Perlman, MD, Director of Psychiatry at St. Joseph’s Medical Center, Yonkers, New York, Legislative Chair of the New York State Psychiatric Association, and esteemed member of the Board of Mental Health News recently stated: “In my 30 years of practice in psychiatry, I have never seen so many balls up in the air at the same time.”
I believe that if health reform, the emergence of behavioral health care networks, and the disappearance of separate silos for departments of mental health, substance abuse, and primary medical care, are to succeed, stakeholders of mental health communities everywhere must come together to safeguard the people we serve so that they are not lost in the shuffle and fall through the cracks. Throughout the United States we are fortunate to have coalitions and advocacy organizations that work tirelessly on behalf of the rights and services of the mental health community and our statewide population of people with mental illness and substance use disorders.
Much of the work to develop NYS’s newly emerging system of behavioral health care lies in the recently formed Behavioral Health Reform Work Group (BHRWG), whose members were selected by the Co-chairs of NYS’s Medicaid Redesign Team, Linda Gibbs, Deputy Mayor of New York City for Health and Human Services and Michael Hogan, Commissioner of NYS’s Office of Mental Health. Members of the BHRWG include: Wendy Brennan, Executive Director, National Alliance on Mental Illness (NAMI)-NYC Metro; Pam Brier, President and CEO, Maimonides Medical Center; Alison Burke, Vice President, Regulatory and Professional Affairs, Greater New York Hospital Association; Lauri Cole, Executive Director, NYS Council for Community Behavioral Healthcare; Donna Colonna, Executive Director, Services for the Underserved; John Coppola, Executive Director, New York State Association of Alcoholism and Substance Abuse Providers; Betty Currier, Board Member, Friends of Recovery – New York; Philip Endress, Commissioner, Erie County Department of Mental Health, Arlene Gonzalez-Sanchez, Commissioner, New York State Office of Alcoholism and Substance Abuse Services; Kelly Hansen, Executive Director, New York State Conference of Local Mental Hygiene Directors; Ellen Healion, Executive Director, Hands Across Long Island; Tino Hernandez, President and CEO, Samaritan Village; Cindy Levernois, Senior Director, Behavioral Health and Workforce, Healthcare Association of New York State (HANYS); Ilene Margolin, Senior Vice President, Public Affairs and Communications, Emblem Health and Health Plan Association; Gail Nayowith, Executive Director, SCO Family of Services; Kathy Riddle, President, Outreach Development Corporation; Harvey Rosenthal, Executive Director, New York Association of Psychiatric Rehabilitation Services, Inc.(NYAPRS); Paul Samuels, Director and President, The Legal Action Center; Phil Saperia, Executive Director, The Coalition of Behavioral Health Agencies, Inc.; Sanjiv Shah, MD, Chief Medical Officer, Fidelis Care NY; Richard Sheola, Executive Vice President, Value Options; and Ann Sullivan, MD, Network Senior Vice President, Queens Hospital Network, NYC Health and Hospital Corporation.
Mental Health News salutes the efforts now underway in NYS and hopes that these guardians of our system of care get it right. Even in this climate of fiscal crisis, the bottom-line is that people’s lives are at stake—a reality that cannot be overlooked—no matter what the cost.
Your comments and suggestions are always welcomed at Mental Health News, write to: iraminot@mhnews.org.
Good luck in your recovery.
Have a wonderful Fall season!
