Grading the States 2006: Maine - Narrative
Maine is a study in contradictions. On the one hand, the state has wisely invested in practices that are proven and cost-effective, such as Assertive Community Treatment (ACT) and supported employment. It has also been a leader in including mental health parity in its program to expand access to health insurance. However, budget cuts have contributed to significant gaps in services and poor outcomes. Additional cuts would reverse Maine's progress and devastate an already stretched system of mental healthcare.
Maine has taken several positive steps to improve its mental health services. Most importantly, it has invested in evidence-based practices (EBPs). It received a federal grant to expand use of these cost-effective services in the state. Both the Department of Corrections and the Department of Mental Health are focused on EBPs and are moving the Medicaid system to reimburse these services. The state has seven ACT teams, 24 supported employment programs, three Family Psychoeducation programs, and 59 programs for integrated mental illness and substance abuse treatment. The state has alsodeveloped a Peer Recovery Specialist training program.
Maine has also been a leader in the fight for insurance parity, passing one of the first state parity laws. Governor Baldacci deserves credit for including full parity in Dirigo Health, his signature program to provide health insurance to the uninsured. Many states have been shortsighted in limiting or excluding mental health care in their efforts to expand eligibility for insurance. The governor's recognition that true health insurance must include mental as well as physical healthcare should be a model for other states. Baldacci has also positioned Maine to be the first state to provide wrap-aroundservices for the Mainers who were dual eligible for Medicare as part of the Medicare Part D rollout.
Maine has worked to reduce involvement of individuals with mental illness in the criminal justice system, which is a significant problem in the state. The Department of Behavioral and Developmental Services has developed a joint action plan with the Department of Corrections, and they have begun implementation. The state also has 11 jail diversion programs.
Despite these examples of progress, significant problems remain. Funding for mental health services has declined. Most recently, the legislature proposed slashing $26 million from the adult and children's community mental health services. At the same time, individuals with serious mental illness in Maine are experiencing long waitlists for community services, crowded emergency rooms, involvement with the criminal justice system, and a shortage of state hospital beds, with hospitals turning away, in the first four months of 2005, 57 percent of those eligible for admission. This is a significant increase over 2004's average of 46 percent of those seeking admission.
The state mental health and Medicaid agencies are working on a transition from a cost-based, fee-for-service model to a behavioral, managed care design. It remains to be seen whether the new system for managed care can lead to cost savings without compromising quality. Significant concerns exist as to the quality of the planning and the timeline for implementation of this significant change. Advocates fear an undue emphasis on cost containment in the state in response to a study by the Muskie Institute claiming that behavioral health costs are rising much more rapidly than other healthcare costs. Although the methodology has been criticized, the report has been used by some policymakers to support cutting funds.
Budget cuts could also jeopardize the state's ability to meet its legal obligations. The Maine mental health system continues to operate under a 1990 consent decree to address deficiencies in the care of current and future patients at Augusta Mental Health Institute (AMHI). AMHI has been replaced by a new facility, but the case continues because the judge found that the state was not meeting class members' needs for community, emergency, and hospital services. The court master and others have expressed concern about the impact of managed care on the mental health system.
Maine has been a leader in both parity and employing evidence-based practices. But the state still falls short in providing an adequate mental health system. If the implementation of managed care focuses on cost cutting, the situation will get worse. For progress to continue, Maine must build upon its strengths, develop a consistent vision and the political will necessary to stop the budget cutting, and focus on filling the existing gaps in services.
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