House Passes H.R. 4365, President Clinton
At yesterday's NAMI and APA (American Psychiatric Association) luncheon marking the upcoming Mental Illness Awareness Week, featured speaker Senator Pete Domenici (R-NM), accompanied by his wife Nancy Domenici, a strong advocate for people with mental illness, commented on the passage of H.R. 4365. Senator Domenici, whose Congressional leadership resulted in many positive provisions for people with severe mental illnesses and their families being included in H.R. 4365, emphasized the importance of the following initiatives: teacher and emergency personnel training, emergency services that include mobile crisis teams, jail diversion, integrated treatment for co-occurring disorders, suicide prevention, and coordination of child welfare and mental health services.
The previous two NAMI E-News summarized the creation of a national restraint standard and provisions addressing integrated treatment for persons with co-occurring disorders in the legislation. This E-News will report on the issue of block grant accountability in the SAMHSA reauthorization section of the bill and summarize a number of key provisions contained in the Mental Health Early Intervention, Treatment and Prevention Act (S. 2639/H.R. 5091) that were added to H.R. 4365. S 2639 and HR 5091 were introduced earlier this year by Senators Pete Domenici (R-NM) and Edward M. Kennedy (D-MA) and Representatives Ted Strickland (D-OH) and Heather Wilson (R-NM). Among these are new authorizations for SAMHSA programs on jail diversion, emergency mental health services (including mobile crisis teams), suicide prevention and mental illness screening for at-risk children. This E-News will also summarize important provisions contained in the legislation on numerous special grant programs relating to mental illness, mental health, and substance abuse in children and adolescents.
It is important to note that H.R. 4365 is an "authorization" bill. As such it creates the legal authority for agencies such as SAMHSA to spend federal dollars. Actual federal outlays are enacted through separate appropriations bills - in the case of SAMHSA and CMHS, the Labor HHS appropriations bill. In the next few days, Congress is expected to complete action on the FY 2001 Labor HHS appropriations bill that will include funding for some, but not all, of these programs. It will not be until next year that Congress will be able to fund the newly authorized programs in H.R. 4365. Therefore, the "authorization levels" for these programs will not translate into real dollars until the new Congress and the new administration take office next year.
BLOCK GRANT ACCOUNTABILITY
No later than 2 years after enactment of H.R. 4365, SAMHSA must submit to Congress proposed separate mental health and substance abuse performance partnership plans which describe a common set of performance measures for accountability. These plans are to be developed by SAMHSA in conjunction with States and other interested groups.
For mental health plans, performance measures must be targeted to children with serious emotional disturbance, adults with serious mental illness, and "individuals with co-occurring mental health and substance abuse disorders." For substance abuse plans, performance measures must be targeted to pregnant addicts, HIV transmission, tuberculosis, and "those with co-occurring substance abuse and mental disorders." The plans must include definitions of data elements. States are encouraged to provide data to SAMHSA on a voluntary basis. The plans must identify obstacles to implementing such performance measures and data collection, resources needed for such implementation, and an implementation strategy complete with any necessary legislation.
Data Infrastructure Development grants are authorized to help states develop the capacity to report the data needed in the performance measures. These funds are to be divided equally between mental health and substance abuse agencies. As a condition of receiving these grants, the state must actually have developed a core set of performance measures. The grants are to assist states in developing and operating data collection, analysis, and reporting systems.
With a successful focus on restraints, integrated treatment, homeless programs, and jail diversion programs in H.R. 4365, NAMI was unsuccessful in also convincing the Congress to require an unduplicated count of persons served both through the block grant and in the public mental health system. Without a such an unduplicated count, there is no guarantee that persons with severe and persistent mental illness will actually be served and no guarantee that they will receive the intensity of services that they require.
While the existing annual mental health plan, required until it is replaced by the performance partnership grant performance measures, requires states to describe the services and resources for individuals "dually diagnosed" with mental illness and addictive disorders, the substance abuse currently required annual plan is silent on persons with co-occurring disorders.
JAIL DIVERSION PROGRAMS
The U.S. Department of Justice reported in 1999 that 16% of all inmates in state and federal jails have a severe mental illness. 283,000 people with serious mental illnesses were in jail or prison. H.R. 4365 adopts a jail diversion program initiative from the Mental Health Early Intervention, Treatment and Prevention Act to help stem the tide of the criminalization of people with severe mental illnesses. The measure provides up to125 grants to states to develop and implement programs to divert individuals with a mental illness from the criminal justice system to community-based services. The grant program is established for three years (2001 through 2003) and appropriates $10 million for the first year and whatever sums are necessary for the following years.
EMERGENCY MENTAL HEALTH SERVICES
H.R. 4365 authorizes a new $25 million dollar program at CMHS for grants to states and communities to establish emergency mental health centers. Applicants can use these funds to establish and train mobile crisis intervention teams. In addition, agencies receiving funds under this new program would have to serve as a central receiving point for persons in crisis and provide mental illness treatment and referral to appropriate programs.
Emergency mental health centers were originally included in the Mental Health Early Intervention, Treatment and Prevention Act referenced above, but at an authorization of $50 million. However sponsors of the legislation were forced to lower this level to stay under an agreed upon authorization limit. Several other provisions were also reduced when they were added to H.R. 4365, e.g. integrated treatment funding was reduced from $50 to $40 million, training grants for teachers and emergency personnel were reduced from $50 to $25 million.
H.R. 4365 also authorizes the PATH (Projects for Assistance in Transition from Homelessness) program. In addition, the bill establishes a new, separate discretionary program for the homeless within CMHS. This new $50 million grant program is intended to expand treatment services to homeless individuals. The program authorizes CMHS to award public mental health agencies and non-profits grants for integrated treatment for individuals with co-occurring mental illness and substance abuse disorder. CMHS will also be required to ensure that applicant agencies do not exclude persons who have addictive disorder, but not a mental illness diagnosis. Likewise, applicant agencies will have to demonstrate that they do not have a policy of excluding persons who are actively abusing drugs and alcohol.
MENTAL ILLNESS AWARENESS TRAINING GRANTS
Section 3213 of the bill establishes grants to the states to train and heighten awareness of teachers and school personnel who may be the first point of contact for children and adolescents with mental illnesses. These training grants are also specifically designed for emergency services personnel who are often called when someone with a severe mental illness is in crisis. The grant program is also established for three years and the bill appropriates $25 million the first year for the following:
PROTECTION AND ADVOCACY AGENCIES SERVING PERSONS WITH MENTAL ILLNESS
H.R. 4365 broadens the authority of the P&As to investigate abuse and neglect in community settings, when the annual federal appropriation reaches $30 million. The current fiscal year Protection and Advocacy for Mentally Ill Individuals (PAMII) Act appropriation is $24.9 million with an expected $1 million increase for FY 2001.
Of great controversy is a provision which allows religious based organizations to receive substance abuse funding "without impairing the religious character of the organizations or the religious freedom of the individuals." This proposal, known as "charitable choice," is also included in a separate economic and community development bill known as the "New Market Initiative" that is expected to pass later this year. These guidelines will apply only to substance abuse programs funded by SAMHSA.
INTEGRATION WITH PRIMARY HEALTH CARE
CMHS' general discretionary grant authority is expanded and refined in H.R. 4365 to include "targeted capacity response" and "systems change grants" (including grants for family networking and consumer-run programs). These new authorities are on top of CMHS' existing Knowledge, Development and Application programs (KDA). For FY 2001, CMHS' KDA budget is expected to be 146 million. The legislation also directs CMHS to place the highest priority on using these grants to integrate mental health services into primary health care systems.
CHILDREN AND ADOLESCENTS
H.R. 4365 contains numerous targeted and special grant programs relating to the mental illness, mental health, and substance abuse of children and adolescents. The following are some important programs that affect children and adolescents with mental illnesses contained in the bill.
Suicide Prevention: Federal financial assistance is authorized for programs to reduce suicide deaths. Special attention is given to communities or groups that experience high or rapidly rising rates of suicides. A special study is required providing unique profiles of children under the age of 13 and youths between the ages of 13 and 21 who attempt or complete suicide.
Coordinated Services Through the Integration of Child Welfare and Mental Health: Federal financial assistance is authorized for children and youth age 19 or under to provide integrated child welfare and mental health services. These programs must ensure that there is a single point of access for such coordinated services.
Youth Offenders: Federal grants are authorized to state and local juvenile justice agencies to provide for aftercare services for young offenders who have a serious emotional disturbance or at risk of developing such disturbances.
Youth Violence: Federal grants are authorized to local communities to develop ways to assist children in dealing with violence, grants are authorized to address the problems of persons who experience violence related stress, financial assistance is authorized to address emergency substance abuse or mental health needs in local communities, and a new statutory requirement of the Center for Mental Health Services is to collaborate with the Departments of Education and Justice "to develop programs to assist local communities in addressing violence among children and adolescents."