Looking Back to See Forward: Our Salute to President John Kennedy on the 50th Anniversary of the Community Mental Health Act

Two behavioral health bookends define the past half century. They are President John Kennedy’s Community Mental Health Act of 1963 (CMHA) and President Barack Obama’s Affordable Care Act of 2010 (ACA). These two Acts are very similar in key respects: badly needed when enacted; basically beneficial for behavioral health; broadly promising for the future. Yet, these two monumental Acts also occurred in very different eras. The early 1960s were a period of exceptional growth and promise: people believed that everything was getting better! By contrast, the early 2010s are a period of much doubt and cut back: many people are fearful of the future! Because of these similarities and differences, we must learn from our 50-year response to the CMHA in order to help us plan effectively for the coming ACA era.

Clearly, the past half-century has been very uneven terrain for those directing mental health and substance use services, especially county directors of these programs, who are on the front lines of care. We have gone from soaring heights to sinking depths several times during the 50 year period between 1963 and 2013. The peaks include the CMHA, passage of the Mental Health Systems Act of 1980, President Clinton’s efforts to pass the Health Security Act in 1993; the Surgeon General’s first-ever Report on Mental Health in 1999; the President’s New Freedom Commission on Mental Health in 2003; and the remarkable growth of the consumer movement, which has brought us the crystal clear promise of recovery.

Arguably, the valleys include obvious failures of deinstitutionalization in the 1970s and 1980s, which resulted in many adult mentally ill persons becoming homeless or incarcerated; the repeal of the Mental Health Systems Act in 1981, which delayed by a quarter century our organized response for adults with serious mental illness; elimination of substance use as a source of disability for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) in 1998, which resulted in considerable pent-up demand for substance use services;  and much angst over organizational and provider reimbursement, as states instituted managed care, and as budgets tightened in the 2000s,  especially after 2008, with the onset of the Great Recession.

What have we learned from all of these ups and downs? Here, I will cite several different things that strike me as very important learnings for the future. These items are suggestive rather than exhaustive. You may want to think about this issue and add your own items to my list.

• Lack of health insurance is a huge, perhaps insurmountable barrier to effective care. Lack of health insurance forces any care to occur in the “cracks of the system”, in emergency rooms, in jails, or literally through self-medication. Because of a lack of health insurance, today, up to half of those with mental illness and about 90% of those with substance use issues receive no care whatsoever.
• A majority of persons with mental health and substance use conditions have these conditions as a result of trauma. Such traumas can range from child abuse, to the physical, sexual, and psychological abuse associated with poverty, to the mental and physical trauma of the battlefield. Trauma is extremely pervasive in modern American society, and it plays a major role in generating illnesses.
• “Handing people off” from provider to provider simply doesn’t work. The failures of treat-refer systems can be seen in the 25 years of life lost by the adults cared for in our public mental health and substance use delivery systems. Most of these people never receive the primary care that they critically need. Clearly, this dire situation should be unacceptable to all of us.
• Health care services, alone, will not lead to good care outcomes. Many health care recipients also need support services, including job, housing, and social supports. 
• Recovery and wellness are required for a full life in the community. The process of recovering can lead to states of wellness that actually make life possible in the community. Thus, recovery and wellness must be part of our core mission.

Much as the 1963 CMHA, the 2010 ACA offers us a once-in-ever opportunity to “reset” and to change direction in order to address these fundamental learnings. With no exaggeration, the ACA will produce a dramatic change in how we do health care in the United States. President Barack Obama’s ACA is on a par with President Franklin Roosevelt’s creation of Social Security in 1935 and President Lyndon Johnson’s creation of Medicare and Medicaid in 1964.

Three key features of the ACA are directly relevant to our mission going forward. These are health insurance reform, coverage reform, and service quality reform. Here, I just wish to show how they are relevant to our learnings  and our mission. I encourage you to immerse yourself directly in each of these reforms.

• Health Insurance Reform. Through the state Health Insurance Marketplaces and the optional state Medicaid Expansions, a wonderful opportunity exists to enroll about 39 million people in health insurance, many for the very first time. We estimate that as many as 11 million of these persons have a prior mental health or substance use condition. With appropriate health insurance coverage and parity in behavioral health benefits, better care will become possible for these Americans. Enrollment began just a few short days ago, on October 1. How are you planning to participate in this major enrollment initiative?
• Coverage Reform. Unlike the past, where health insurance only covered “sick-care” services, the ACA recognizes that it is vitally important to address the social and physical determinants of health, such as reducing trauma, and to introduce population and personal health promotion and disease prevention interventions. These actions can reduce the prevalence of downstream illnesses. Funds have been set aside for prevention interventions directed at populations, and health insurance benefits have been adjusted to accommodate personal prevention interventions. Since much of personal prevention, such as smoking and obesity reduction, reducing the impact of trauma, etc., is rooted in behavioral health, coverage reform represents a very distinct opportunity for our field. How are you planning to adapt your programs to incorporate personal and community prevention interventions that promote resiliency?
• Service Quality Reform.  Reforming the quality of health care services has two distinct components in the ACA. First, a major effort will be undertaken to promote person-centered care and whole health care through the creation of Health Homes which will integrate primary, mental health, and substance use care. Some of these Health Homes will operate out of the primary care sector; some, out of the specialty behavioral health sector. Second, financing arrangements and performance assessments will become adapted to these Health Homes. Financing arrangements will move away from fee-for-service and toward case or capitation rates. Performance assessments will move toward personal evaluations of wellness and health-related quality of life, both of which are of great importance in a context that will emphasize resiliency and recovery. How are you planning to participate in a Health Home?

Thus, these major ACA reforms do fit very well with our learnings from the past half century. In fact, the ACA promotes our core agenda remarkably well. I am sure that President Kennedy would be quite proud of the progress that we have made in the last 50 years, and he would encourage us to undertake the ACA with great “vigor”.  I can see him smiling in the distance right now!