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Elections 2004 and Mental Health Policy

Whatever the outcome of the 2004 presidential election, President W. Bush or Senator John F. Kerry will face massive budget deficits next year, ABC News anchor George Stephanapoulos told NAMI’s 25th annual convention.

Declining federal resources will continue to squeeze state budgets -- with implications for mental health policy. In 2003, President Bush’s New Freedom Commission on Mental Health reported that the nation’s fragmented mental health care system is “a system in shambles.”

Medicaid in particular is in crisis. It is the second largest, fastest growing part of state budgets -- a total of almost $250 billion in 2002. But states are under pressure to cut budget cuts across the board, which often leads to pressure to cut Medicaid costs and in turn cutting services or even transforming systems.

On Friday, September 10, Ohio Commissioner of Mental Health Michael Hogan, Ph.D., who served as chairman of the New Freedom Commission, and others, spoke to a packed room at the NAMI convention on Medicaid financing challenges.

Diane Rowland, Sc.D., Executive Vice-President of the Kaiser Family Foundation and Executive Director of the Kaiser Commission on Medicaid on the Uninsured noted that as part of the nation’s public health system, Medicaid serves 50 million people, approximately 6.5 million or 13% of whom receive mental health services. Within that population, 36% are people with disabilities, 32% are children and 29% are non-disabled adults. Overall, Medicaid covers 38 million people in low-income families and one in five children nationwide.

Cutting mental health costs usually means:

  • Closing or shrinking inpatient facilities
  • Restricting access to newer, more effective medicines
  • Narrowing silos of care
  • Short-term choices that shift costs to businesses, schools, emergency rooms, or the criminal justice system.
  • On the plus side -- movement toward the most effective, evidence-based clinical practices.

Fiscal pressures are not the result of the recent recession. They run deeper and are structural in nature: having been built over 25 years. NAMI is non-partisan and mental illnesses recognize no political boundaries. They affect Republicans and Democrats alike.

In addressing needs of people with mental illnesses and their families, regardless of party, NAMI members and candidates must be prepared to confront tax and budget issues at every level of government.

"People say there are hard choices," said one NAMI member in Friday’s session, "but what’s important is making right choices. We don’t need elected officials who say they understand and then vote the other way."

NAMI Executive Director Michael J. Fitzpatrick expressed a similar sentiment at the September 9th opening session of the convention, advising approximately 3,000 members:

"Listen hard at this convention. Then go home and listen hard to every federal, state and local candidate. It’s going to be another close election. No matter what your registration --- Democrat, Republican, or Independent -- this year pledge to be a swing voter. Suspend your usual allegiances. Don’t let anyone take you for granted. Tell every candidate that and draw a line in the sand."

On Friday’s panel, the Kaiser Foundation’s Rowland emphasized:

  • Medicaid is critical for the provision of mental health services to low-income Americans.
  • Much of the coverage and many of the services provide by Medicare to people with mental illnesses are unavailable from any other source.
  • Medicaid restructuring must include safeguards for those who use mental health services, particularly those who are disabled.

Leslie Tremaine, Ed.D., behavioral health manager for New Mexico’s Department of Human Services outlined one model for system transformation: an interagency behavioral health purchasing collaborative intended to focus on recovery and resiliency as specific goals and outcomes -- while also achieving better program access, services and use of taxpayer dollars.

The New Mexico initiative reflects the importance of political leadership and both the power and limits of structural changes. Perhaps even more important, its lessons thus far include: "System improvement is a process, not an event"; "It can’t be done overnight"; and "You can’t have change without changing."

That perspective is especially important in looking not only at Election 2004, but also the legislative sessions that will follow, and other elections beyond. Transforming the mental health care system must start now -- and will only happen by drawing strong lines in the sand with candidates, regardless of past allegiances. But the task will not be finished in November. Hard challenges lie ahead.

View more 2004 Convention coverage.