MHW: BH Leaders Identify Opportunities, Challenges for Momentous 2019

Opportunities, Challenges for Field in 2019 Signal Busy Year

For our first issue of the year, we asked our readers for their thoughts on the challenges and opportunities awaiting the field in 2019. Here are some of the comments we received. Many thanks to all who responded.

Mental Health Weekly January 8-15, 2019

Joseph Rogers, executive director of the National Mental Health Consumers’ Self-Help Clearinghouse:

Our challenge is the continuing struggle between organizations that work to promote freedom, dignity and equality, and organizations that work to limit these essential commodities.

Our organization advocates for human rights, so the groups that use every excuse to curtail people’s rights make it tougher to do our work. One example is the Treatment Advocacy Center, which fights to limit freedom and equality for people with serious mental health challenges — and twists the truth to do so, as detailed in an article published by FAIR (“Mindless and Deadly,” May 1, 2001). Adding to the burden is the current administration, which is not supportive of human rights. That we are fighting an uphill battle makes our work even more necessary.

“Don’t waste any time mourning. Organize!”— the immortal words of labor organizer Joe Hill, falsely accused of murder and executed in 1915, in a telegram to activist Big Bill Haywood — is our call to action. We could be discouraged, but instead we are galvanized! We are working in coalition with such organizations as the National Coalition for Mental Health Recovery, and helping support the 2019 Alternatives conference, to make sure our voices are heard in the halls of Congress.

Debra L. Wentz, Ph.D., president and CEO of the New Jersey Association of Mental Health and Addictions Agencies Inc.:

Despite the many significant factors currently impacting New Jersey’s community-based behavioral health system of care — move to fee-for service (FFS), transition to managed care for specialty populations, inadequate rates and electronic records requirements, to name a few — the greatest issue in 2019 will be workforce shortages. The decades-old psychiatrist and nursing shortages become more challenging each year and are exacerbated by certain inadequate FFS rates. Now, staffing shortages extend to all clinicians, and direct care staff as well. The community-based system of care has always been at a disadvantage in recruiting and retaining staff since state departments, educational institutions and the private sector have significantly higher base salaries, and more generous benefit packages. Now, with retailers and other industries raising starting wages, and a minimum wage increase to $15 (by 2024) expected here, recruitment and retention of all staff is increasingly challenging. The impact of the workforce difficulties is magnified by the ever-increasing demand for services at a time when baby boomers are retiring in droves. While agencies and schools can work around the edges of the problem, it can only be fully addressed with significant state investments in the workforce. I will continue to fight for those investments every day.

Linda Rosenberg, president and CEO, National Council for Behavioral Health:

The National Council for Behavioral Health celebrates its 50th anniversary in 2019. To honor the past 50 years, we rededicate ourselves to our singular vision: healthy and safe communities. That means Americans must be able to get quality mental health and addictions treatment when and where they need it. Startling figures show average life expectancy in the United States dropped for the third straight year, driven by increasing overdose deaths and suicides. Lack of access has replaced stigma as the leading barrier to care.

Mental Health First Aid teaches Americans the signs and symptoms of mental and addictive disorders; now it’s up to us to ensure there is capacity. Building on the accomplishments of the past 50 years in science, inclusion and parity, we’ll continue to fight for the Excellence in Mental Health and Addiction Treatment Expansion Act. Extending the Certified Community Behavioral Health Clinic program will allow us to meet growing demand with high quality care. In 2019, we will celebrate those in recovery, but never forget the patients and families still suffering. Everyone must have the opportunity to recover.

Ron Manderscheid, Ph.D., executive director of the National Association of  County Behavioral Health and Developmental Disability Directors and the National Association for Rural Mental Health:

The recent Federal District Court decision in Texas v. Azar will rivet our attention in 2019. This decision invalidates the Affordable Care Act, but fortunately specifies no date for implementation of that decision. Already, Kentucky Attorney General Andy Beshear has initiated a case challenging the decision and has invited other states to join the suit. Kentucky would lose insurance coverage for 1.3 million people and $50 billion in insurance and subsidy payments if the decision stands.

Clearly, the national mental health and substance use care community must organize immediately with other components of the health field to fight the decision and to mobilize needed action in the House and Senate, and in our local communities.

Our twin field crises — opioid deaths and suicides — will demand much attention in 2019. At best, the rate of increase in these conditions is declining. Hence, we need to shore up key treatment systems and also to expand prevention and health promotion activities. In 2019, the linkage between mental illness and opioid addiction will receive much-needed attention.

Inappropriate incarcerations continue for persons with behavioral health and intellectual/developmental disability conditions. National prison and jail reforms may begin to address this problem. We must help to advance this agenda. On balance, 2019 will be a very busy and demanding year.

Paul Gionfriddo, president and CEO of Mental Health America:

With so much political uncertainty on the policy horizon in 2019, it is tempting to say that our greatest challenge as mental health advocate may be in holding onto the gains we made through the Affordable Care Act (ACA), Medicaid expansion, the 21st Century CURES Act, and the Mental Health Parity and Addiction Equity Act. But people concerned about behavioral health policy don’t have the option of just playing defense this coming year. Suicide rates are rising; integration of behavioral health into physical health, educational and workplace systems still has a long way to go; children’s mental health services are woefully inadequate; and we have an ongoing shortage of mental health professionals.

We need to commit to prevention, early intervention and services integration. If we want to improve prospects for recovery by implementing interventions before Stage 4 crises occur, then we need a 2019 agenda that makes mental health screening as ubiquitous as vision and hearing screening, beginning during childhood; improves special education services for children with mental health conditions; fixes rules like 42 CFR Part 2 that prevent effective services integration; promotes workplace mental health innovations; adds more peers to the behavioral health workforce; and stops using jails as custodial care institutions for people with mental health conditions.

Joel E. Miller, executive director and CEO of the American Mental Health Counselors Association:

We continue to see the most important program benefiting the behavioral health needs of all Americans go by the board one step at a time — namely, the dismantling of Obamacare through the courts or executive orders or U.S. Department of Health and Human Services regulations that try to diminish its impact. First, the passage of the ACA was a major milestone in our longstanding efforts to ensure access for all Americans to appropriate, high quality and affordable behavioral health care prevention and treatment services. Many of the prominent features (e.g., essential health benefits, Medicaid expansion) of the ACA were instrumental in establishing the centrality of behavioral health services within the overall U.S. health care delivery system. The key point — we are talking real money. The coverage expansions are real funding invested in advancing behavioral health — not demonstrations or long-term grants. We are talking real, major tangible increases in funding of behavioral health care since the ACA was implemented in 2013. So, let’s be sure we protect the ACA on many fronts.

Second, now we must begin to advance behavioral health and a new message that better behavioral health can transform lives and save money everywhere we can. We behavioral health leaders have allowed other health care stakeholders to frame pivotal debates concerning behavioral health care policy and programs. Beyond Obamacare (which should be improved), our overarching goal should be to secure the primacy of behavioral health, and through new messaging and positioning.

And we better become more aggressive right quick, as the other health care stakeholders have been positioning themselves to fight over the health care reimbursement pie, which will grow much more slowly.

We need to highlight that as much of an individual’s health status is tied to behavior and lifestyle choices, it makes sense that behavioral health providers — such as clinical mental health counselors —would be a much better resource and site to deliver care coordination and chronic and severe disease management than the prevailing model.

So mental health and substance abuse caregivers should be positioned as a key asset in the overall health care sphere! Decision-makers need to recognize this value proposition and position behavioral health within the larger health care landscape.

The behavioral health community should implement a major, collective marketing campaign that includes the importance of health behaviors, the prevalence of disabling behavioral health conditions and the superiority of treatment that is more efficacious than many common physical health treatments today.

If the critics of the ACA are hellbent on stripping away the key components of the law, we better be ready as a “behavioral health movement “to put our parochial ambitions aside, in order to make our case on the primacy of behavioral health under new legislative policies and programs for universal coverage that will be offered up in the 2020 presidential election cycle. That begins right now here in early 2019. People with behavioral health conditions are counting on us.

Brian Hepburn, director of the National Association of State Mental Health Program Directors:

The National Association of State Mental Health Program Directors (NASMHPD) looks forward to 2019 and will continue our emphasis on Beyond Beds, which focuses on building a robust continuum of care that looks beyond only inpatient care. NASMHPD has developed a key series of technical assistance working assessment papers addressing Beyond Beds, which can be found on the NASMHPD website at https://www.nasmhpd.org/content/tac-assessment-papers.

As part of this paper series, NASMHPD emphasizes the need to implement the core elements of crisis services found on www.CrisisNow.com, a resource website developed in partnership between NASMHPD and RI International. In alignment with this emphasis, we were pleased with the recent Centers for Medicare & Medicaid Services (CMS) State Medicaid Letter proposing a new §1115(a) waiver allowing short-term, acute-care inpatient stays in institutions of medical disease,” conditioned on states maintaining their efforts at providing community-based services, including outpatient crisis stabilization services.

NASMHPD will also continue to prioritize the significant effectiveness of Cognitive Therapy for Recovery (CT-R), which has been successfully piloted in six states through the Substance Abuse and Mental Health Services Administration (SAMHSA)–funded and NASMHPD administered Transformation Transfer Initiative. CT-R has been shown to help people who have been stuck in long inpatient stays to ultimately thrive in the community and will be one of the topics of the 2019 Beyond Beds papers.

We are also excited to be jointly working with the International Initiative for Mental Health Leadership (IIMHL) and SAMHSA to hold the 2019 IIMHL conference in September.

We look forward to working with Congress, the CMS and our advocacy allies across the behavioral health field in achieving these important goals in the coming year.

Kim Mills, spokesperson for the American Psychological Association:

The American Psychological Association (APA) will be expanding its advocacy efforts in 2019, working in a bipartisan fashion to protect and expand access to health insurance, address the opioid epidemic, reduce gun violence, increase federal funding for psychological research and graduate education, and ensure that migrant families remain intact and receive necessary health care while awaiting immigration proceedings. Defending the Affordable Care Act against legal challenges will remain a key priority as well.

The APA will continue promoting psychology’s role in such new technologies as artificial intelligence, self-driving vehicles and the internet of things. And the association will focus on the issue of deep poverty in America, looking at how psychology can help understand and address this vexing problem.

John Snooks, executive director of the Treatment Advocacy Center:

Created 20 years ago, the Treatment Advocacy Center remains steadfast in our mission: eliminating barriers to timely and effective psychiatric treatment for people with severe mental illnesses. Recent tragedies have only reaffirmed the need for us to remain focused, even as the dialogue on mental illness shifts toward our view, that failing to prioritize the needs of the most severely ill has dire consequences. The federal government and state legislatures have taken courageous steps toward reform, but until those legislative changes are embraced and implemented everywhere, the most pressing question will persist: How do we structure a treatment system to serve the most difficult to care for and vulnerable among us?

In the new year, the Treatment Advocacy Center will continue to fight for a system where people with severe mental illness are never locked out of care simply because they are too sick to seek it for themselves.

And we will remain vigilant in ensuring that promises made are promises kept — fighting to ensure that good laws are appropriately funded, stopping state laws from becoming barriers to treatment that force the severely ill into jails, emergency rooms, homelessness or suicide; and ending discrimination against people with psychiatric illnesses.

Harvey Rosenthal, CEO of the New York Association of Psychiatric Rehabilitation Services Inc.:

2019 will hopefully bring into action the full force of our combined efforts to aid Americans with the most advanced mental health and addiction-related conditions, but without the growing emphasis on forced hospital and community treatment in lieu of appropriate and adequate outreach, engagement and service efforts.

We now know how to engage and support individuals with even the most pernicious challenges to recover and to improve their health and lives free of avoidable tragic cycles of homelessness, incarceration, frequent re-hospitalizations and suicide.

We are seeing impressive evidence of our ability to do so when policymakers, payers and providers make available a full menu of coordinated and integrated service options across the continuum of treatment and rehabilitative approaches that assure access to peer support and that address the social determinants of health.

But these instances are the exception to the rule, and most Americans are denied the benefits of a fully functioning community service system. They do not have access to homeless outreach, housing first and a full continuum of supportive housing options. They are not offered walk-in psychiatric urgent care or mobile rehabilitation services or peer community engagement, peer bridger, crisis respite and community health worker services.

And they cannot maintain their hope, trust and participation in our services when hard-won relationships with staff are regularly compromised by our inability to pay and retain an adequate and appropriate workforce.

Yet, recent policy trends appear to be more focused on increasing hospital beds and outpatient commitment orders and potentially decreasing choice, right and privacy protections.

Instead, let’s come together in 2019 to raise the bar much higher for what people can achieve and policymakers and providers can and should offer.

One exciting trend: some states are exploring using Medicaid to fund a full range of housing, employment, and peer and family support programs. Let’s work with federal and state Medicaid programs this year to increase funding and access to the full continuum of community services and supports Americans with the most serious conditions need and deserve to recover.

Jennifer Mathis, director of policy and legal advocacy for the Bazelon Center for Mental Health Law:

The past year brought important victories in staving off legislative efforts that would have undermined rights under the Americans with Disabilities Act, gutted the Affordable Care Act and weakened the Medicaid program.

At the same time, however, actions were taken by administrative agencies that will make it harder for people to get needed mental health services. For example, new federal Medicaid regulations cut back on the Affordable Care Act’s protections, allowing the expansion of short-term limited-duration health plans that provide very limited benefits and threaten to undermine protections for people with pre-existing conditions. The Centers for Medicare & Medicaid Services also began approving waivers allowing state Medicaid programs to condition benefits on meeting work requirements without assuring that the services beneficiaries may need to work are available; thousands of individuals have lost health insurance as a result. The Department of Housing and Urban Development suspended rules that required fair housing planning processes to take into account the needs of people with disabilities, including those who need housing in order to transition out of institutions.

We do see opportunities in the coming year, including opportunities to expand competitive integrated employment opportunities through implementation of affirmative action requirements for employment of people with disabilities by federal agencies and federal contractors, as well as efforts to expand the availability of supported employment services for people with psychiatric disabilities. Promoting employment is a bipartisan issue, and there is solid potential to achieve gains in this area even during an era of divided government. We will also continue our litigation and policy work to expand the availability of community mental health services needed to support people with significant psychiatric disabilities to live, work and thrive in their own homes and communities; to enable children with mental health disabilities to succeed in school; and to reduce the needless incarceration of people with psychiatric disabilities.

David W. Covington, LPC, CEOand president of RI International and member of the Interdepartmental Serious Mental Illness Coordinating Committee:

As we begin 2019, the support for an individual in psychiatric crisis in most of the United States is abysmal.

In a recent American College of Emergency Physicians survey, one in five hospitals were currently holding someone in their emergency department more than five days. But there will be very significant and promising developments next year.

The Substance Abuse and Mental Health Services Administration and the Department of Veterans Affairs will report to the Federal Communications Commission on a possible 611 crisis hotline. Under the leadership of Assistant Secretary Elinore McCance-Katz, the Interdepartmental Serious Mental Illness Coordinating Committee will drive its Way Forward recommendations. The Department of Health and Human Services and Centers for Medicare & Medicaid Services will require an assessment of the crisis continuum, with specific attention to inpatient alternatives like crisis stabilization programs, for states that pursue the Medicaid Institutions for Mental Diseases waivers. And the National Association of State Mental Health Program Directors will host a crisis summit at the September International Initiative for Mental Health Leadership conference focused on the development of an international declaration and provide additional tools and supports at the http://www.CrisisNow.com website. Together, these initiatives promise very important first steps for ensuring an effective response to all in psychiatric emergency.