National Alliance on Mental Illness
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Grading the States 2006: Introduction - Common Trends
The state narratives can be read individually or as a compilation in which common themes emerge. It is not enough to say that a state receives a "D" or a "B" without having some context for the obstacles it faces or efforts it makes. Several themes are worth noting here.
State Budget Crises
Most states have cut spending. Some have frozen spending. Some have given modest or small increases to mental health services. In New Jersey, in the face of a $4 billion deficit, Acting Gov. Richard Codey provided a $40 million increase in mental health services and $200 million for a housing trust fund for people with special needs that will construct 10,000 units over 10 years. In 2005, former Gov. Mark Warner of Virginia proposed a $460 million investment in the state mental healthcare system out of a state budget surplus of $1 billion.
Budgets represent choices.
In many cases, the budget squeeze has been over Medicaid. Overall, the public sector pays for more than 50 percent of mental health services. Medicaid, in turn, pays for 50 percent of the services that the states administer. In human terms, that translates to approximately 5 million people.
Nationally, because of a range of barriers, less than one-third of adults with diagnosable mental illnesses receive treatment. Worry about cost is one reason. For people on Medicaid, approximately 60 percent also identify as a barrier "the inability to obtain an appointment soon enough because of an insufficient supply of services." For much of the discussion in this report, that one fact - whether it applies to inpatient hospital care or outpatient community services - is centrally relevant. The system does not reach most people who need help. Nor does it encourage them.
Today, states are moving to contain Medicaid costs. In Tennessee, the state dropped approximately 200,000 adults generally from Tenncare, and imposed restrictions on benefits for an additional 400,000. Other states, such as Florida, are imposing co-payments, limits on the number of prescriptions per month, restricted formularies, "fail first" policies and prior authorizations for medications.
Restrictions also represent choices. They are not mandatory. They are not predestined. They are choices made by governors and legislatures, often made without full appreciation of the nature of serious mental illnesses, psychiatric medications, or proven, cost-effective practices.
Cost-Shifting: Penny Wise, Pound Foolish
States have to make tough choices - but these have to be smart choices, too. Everyone benefits when people with mental illness are able to live productive lives. On the other hand, the long-run costs of Medicaid "reforms" often run higher than short-term savings. Costs are only shifted elsewhere.
Cuts shift costs to hospital emergency departments. Most of the states in this report are experiencing problems in emergency rooms. In a 2004 national survey, 60 percent of emergency physicians reported that an upsurge in people with mental illness seeking treatment in community emergency departments was negatively affecting patient care, causing longer wait times, and affecting everyone's access to lifesaving treatment. Two-thirds of responding physicians attributed the recent escalation to state healthcare budget cutbacks and the decreasing number of psychiatric beds for consumers in crisis.
Inadequate treatment leads to relapses. Relapses lead to hospitalizations. Medicaid "reforms" come with a price.
Inadequate treatment can also lead to jail or prison. Almost 20 percent of individuals incarcerated today in the corrections system have serious mental illnesses. "First responders" in times of psychiatric crisis often are police. In states such as Ohio, leaders in the criminal justice system are playing an important role in working with SMHAs or local communities to achieve reforms in the mental healthcare system. "Decriminalization" of mental illness involves police Crisis Intervention Teams (CITs), mental health courts and other jail diversion programs. But those innovations cannot work without the availability of community-based services.
Cost-shifting also is involved in the debate over state mental health insurance parity. About a dozen states, like Michigan, have not passed parity laws. Others have only limited versions. Failure to adopt such measures costs states money. These measures are important in helping to stem the flow of people with private insurance into the public system. Simply put, when middle class families lack mental health benefits under private insurance plans, they often are forced to spend down assets and enter the public system - or go without treatment. They end up in emergency rooms, hospitalized, or worse. Lack of parity comes with a price.
The Crisis of Capacity
"Deinstitutionalization," in which treatment began shifting out of state hospitals in the 1960s, was the result of better medications and a better understanding that the best outcomes for individuals with serious mental illnesses occurred when they remained "connected" to home communities. The failure of that transition was the result of a failure to invest adequately in community services.
Every mental health system requires carefully balanced levels of care. That continuum of care includes state hospitals, short-term acute inpatient and intermediate care facilities, crisis centers, and outpatient services like Assertive Community Treatment (ACT), supported housing, and independent living options.
When community services are not available, the entire system backs up. Long waiting lists reduce access. People languish in hospital beds because they can't be placed elsewhere, or can't be discharged because outpatient services aren't immediately available. Overcrowding and shortages arise. Closures, reductions, or conversions in private hospitals and other private facilities aggravate these problems in the public system.
In state after state, shortages are occurring. The problem is one of overall capacity, hinging on community services. In many cases, states are repeating the mistakes of the past - closing, consolidating, or reducing state hospitals before sufficient community services are in place.
Concern for outcomes - through proven, cost-effective treatment - should drive transformation of the mental healthcare system. The goal of treatment is shifting beyond prevention of further deterioration in a person's condition, and beyond maintenance, to the fullest possible level of recovery.
Evidence-based practices (EBPs) focus on outcomes. Adoption of EBPs varies widely among the states, within states and among providers. Many states are neither modernizing their systems of care, nor getting "the biggest bang for their buck." Gaps also exist in systematic collection of data to broaden the evidence base, especially by measuring outcomes relative to a range of factors. How well treatment works is often related to housing, income support, and employment-related activities in the community.
Information Accessibility and Participation
Agency transparency, information accessibility, and opportunities for consumer and family participation vary widely among the states. In a world where access to information is usually a prerequisite to care, a stunning result of our "Consumer and Family Test Drive" was the finding that 80 percent of all states did not score even half the total possible points on the survey. This indicates that SMHAs are not communicating basic information to their customers.
Today's crises occur at a time of transition. The goal of advancing both knowledge and recognition of a greater range of needs is shaping a new vision of a mental healthcare system, one that is flexible, adaptable, and better-suited to serve the people for whom it is intended. Themes of transformation therefore also are reflected in the state narratives, including discussions of recovery principles, consumer and family driven choices, cultural competence, the information age, workforce development, and the need for distinctly rural strategies. Transformation is not an easy challenge.
For an outline of a high-quality system as the standard for this report and future progress, please refer to the article following this introduction, "Standards for a Quality Mental Health System: A Vision of Recovery." It includes the following components:
Innovations and Urgent Needs
Each state narrative includes a list of "Innovations" being undertaken in the states. "Urgent needs" also are identified, based on NAMI's analysis.
One purpose of this report is to stimulate discussion of different ways that common issues can be addressed. There is much that states - and advocates - can learn from one another. Although the grades of the state systems are in most cases disappointing, NAMI takes encouragement from the level of creativity which many states are exhibiting in trying to address the challenges of the current environment. For example:
A longer list of "Innovations," compiled from the state narratives, can be read in the Innovations section.
We hope the report will provide a springboard for action by both advocates and policymakers. As the grade distribution in the report demonstrates, we still have a long way to go to achieve a "New Freedom" - based on recovery and individual dignity - for people living with serious mental illness.