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Grading the States 2006: Policy Recommendations

1.   Increase funding tied to performance and outcomes. 

In recent years, most states either have reduced funding of services for people with serious mental illnesses or have level-funded these programs. The impact of inadequate funding has been devastating - we now see overflowing emergency rooms with no place for people to go, increased numbers of people with serious mental illnesses in jails and prisons, and large numbers of people without access to desperately needed services.

State legislators and policymakers must realize that cuts to vital services for people with serious mental illnesses raise rather than reduce overall costs to society. These cuts affect systems in a very negative way. Corrections systems, indigent care systems, emergency medicine, or homeless service providers are left to pick up the pieces.

At the same time, NAMI understands and supports the importance of linking public-sector mental health expenditures with positive outcomes. Thus, we believe that states should be able to demonstrate that mental health services funded through Medicaid, the Federal Mental Health Services Block Grant, or state dollars achieve positive outcomes such as reduced symptoms, increased independence, employment, housing, and increased consumer satisfaction. States also should be able to show that these expenditures reduce negative outcomes such as hospitalizations, homelessness, criminal justice involvement, and suicides.

If a state mental health system is unable to demonstrate the positive impact of the services it funds, legislators and policymakers are justified in raising questions about the value of the funding. We believe that the federal government, through the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute of Mental Health (NIMH), and other agencies administering services and programs that affect people with serious mental illnesses, should provide technical assistance to ensure that such funds are being used appropriately and achieving positive outcomes.

As a last resort, non-performance by a mental health system may be a justifiable reason to reallocate mental health funds to other systems and programs that bear the burdens of failed mental health policies and services, such as jail diversion programs, homeless shelters, and emergency rooms.

2.  Invest in evidence-based and emerging best practices.

In the section of this report entitled "Standards for a Quality Mental Health System - A Vision for Recovery" we have described the elements of what we believe constitute high-quality services for people with serious mental illness. Unfortunately, the research we conducted in preparing this report revealed that the services discussed in that section are in short supply, or even non-existent, in many parts of the country.

This is not acceptable. If services with an established research base of demonstrated effectiveness are not translated into practice, the cynicism of policymakers may be justified. On a more positive note, SAMHSA and the National Association of State Mental Health Program Directors (NASMHPD) are engaging in efforts to promote the widespread adoption of evidence-based and emerging best practices. And state mental health authorities in some states are taking leadership in working with other agencies and systems on jail diversion, supported housing, employment, and other critical services.

3.  Improve data collection, reporting, and transparency of information.

In preparing this report, we tried to find existing data that would help give advocates and consumers information about state mental health systems and how well they were performing. We found very little. The data that exist are not designed to allow easy state comparisons and are not linked to consumer outcomes.

SAMHSA, as the agency with responsibility for oversight of mental health services, must develop uniform outcomes measures and insist that states provide data on these measures as part of their block grant reporting requirements. This information should be accessible and transparent and be used to guide the development of priorities by state legislators and policymakers.

Our research for this report also revealed that state mental health authorities are, by and large, not doing well in providing easily accessible information about mental illnesses and mental health resources to their customers - consumers and family members. This is another area that requires significant improvement. In this day of enhanced information technology, it is reasonable to expect states to fulfill their fundamental obligation to provide easily accessible and understandable information about the services they provide.

4.  Involve consumers and families in all aspects of the system.

Although lip service is given to the importance of consumer- and family-driven systems, we found very few examples where this important principle actually is being translated into practice. The examples we did find are exemplary and should be replicated in all states.

For example, in recognition of growing evidence about the effectiveness of peer services and supports, Georgia is the first state that reimburses certified peer counselors in its Medicaid program. Other states should follow Georgia's lead.

Another example is the use of independent, third- party, consumer- and family-monitoring teams used to conduct inspections and monitor conditions in psychiatric treatment facilities. These teams have proven effective in the past in states such as Delaware, New Hampshire, Oklahoma, and Pennsylvania. All states should similarly involve consumers and family members in oversight and monitoring activities.

States are required under the Federal Public Health Services Act to include consumers and family members on state mental health planning councils. We strongly believe that the involvement of consumers and family members must extend significantly beyond an advisory function. Unfortunately, on an overall basis, involvement of consumers and families in various aspects of the mental health system (planning, implementation, and evaluation) is token at best. Some states and systems apparently find it difficult to break away from outdated, paternalistic attitudes toward the people they are charged with serving.

5.   Eliminate discrimination.  

People with serious mental illness encounter stigma and discrimination in all aspects of their lives. Overcoming this discrimination requires not only community education, but also the change of certain federal policies that reinforce this discrimination.

For example, Congress continues to sanction discrimination against people with serious mental illness by failing to enact a federal law requiring that mental illnesses be covered on a par with all other medical disorders in health insurance policies.

The federal Medicaid program contains a provision that similarly encourages discrimination toward people with serious mental illness. Since its inception, there has been a provision in federal law prohibiting the use of federal Medicaid dollars to pay for services in an "institution for mental disease" (IMD), defined as a facility with 16 or more beds, at least 50 percent of which are used for psychiatric treatment.  This provision serves as a barrier not only to reimbursing care in psychiatric hospitals, but also to implementing Medicaid-reimbursable home- and community-based waivers of the kind that have been very helpful in facilitating recovery among people with developmental disabilities, and other Medicaid populations.

Finally, the federal Medicare program also contains provisions that discriminate against people with mental illness. For example, while Medicare covers 80 percent of the costs of outpatient treatment for traditional medical disorders, it covers only 50 percent of the costs of outpatient psychiatric treatment.

NAMI calls upon Congress and the President to set an example for the rest of the nation by moving swiftly to change these discriminatory policies. Outdated laws that reinforce stigma and faulty assumptions about mental illnesses should not be allowed to continue.

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