The Special Challenges of Mental Health Care Reform
by Richard J. Bonnie ’69
One in four adults in the United States experiences a diagnosable mental disorder in a given year, and about 6% have serious, chronic mental illnesses, such as bipolar illness or schizophrenia. One in ten children has a serious emotional disorder. When these conditions are untreated or inadequately treated, they exact huge social costs in emergency interventions, hospitalization, social services; distressingly, large numbers of people with acute mental illness are being caught up in the criminal justice system. The stresses of coping with the symptoms of these disorders cause tremendous suffering not only for the troubled individuals but also for their families and communities. Use of alcohol or other drugs can exacerbate the symptoms of mental illness and this can increase the risk of violence (even though people with mental illness are not otherwise significantly more likely to be violent than other people).
One government commission after another has urged states and localities to establish a stable infrastructure for providing services and supports to help people with serious mental illness cope with and recover from their conditions and to ameliorate the effects of crises when they arise. Unfortunately, however, many states and localities have not created or adequately funded this safety net of mental health services. Epidemiological studies show that at any given time, only half of the people who need treatment services for serious mental illness are receiving them. Virginia’s Commission on Mental Health Law Reform found that 40% of the people evaluated for mental health emergencies in June 2007 were uninsured. This number is probably higher now.
Poor access to mental health services is especially troubling for young adults exposed to the stresses of schooling, financial need, unemployment, military deployment and re-entry, and parenting. Many are especially susceptible to acute disorder due to underlying vulnerabilities and substance abuse, which peaks in prevalence at this age. The problems being faced by veterans of the wars in Iraq and Afghanistan have received attention in the media, but many aspects of the problem have been overlooked. To take one highly pertinent example, young adult students in the nation’s community colleges are more likely to be uninsured or underinsured than their peers in the workplace or in four-year colleges, which means they are less likely to be receiving mental health treatment, even though their need for these services may be comparatively higher than it is among their peers. Although no one can know for sure, greater mental health counseling capacity at the Pima Community College or better linkages between the college and the county’s mental health services agency might have increased the likelihood that Jared Loughner would have been referred for and received the services he needed before the tragic shootings in Tucson on January 8.Unfortunately, the already tattered safety net of public mental health services (typically funded by state general fund dollars) is fraying even more in the aftermath of the recent recession. With the disappearance of federal stimulus money, states have cut more than two billion dollars from their mental health budgets over the last two years. More than one-quarter of the states have cut their mental health budgets by at least ten percent. Meanwhile, as Medicaid enrollment and Medicaid costs continue to rise, state after state is curtailing projected Medicaid expenditures as well as direct state funding for public mental health services. Already lengthy waiting lists are growing longer. Housing and community support services for chronically ill patients are also scarce. All of this inevitably increases the pressure on the emergency services system, hospitals and jails -- and heightens the risk of tragedy.
All of us, collectively, pay the price for untreated mental illness. About this, there can be no doubt. A stronger, more effective system for delivering mental health services to people who lack adequate insurance is sorely needed.
How might the Patient Protection and Affordable Care Act (ACA) affect this bleak picture? For one thing, Congress has required insurance companies to cover mental illness and substance abuse disorders on the same terms as medical conditions. That “parity” law went into effect in 2010, and began to address the problem of “underinsurance” for mental illness even among families with health insurance. The ACA extends the parity requirement to the subsidized insurance plans that will be sold on state-run exchanges beginning in 2014. This could make a huge difference, as will the expansion of Medicaid to cover people who are poor but able to work. The number of people needing mental health treatment who are uninsured should decrease markedly. However, many people, including undocumented immigrants, will still be uninsured after these changes go into effect, and many people with chronic mental illness need support services that are not covered by health insurance (although many of them are covered by Medicaid). Thus, a strong publicly funded safety net for crisis intervention services and outpatient mental health services and supports will still be needed even after the ACA is fully implemented.
Unless it is repealed or substantially modified, the ACA is likely to increase access to care for people with mental illness. However, to achieve a major increase in treatment utilization (and in public health), non-financial barriers to treatment participation must also be removed, including the stigma and discomfort that deter people in need of services from seeking them while making family members and friends fearful and reluctant to intervene. Much can be learned from the efforts that have been undertaken by numerous grassroots organizations to promote public education and outreach on the nation’s residential campuses since the Virginia Tech tragedy in April 2007. In addition, desired treatment outcomes are now impeded by a fragmented delivery system that segregates medical care from mental health care.
In sum, the ACA takes an important step forward in increasing access to mental health care, but increased treatment participation and better outcomes will require a transformation of the delivery system to bring mental health care within the mainstream of an integrated, patient-centered system of care.
Richard J. Bonnie ’69 is Harrison Foundation Professor of Law and Medicine, Professor of Psychiatry and Neurobehavioral Sciences, Professor of Public Policy and Director of the Institute of Law, Psychiatry and Public Policy at the University of Virginia. Since 2006, he has served as Chair of Virginia’s Commission on Mental Health Law Reform.