Advocacy must be unending, ongoing work because there is always more to accomplish and always the danger that hard-won gains may be undone. For the past 14 years I have either written or edited the work of guest columnists for the quarterly NYSPA Report in Behavioral Health News (BHN) or in Mental Health News as the publication was previously known. Mostly a labor of love, it nevertheless has meant a great deal of labor. Now retired, this column will be the last regular NYSPA Report for which I shall be responsible.
It has been my hope and that of NYSPA’s members that the Reports served to inform readers about a wide array issues confronting those with an interest the field. Columns over the years have addressed issues as diverse as NYS’s sexual offender law and its implication for the mental health system, the need for passage of Timothy’s law and the federal Parity law and how the complementary provisions benefit New Yorkers, the benefits of Electro Convulsive Therapy and why its continuing availability is important, controversies about prescribing psychotropic medications for children and youth, the opioid epidemic, and many, many others. BHN readers are drawn from an assortment of interested persons including family members of those suffering from mental illness and/ or substance use disorders (MH/SU), consumers/ patients, professionals, policy makers, and advocates. While their viewpoints may not always coincide, I believe that all stakeholders sincerely desire improvements in the delivery system through which care is provided and research advanced with the goal of improving the lives of those diagnosed MH/SU.
My final column is written at a fraught time for those concerned about the future for those with MH/SU. We worry about whether the gains achieved in recent years will survive the transition to a new administration which, although not antithetic to access to quality mental health services, does intend to undue many of the relevant statutory and regulatory gains of the Obama years and before. As advocates for sound mental health policy we know of areas which are in danger of suffering collateral damage as a consequence of Republican attacks directed at the Patient Protection and Affordable Care Act (PPACA) and its mandates along with their efforts to radically alter the way funds are distributed to Medicaid. Medicare too may become a target.
There is irony in what is likely to unfold. The PPACA required that essential health benefits, including those for MH/SU treatment, be explicitly defined and included in the plans sold. The ACA also expanded Medicaid coverage in states which opted to participate. Both of these vastly expanded Americans’ access to MH/SU care and that care was to be available on a nondiscriminatory “parity” basis with physical health care. The expansion of access to MH/SU services resulted in large measure from the requirement that such benefits, when covered, be provided at parity with physical health benefits because of the Mental Health Parity and Addictions Equity Act (federal Parity law) signed into law by President George W. Bush in 2008.
As I write this column, the 21st Century Cures Act has been signed into law; an important goal of it is the improvement of the nation’s mental health system. Many of its provisions, such as moving to improve the integration of mental health care within primary care services, train new behavioral care workers with a priority given to psychiatric residencies, establish a federal Coordinating Committee to study the effect federal programs related to serious mental illness have on public health as well as a policy laboratory to study and promote evidence-based practices and service delivery models to mention but a few are likely to be undercut by the repeal of the PPACA including its expansion of Medicaid, increased reliance on Health Savings Accounts (HSAs) and switching Medicaid to a block grant scheme. For the goals of the 21st Century Cures Act to be realized Americans must be insured! Given Republican’s antipathy to “mandates” and their assertion that individuals should be allowed to buy health coverage which best suits their needs, it is possible that plans entirely lacking MH/SU coverage will emerge on the market. Their stated goal of reshaping Medicaid into a block grant program is intended to hold federal expenditures flat. Mental health advocates must bear in mind that 60% of mental health services in the country are paid for by Medicaid and limiting its funds will have an adverse impact on access to as well as the scope of mental health services. The increased push for HSAs would be unlikely to benefit those with serious MH/SU given their low earning capacity and frequent inability to manage their budgets and lives.
Speaker Paul Ryan was recently quoted in The Milwaukee Journal saying that as a result of the transition from the ACA “no one (will be) worse off” than they currently are. That promise, while being viewed skeptically, should remain the Holy Grail of advocacy work in the years to come.
Recently rereading Albert Deutsch’s “The Mentally Ill in America” reminded me that the words used by concerned citizens, professional and lay, to critique the public system of care for persons with serious mental illness, especially the poor, has little changed since Colonial times. The system has always been described as broken and gaining support for funding needed for improvement has always been a fight. Nevertheless, we who know the history of the field and who have worked or been involved with it over recent decades know true gains in the lives of persons suffering with serious MH/SU have been achieved.
Unfortunately, progress does not always advance in a straight, unbroken line. The period we are entering may be one during which advocates will need to expend their energies sustaining achievements realized. The American Psychiatric Association and NYSPA can be counted on to remain steadfast actors in the struggle collaborating with other advocacy organizations whose missions align around improving the care available for and lives of those with serious mental illness and substance use disorders.