Our compelling case: Behavioral healthcare is a wise national investment

Some mental health practitioners already may have begun to chill the champagne in anticipation of a perceived liberal Democrat moving into the White House. But the simple fact is that no matter who is elected President in November, the mental health and addictions communities could be disappointed. Promises to increase healthcare access, lower costs, and improve quality may win votes, but as former presidential candidate Ross Perot once pointed out, “The devil is in the details.”

We've made tremendous progress. The public increasingly views freedom from mental illnesses and addictions as integral to general health, and with continued stakeholder pressure the next administration will include mental illnesses and addictions in any health benefit expansion. But the reality, pace, or shape of reform is uncertain. Equally uncertain is the likelihood of stakeholders sharing a common definition of healthcare reform.

Healthcare reform quickly is going the way of “recovery” and “transformation— evocative terms that everyone likes but few understand to mean the same thing. Recently reform discussions seem to have shifted from “healthcare” to “health.” “Health” appears to be synonymous with prevention and early intervention, while “healthcare” refers to the delivery system.

Mental illness prevention and early intervention are not entirely new. They were very much part of the original concept of community-based mental healthcare. We justified eliminating the funding for those services by labeling them as dollars wasted on the “worried well.” Prevention and early intervention remain critical issues—and the science about what works is far more robust—but I'm cynically beginning to think that the current focus on health rather than healthcare is in part due to no one wanting to tackle our messy healthcare delivery system. And messy it is.

Economics, politics, and history suggest that any major overhaul of our healthcare delivery system will be a difficult process at best. Now accounting for approximately 15% of GDP and projected to reach 22% by 2025, healthcare is bigger than the “military-industrial complex” about which we were warned in the 1950s, 1960s, and 1970s. And there's no sector of the economy with more politically powerful special interests involved than healthcare: the insurance industry, managed care, hospitals, doctors, pharmaceutical companies, medical equipment manufacturers, the research community, big business, Wall Street, small business, labor, state governments, local governments, seniors, patient advocates, and so many more.

Mental health is a part of a healthcare system that reflects the American belief in the marketplace, a healthcare system that talks universal coverage in a culture that hates taxes; a system that resists cost containment, promoting disease management, prevention, and medical homes as the newest cost-saving strategies; and a system that confuses strategies to improve the quality of care with strategies that save money. Mental healthcare shares the problems of the larger healthcare system and, like the rest of healthcare, suffers unintended consequences. We threw medicine out with the medical model; the result is that people with serious mental illnesses are dying far too young, and yet we're talking as if we've just discovered that mental health is fundamental to health. Like the rest of healthcare, we promoted decentralization and choice, and now we're faced with the same unintended consequence—fragmentation.

There is, however, one way that mental health has behaved differently during decades of ever-escalating healthcare costs. Richard G. Frank, a Harvard economist and co-author of Better But Not Well: Mental Health Policy in the United States Since 1950, uses data from the National Comorbidity Survey to make the case that more money is being spent on mental health. Yet mental healthcare's share of the GDP is constant, and its share of health spending is declining, while access, quality of care, and supports for people with mental illnesses have increased. Mental health has data that tell a compelling story of return on investment.

The new administration might or might not embrace the single-payer system Ezekiel Emanuel describes in Healthcare, Guaranteed: A Simple, Secure Solution for America or a mental health version of the prevention plans developed by the Trust for America's Health, but changes in healthcare are inevitable. When change is being debated in Congress, let's leave the reference to a system in shambles behind. Let's lead with data, with our history as good managers of public dollars, and with an actionable agenda. And like other stakeholders, I have a list of priorities.

We must champion a federal community mental health funding stream dedicated to mental health and integrated treatment services for the uninsured. The uninsured have exceptionally high rates of untreated mental illnesses with co-occurring addiction disorders, and there is no safety net. State general fund mental health dollars were reallocated to the Medicaid match. And now state plans to cover the uninsured are floundering. We have large numbers of individuals with treatable mental illnesses in our overburdened emergency rooms, in jails, and on the streets…and without access to the services that can engage them, treat them, and return them to work. We're denying our economy productive taxpayers. We're wasting human lives.

We need to be forceful advocates for a cost-based-plus-financing model based on salaries commensurate with the skilled staff necessary to implement effective interventions. People want and deserve high-quality services. Yet services depend on staff members' skills, and skilled staff must be adequately compensated. Low salaries have created—and are perpetuating—behavioral healthcare's recruitment and retention crisis. We are calling for increased skills and commitment but offering salaries far below those of any other professional industry. We need staff who can provide state-of-the-science behavioral health interventions, staff who can treat and triage general health disorders, and staff who can lead site-of-service performance improvements. The public increasingly accepts that mental illnesses and addictions are treatable disorders and that recovery is possible. Now we must be sure that the supply of skilled practitioners is adequate.

We need to create a pool of funds that supports investments by behavioral healthcare organizations in information technology. We talk information technology and service transparency, yet organizations that move forward to automate their clinical systems find little available support, funding, or technical assistance. A September 2006 National Council poll of community behavioral healthcare providers from across the country indicated that 8% had implemented an electronic health record system with clinical components fully functioning. Technology offers critical support to the service improvement process, promotes the application of protocols and guidelines, helps maintain contact with individuals who move through complex systems, and holds the promise to reduce the enormous financial burden of paperwork and reporting duplication—all efficiencies that improve service quality. The time has come to walk the technology talk.

We must have increased emphasis and greater funding for research-based education and prevention practices. We have prevention and education programs that work, such as research-based prevention programs that reduce the risk of childhood serious emotional disturbance by treating maternal depression and the Nurse-Family Partnership program, which has an array of consistent positive effects across multiple trials. And there are research-based education programs like Mental Health First Aid (introduced in the United States by the National Council) that increase mental health literacy. An Institute of Medicine report to be issued later this year is expected to underscore the importance of greater emphasis on prevention and health-promotion practices that can impede the onset or reduce the severity of mental health and substance-use disorders in children, youths, and young adults. This report will present an excellent opportunity to place prevention practices on the new administration's table. Let's not let opportunity pass us by.

Our national leaders are learning more and more about the economic and social costs of mental illnesses and addictions. It is up to us to build upon past success and work with the next administration to tackle what appear to be intractable problems. We can help those who are mentally ill and uninsured become productive members of their communities; we can ensure an effective workforce; we can benefit from the promise of technology; and we can secure a renewed commitment to and funding for research-based prevention practices. Regardless of who resides at 1600 Pennsylvania Avenue, we can help create a healthier America. Mental health is a good investment.

Linda Rosenberg, MSW, is President/CEO of the National Council for Community Behavioral Healthcare. To contact the author, e-mail lindar@thenationalcouncil.org.

Behavioral Healthcare 2008 September;28(9):26-28