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National Alliance on Mental Illness
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What’s at Stake in the 2012 Elections?


By Beth Anne Hendrickson, NAMI Policy Intern

What does this year’s election season have to do with mental health? The answer is everything. Candidates elected into office during this time of critical health care debate and reform will make decisions with lasting impact on access to mental health treatment and services. New reforms make mental health parity a requirement and care more affordable, but these policies are still being debated. We need leaders who are ready to move forward to ensure that individuals receive the full effect of intended benefits. For people living with mental illness and their families, much is at stake in these elections. Now is the time for you, NAMI voters, to weigh in and tell candidates, “Mental health care gets my vote!”

We have the opportunity to impact how the nation and health systems view mental illness.

Exercising the right to vote is important in each election, but there are several opportunities in the 2012 elections that make this campaign season imperative to mental health: the timing, NAMI policy priorities, local leadership and the opportunity to connect with candidates.

Timing Is Everything

Reactions to the Supreme Court’s June ruling upholding the Patient Protection and Affordable Care Act (PPACA) range from cheers to backlash, and everything in between. The debate itself is more than hype and headlines, though. The hot-button issues align with the heart of NAMI’s advocacy priorities: protect public mental health funding, expand access to care, and make prompt, effective mental health care available to all in need.

For mental health advocates, these coverage, access and care concerns are nothing new. NAMI, NAMI State Organizations and NAMI Affiliates have been working to advance mental health issues in national, state and local policy for decades. Although the fight for better mental health care is ongoing, these issues are currently in the spotlight, making this election a moment of opportunity to connect with candidates.

The PPACA debate has built a platform for mental health advocates to promote better mental health policy to a wide audience across the political spectrum, including candidates who want to know voter priorities. That means we have the opportunity to impact how the nation and health systems view mental illness.

Candidates and incumbents up for re-election need to become aware of NAMI’s mental health policy priorities and form positions on these issues, which affect millions of Americans.

Policies in Limbo

Key legislation and funding measures currently in debate add to the significance of the elections. The bipartisan initiatives included in PPACA mark key victories toward a uniquely American solution, being good for business while reforming a health care system that inefficiently drains the budget and ill-serves those who need care.

Candidates and incumbents up for re-election need to become aware of NAMI’s mental health policy priorities and form positions on these issues, which affect millions of Americans.

Yet as the health care debate blazes on, principles that are the foundation of health care reform could be in jeopardy, lost in “who said what” political clash. With this pivotal moment in health care reform, current and future policy-makers need to know what issues take priority in the debate for voters, including mental health. NAMI’s trifold policy agenda sets forth key focal points to get the message across to candidates: protect mental health funding, expand coverage, and improve and increase access to mental health services.

Priorities: Protect Funding

Because federal, state and personal pocketbooks are stretched thin, officials at all levels seek to cut excess spending. It is vital to communicate that mental health services have been seriously eroded during the recession and cannot be cut further without serious consequences for individuals, families and communities. The stress of hard economic times should provide incentives to strengthen, not drain, necessary mental health supports. Short-term skimping on the care and services Americans need to live healthier, fulfilling lives undercuts recent advances in recovery-oriented care that now offer a brighter future to people living with mental illness.

Medicaid: Under fire in the wake of the Supreme Court’s decision on PPACA is the plan to expand Medicaid to cover all Americans with incomes at or below 133 percent of the Federal Poverty Level. Medicaid, a federal- and state-funded health coverage program, currently provides health care services to children, parents and adults with disabilities living in poverty. Medicaid covers more mental health service costs than any other insurer, public or private, and helps children access critical early-prevention care.

The June Supreme Court ruling struck down penalties for states not complying with the PPACA provision extending Medicaid coverage to all individuals with incomes at or below 133 percent of the federal poverty line. Medicaid expansion would provide health care coverage to more than 17 million more Americans.

To some, the decision has provided wiggle room for states not only to refuse to expand Medicaid, but to continue to trim current programs. Budgets remain tight, and states are worried about their ability to pay for Medicaid while maintaining quality of service for more members once federal funds scale back.

The new Medicaid qualifications mean that many more Americans would receive coverage (although a slimmer set of benefits) through what is already America’s broadest insurance program. This worries states, which are feeling budget crunches and looking for ways to shave excess spending. While federal funds would pick up the entire tab for new enrollees for the first few years, states would eventually be required to pay 10 percent of expansion costs in addition to an average of 43 percent for current Medicaid enrollees.

As this article goes to print, 13 states are making plans for hefty Medicaid cuts. Some states are tightening eligibility, making it harder for people to qualify for Medicaid. In states not expanding Medicaid, people with incomes below the Federal Poverty Level could be most disadvantaged. These individuals would not qualify for Medicaid but would be required to purchase health care, even though there is no provision for federal insurance subsidies in private health insurance exchange plans for incomes below 100 percent of the Federal Poverty Level.

“The Supreme Court decision gives power to the states,” said NAMI Executive Director Michael J. Fitzpatrick. “The challenge now is to make sure they use it wisely. They can’t hide from problems that will only hurt people if left unattended.” Candidates need to know that Medicaid is a state budget priority.

Private Health Insurance with Parity: To make shopping for private health care plans a better experience, states will establish online exchange “marketplaces” to compare plans. Under the new law, families earning between 100 and 400 percent of the Federal Poverty Level are eligible for subsidies or tax credits to make health care more affordable.

“The Supreme Court decision gives power to the states,” said NAMI Executive Director Michael J. Fitzpatrick. “The challenge now is to make sure they use it wisely. They can’t hide from problems that will only hurt people if left unattended.” Candidates need to know that Medicaid is a state budget priority.

State-Funded Mental Health Services: Essential recovery-oriented services may not be covered by Medicaid expansion or health insurance exchange plans. Services funded with state mental health dollars will still be necessary. Candidates at the state and local levels must be informed about the need for wraparound services such as housing supports, employment assistance and peer support. Supported housing and employment services help people affected by mental illness live healthier, more independent lives. Funds for these services are a priority, not an opportunity for budget cuts.

Medicare: The new health law affects Medicare, a federally funded program providing coverage to senior citizens and people under 65 after they have received Social Security Disability Insurance (SSDI) for two years. The new health care law will provide subsidies and discounts for medications, closing the Medicare coverage gap known as the “donut hole.”

Veterans: Thousands of military service members, veterans and their families are struggling with the psychological effects of the wars in Iraq and Afghanistan, dramatically increasing the demand for mental health services. To serve those who have served the nation, federal and state leaders must close system gaps, ensure parity and increase military-informed treatment capacity by investing in care and requiring coordination among the Department of Defense, the Veterans Administration and civilian mental health services.

When it comes to funding services that affect millions of Americans, candidates across the political spectrum need to understand that this is not a debate about political capital; the nation’s mental health is at stake. “Mental illness can strike anyone at any time,” Fitzpatrick said. “It does not discriminate between Republicans, Democrats and Independents. NAMI is nonpartisan, and ours is a nonpartisan agenda.”

Short-sighted cuts are not a solution because costs simply get shifted to crisis care, hospitals and jails. Federal and state funding for mental health services promotes self-sufficiency and is an investment in America’s future.

Priorities: Expand coverage

Parity: PPACA has strengthened the Mental Health Parity and Addiction Equity Act (2008) by extending parity requirements—previously only applicable to plans covered by companies with 50 or more employees—to all health plans offered through health insurance exchanges and to all Medicaid expansion plans.

This is a victory for advocates who are fighting to end discrimination and for mental illness to receive treatment comparable with other medical conditions in the health care system. With mandated psychiatric coverage, more Americans will receive the mental health services they need without facing unfair coverage limits.

Patient Protections: The new health law prohibits insurers from denying coverage for pre-existing conditions, placing annual or lifetime limits on essential health benefits or withdrawing coverage if you get sick. Plans must provide free preventive care and must cover uninsured young people up to age 26 on their parents’ plan. Plans are required to spend at least 80–85 percent of their revenue on direct health care costs and must limit your out-of-pocket expenses to federal guidelines. This is a long-fought battle for people affected by mental illness, and our country needs leaders who recognize the value of mental health parity and continue forward toward expanding coverage. The new parity requirements are cause for celebration and should be a step toward providing the millions of Americans living with mental illness access to services that increase their quality of life.

Priorities: Improve Service Access

Parity coverage requirements under the new health law are integral to mental health reform, but robust community mental health services must be available to ensure that people can get the right help at the right time. Effective services and a community health infrastructure requires funding treatment that works. Leaders need to know that mental health services are a priority, and candidates should develop positions on how to fund high-quality care. Promoting effective community treatment has several components.

Leadership is needed to coordinate hospital and community services to help individuals living with serious mental illness transition into the community.

NAMI recommends a comprehensive mental health services array, a concrete listing of programs that can be easily shared with candidates and community leaders. Early intervention has proven effective in reducing symptoms for both children and adults. Service arrays must reflect the broad mental health needs of people living with mild to severe mental illness in order to treat individuals in the most effective and appropriate setting.

“Mental health needs exist along a continuum of care,” Fitzpatrick noted. “Not everyone needs the same level of treatment or services that the most severely ill individuals require. Flexibility saves money. But no one at either end of the scale should be abandoned.” To learn more about the service array and what supports are included “Make a Connection.”

Following the Supreme Court’s decision in Olmstead (1999), there has been a push toward care that allows people to receive mental health treatment in the least restrictive setting for the level of services needed. Community integration of services makes this possible, allowing people to access effective treatment where they live.

While many states and communities are shifting away from large state hospitals and residential facilities, intensive community-based inpatient care and long-term community-based care are necessary to serve those with intensive mental health care needs. It is up to the states to implement these measures and promote community integration. Leadership is needed to coordinate hospital and community services to help individuals living with serious mental illness transition into the community.

Supported Employment: People with mental illness have been among the hardest hit when the recession undercut the job market. Supported employment services empower individuals affected by mental illness to develop skills, get jobs and succeed in the workplace. “Work is often one of the best tools for recovery,” Fitzpatrick added. Because supported employment is good for the employee, employer and the local economy, candidates need to know that these services are a win-win for their communities.

Mental Health Workforce Shortage: Lack of qualified mental health service providers unfortunately eclipses the availability of local services in many areas. The challenge is not only to recruit more workers, but also to provide adequate training in best practice treatment for serious mental illness. Mental health professionals need the skills necessary to deliver effective services to culturally diverse communities that are chronically underserved.

The shortage of professionals is drastic in rural communities, but limitations in personnel reduce the availability of specialty mental health services in all geographic areas. Even in large urban pockets around the country, people receiving Medicaid and Medicare benefits may have difficulty finding providers to treat them.

A recent Institute of Medicine report (2012) stated that the mental health personnel shortage has serious consequences for older Americans. With the over-65 population growing rapidly (expected to escalate from 40.3 million to 72.1 million between 2010-2030), this age group is also becoming more racially, ethnically and culturally diverse than ever before. The report notes that about one in five seniors experiences a mental health condition, often along with other medical illnesses, but there are not enough geriatric mental health and substance-abuse professionals to meet their unique health needs. That gap will continue to widen as the older adult population grows.

To meet the mental health needs of all populations, states should address the shortage by adding to the workforce professionals who are thoroughly trained in delivering mental health services to a diverse population with varying treatment needs. An adequate mental health workforce will be able to more effectively and efficiently deliver the services necessary to help Americans live well. Fortunately, this is an area where jobs need to be created, and that’s good news in this economy.

Candidates from all parties need to know the facts on mental illness in order to best serve the people they hope to represent in the future.

Medication: The right medication can be make all the difference for someone living with mental illness. Policies should promote an array of medications adequate to serve individualized needs. Because responses to psychiatric medication vary widely, people need to be able to work with their health care providers to to find the most effective treatment for themselves. Individualized access to medications can prevent costly crisis care and is a wise investment for public and private health coverage.

Research: Finally, effective treatment is strengthened through research and accountability. When states are required to collect and publish data on health care systems, the public benefits. Outcome-based care begins with standardized measures to compare and improve current care models. Mental health research lacks resources and attention compared to other medical fields. The investment in research into causes and treatment of mental illness will improve quality of care and create more efficient, cost-effective systems for states.

Local Implementation

The presidential race certainly attracts the most attention, but congressional, state and local primaries and elections are equally important to mental health. For example, on Election Day (Nov. 6, 2012), 468 U.S. Congressional seats will be up for election. The outcome could affect the majority balance in both the House of Representatives and the Senate. Your representatives and senators give voice to voters’ concerns in federal legislation, and your members of Congress directly impact mental health policy for the nation.

PPACA is scheduled for full implementation in 2014, and many of the candidates chosen in this election cycle will oversee that transition. While PPACA is a federal law, it is up to state officials to determine how PPACA will provide coverage and care for its residents. Your vote will help determine who makes these decisions and how aware they are of our needs.

At last count, there were more than 87,500 local governing bodies throughout the United States, according to the U.S. Census of Governments. These city and county governments partner with community organizations to implement community-based mental health services. Local elected officials can make all the difference in establishing a framework for community health and making a range of services accessible. Members of these local government units, including school district officials, sheriffs and judges, influence how people living with mental illness are treated in educational settings, crisis response units and the justice system.

Partnerships that Last

There is much at stake in the weeks and months leading up to final count at election day. Campaigning gives candidates a chance to not only voice their ideas but to hear yours. Elected officials represent the entire population and need to know that mental health is a priority with their constituents. When voters speak up on an issue, candidates are likely to listen, especially during campaign season.

Candidates from all parties need to know the facts on mental illness in order to best serve the people they hope to represent in the future. The success of community-based care depends on partnerships among policy-makers, independent organizations and individuals. Connecting with candidates now lays the foundation for effective advocacy in the future.

Consider partnering with other organizations in your community to host candidate forums for federal, state and local candidates.

There is a lot at stake this election season, but NAMI advocates can embrace the opportunity to make a difference. It is important to connect with candidates and, more importantly, vote.

“We live in a democracy,” said Fitzpatrick. “People don’t always believe it, but every vote counts, particularly in close elections. By speaking out, NAMI voters influence other voters. We have more power than we realize—but only if we use it.”

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