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Seven governing realities of mental health policy
A subtle shift has occurred during the 17 years that this column has appeared. In the 1990s, leading Washington-based representatives of the behavioral health community confidently lectured members of the press on their strategy to advance their objectives on Capitol Hill. Those strategies changed over time, as objectives changed from ensuring a role for behavioral health in President Clinton's comprehensive healthcare financing plan to convincing a newly elected Republican congressional majority of the cost-effectiveness of mental health spending. At that time the people who lobbied for mental healthcare and substance abuse treatment felt that they understood the game and how to win it.
This is no longer true. Policy advocates for behavioral healthcare at the midpoint of George W. Bush's presidency generally appear grumpy and cynical. Behavioral healthcare scores occasional victories on Capitol Hill and in the courts, but these occur (literally) on a case-by-case basis. As a result, supporters of greater access to affordable, quality behavioral healthcare privately look toward a major electoral revolution in Washington as the best hope for substantive progress.
Advocates for changes in the behavioral healthcare system are running against barriers imposed by long-term realities governing U.S. mental health policy. Regardless of who is in power in the White House, Congress, and state legislatures across the country, laws and policies affecting mental healthcare are strongly influenced by beliefs and principles inherent in our society.
Recently, I invited several longtime students of behavioral healthcare policy initiatives to join in developing a short list of these governing realities of behavioral healthcare policy. There was surprisingly little dissension in this task, except for the question of how the stigma of mental illness affects policy making. Leaving aside that one debatable point, the following represents a consensus on the seven most important principles driving government action (and inaction) in the mental health field.
It's all about the money. Ten years ago, a keynote speaker entertained the Washington meeting of a professional association by proclaiming that he had finally discovered exactly what the American people wanted from national healthcare policy: “universal access to comprehensive, high-quality prevention and treatment services… paid for by Germany.” The joke's punch line rests on the simple truth that all healthcare issues really focus on how much quality costs and who should pay for it.
This is hardly new. When Massachusetts and Virginia were still colonies of British North America, their legislatures debated whether the cost of care for the mentally ill should rest with the entire colony or with local parishes. The debate continues today because there is no consensus on what part of government should bear the primary cost of mental health services. Even the idea that Washington should share responsibility for paying for mental healthcare for other Americans is barely 50 years old and is still not universally accepted. Well into the 20th century, the national government had financial responsibility for mental healthcare only for a small number of wards of the state: armed forces personnel, veterans, residents of Native American reservations and overseas territories, and residents of the District of Columbia.
The question of who should pay for quality care might be easier to answer if there were a clear measure of the size of the bill. Behavioral health advocates in Washington are quick to dispel the widespread image of lifelong weekly psychotherapy for millions of prospective patients, but they cannot define a plausible cost for effective care for everyone in need. We know that current spending on treatment and outreach fails to reach a large percentage of the population who could benefit from behavioral healthcare, but we don't know how much more those patients would cost. We also don't know how much society overall would benefit from paying for care and prevention services for an additional two, four, or ten million Americans. For this reason, every government appropriation for mental health services will probably fall short of someone's definition of adequate effort.
Because government doesn't try to meet the mental health needs of all residents, the real policy question tends to center on the choices that must be made in spending. Do we pay for the greatest good for the greatest number of people, even if it means skimping on quality? Do we pay for care for those with the greatest need, such as people with severely disabling conditions, at the cost of providing benefits to people who have a greater likelihood of maintaining recovery from mental illness? Do we focus government efforts on populations who have the greatest claim on government largesse, such as incarcerated prisoners, war veterans, first responders to natural disasters, and the poor and helpless? Or do we concentrate national government spending on support for scientific and medical research? There is little likelihood that the behavioral health field can hammer out a compromise to present to elected officials. And, in the absence of a compromise, elected officials will continue to make decisions on behavioral healthcare financing that will leave most of our field unsatisfied.
Mental health and mental illness are not major priorities for most elected officials. During the 1960s, a series of newspaper and documentary film exposés brought widespread public and political attention to conditions in underfunded state mental hospitals. This was not the first time that humane treatment of the mentally ill became a major priority for government; a similar campaign led by patient-activist Dorothea Dix galvanized reform in state-funded care in the 1840s and 1850s. Between these peaks of activity, however, mental healthcare was not a significant issue in most state legislatures.
We seem to be in another period of limited public interest in the needs of patients with mental health disorders. No survey has found the public listing mental health as one of the top 10 issues facing government today. A far more potent policy topic is the need of society to be protected from random crime and violence. Lurid press reports and depictions of crime in fiction help to fuel widespread fear of random homicidal attacks by deranged strangers, despite the fact that the majority of attempted murders are committed by acquaintances and family members. During the past ten years, most public-sector mental health promotion initiatives have been targeted at preventing crime and violence, or reducing homelessness. Involuntary commitment of criminal offenders convicted of a variety of crimes also has enjoyed some increase in popularity. The possibility that such initiatives may help someone is treated as a pleasant bonus, but rarely is seen as a central goal.
Mental illness becomes a major priority when it's a personal concern. The period of intense publicity on the plight of hospitalized patients diagnosed with mental illness occurred during the presidency of John F. Kennedy. Not surprisingly, Kennedy was the most active innovator of all presidents in the field of mental health. He also was the only recent president with a close family member who is known to have been a victim of ineffective mental healthcare. Rose Marie Kennedy, President Kennedy's younger sister, underwent a lobotomy at age 23, allegedly after displaying increasingly erratic behavior. Before the operation, “Rosie” Kennedy kept a diary and was a guest at both the White House and Buckingham Palace; after the lobotomy, she remained inarticulate and incapacitated until her death in 2005. The numerous elected officials in the Kennedy family have referred to Rose Marie's tragedy in discussing their strong support for mental health causes.
Harold Everett Hughes, elected governor of Iowa in 1962 and to the U.S. Senate in 1968, provides an even more dramatic illustration of personal experience influencing a politician's support for behavioral health. During his single term in the Senate, he successfully pushed for the creation of the National Institute on Alcohol Abuse and Alcoholism and a package of other precedent-setting measures addressing alcohol addiction, known collectively as the Hughes Act. Hughes acknowledged before retiring from politics in 1974 that he was in recovery from alcoholic blackouts and alcohol dependence.
The Mental Health Parity Act of 1996 presents a remarkable case of the extent to which behavioral health initiatives depend on politicians with intimate knowledge of the problems. The bipartisan coalition which successfully pushed the legislation included Sens. Pete Domenici (R-N.Mex.), the late Paul Wellstone (D-Minn.), Ted Kennedy (D-Mass.), and Alan Simpson (R-Wyo.). All four had children, siblings, or parents with severe mental illness. “There has been a personal, crystallizing experience in each of our lives,” Wellstone admitted. “You almost wish it didn't have to work that way, that all of us would care deeply anyway about people who were vulnerable and not getting the care they need. But this kind of thing happens a lot in politics for fully human reasons.” As this issue was going to press, Sens. Domenici and Kennedy, along with Sens. Gordon H. Smith (R-Ore.) and Tom Harkin (D-Iowa), announced the establishment of the Senate Caucus on Mental Health Reform. Smith also has a personal connection with mental health issues; his son committed suicide after struggling with bipolar disorder.
Most voters are willing to support high-quality care for the mentally ill—as long as it doesn't interfere with something else they want. Surveys and referenda repeatedly find that Americans generally want to spend tax money to care for—or at least shelter—individuals with mental health problems. California's Proposition 63 in 2004, for example, was enacted by a 54.5% majority in a ballot referendum and will provide at least $800 million in support for mental healthcare. The victory of Proposition 63 has been extolled by A. Kathryn Power, director of SAMHSA's Center for Mental Health Services, as evidence that the administration's hope for “transformation” of the mental health system (through state, local, and private funds) enjoys widespread popular support.
Before advocates get too excited about Proposition 63, however, two points should be remembered. First, surveys conducted by mental health advocates two years in advance of Proposition 63 reported that nearly 75% of the voters wanted to provide comprehensive services to residents with disabling mental health services. When confronted with the prospect of choosing to spend real state tax money on prevention, screening, and treatment of behavioral health disorders, nearly one-third of these supportive voters disappeared. Second, Proposition 63 is unusual because it is funded by a 1% “supertax” on residents with personal income more than $1 million. In effect, most voters who endorsed the measure knew that they wouldn't have to pay for it.
The real lesson of Proposition 63 is that Americans are widely supportive of some types of publicly financed mental healthcare in the abstract, but are more reluctant to endorse an expansion of services that might come out of their pocket or the budget for other state and local services.
In the United States, healthcare is a commodity in which consumer choice allegedly determines quality and quantity. Advocates for fair and equitable access to mental healthcare continually promote the objective of “eliminating disparities” in care. This sounds like a noble cause especially if the implication is that the disparities are caused by racism, gender discrimination, or even the inability of the poor and uninsured to obtain quality services. For that reason, “elimination of disparities” is included in the description of much of the health-related legislation introduced in Congress.
Unfortunately, one fundamental principle of healthcare in the United States runs counter to the objective of eliminating disparities. Healthcare is a commodity, offered competitively to consumers and private payers. It is not, primarily, viewed as a community service. Licensing and credentialing create a “floor” of quality, but both the public and healthcare providers operate on the premise that consumers should pay more for “the best” services. In other words, disparity in quality is viewed as a rationale for the consumer to invest more money to obtain the services of the most prestigious and best-qualified clinicians in the most comfortable and up-to-date facilities. Many of the quality improvement measures offered by the government and the mental health professions are targeted at raising the quality floor rather than the probably unobtainable and possibly undesirable goal of eliminating disparities resulting from consumer choices.
Politicians view scientific evidence as merely one version of “truth.” The quality issue also invokes the growing demand for evidence-based practices as a measure of the appropriateness of public-sector investment in behavioral healthcare. At first glance, this sounds as if scientific evidence is emerging as the basis for policy decisions in mental health and substance abuse. A session at this past year's annual meeting of the American Public Health Association (entitled “Evidence in the Policy Process: Whose Evidence Is Used, Why and How?”) provided extensive support for an opposing view. The speakers, including Dr. Michael Silverstein of the University of Washington and Dr. David Michaels of George Washington University, offered several detailed case studies in which scientific findings were treated in the policy process as simply one of many competing perspectives.
The role of science in public-sector decisions is a sensitive area for me because I am intimately involved with the development of standards for evidence-based practices in behavioral health policy. Too frequently, I have encountered public officials insisting on policy statements that contradict the available scientific evidence. One agency, for example, confronted with years of studies demonstrating that a specific behavioral health practice had no measurable effect on its recipients, continued to demand that reports of the practice describe it as “not yet proven effective.” The description allowed the agency to salvage its previous endorsement of the practice while implying that all of the research to date was inconclusive or inept.
Government officials should not be blamed too harshly for this practice. Scientific research generally is a slow process, and its findings often are phrased cautiously to permit the possibility of future reevaluation. In contrast, government is expected to provide quick solutions to current problems. When the snaillike pace of research finally catches up with the rapid pace of publicly supported action, officials are faced with the dilemma of admitting that they backed the wrong approach or casting doubt on the validity of the scientific evidence. The latter is usually the safer alternative.
Stigma is a larger constraint on advocacy than it is on politicians. Students of mental health policy do not agree on the exact role of the stigma of mental illness in the policy process. Some argued that stigma explains a large amount of the underfunding, rationing, and unfair reimbursement rates in public-sector behavioral healthcare. Others point out that most public-sector healthcare is underfunded, severely rationed, and burdened with provider reimbursement rates that fall far short of market prices.
One aspect of stigma is not controversial: Stigma acts as a potent barrier to becoming an advocate for behavioral health policy. We have come a long way since the 1970s, when Hughes had to choose between disclosing his alcohol dependence and running for reelection, and Sen. Thomas Eagleton was dumped from the Democratic presidential ticket after admitting to past treatment for depression. Nevertheless, many people who have a personal stake in mental healthcare policy continue to be dissuaded from active advocacy because of the stigma associated with mental and behavioral health disorders. Survivors of cancer, heart disease, and other conditions can demand attention without fear that they will suffer for recovering from “their” disease. Survivors of mental illnesses, emotional disorders, and substance abuse know that some people will treat them with suspicion, fear, and contempt when they relate policy choices to their personal experience.
Until that changes, the other six realities will continue to dominate mental health policy.
