States in Crisis:
The Grassroots Response
NAMI Washington and the 2002 State Legislature
NAMI Washington was involved in major budget and policy issues in this year of precipitous declines for businesses in general and for the state's business tax revenues in particular.
As most NAMI Members know, the recent economic down turn and events of September 11th have put the state in significant financial trouble. Washington lives or dies on sales tax revenues. The Legislature came to Olympia in January to face the daunting task of filling a $1.6 billion hole in the general fund budget. They tried to make up the funding with a combination of program cuts and creative financing, including dipping into future year pots of the federal tobacco settlement money. With a strong lobbying effort from NAMI Washington and other ally groups the state's Mental Health Budget has gone to the Governor's desk for signing in much better shape than would have been the case if the 15% cuts that the Administration first asked for had prevailed.
Overall, given the state of the state's finances, we certainly could have done much worse, and many other social service programs did much worse; and they will affect the wrap around capacity of ancillary government programs on which people who are struggling to recover from mental illness rely. This has been a very tough year - and next year may be even tougher for those who balance the state's budget.
- Over all, the mental health budget was reduced by a total of $3.56 million - that's less than half of one percent of the total Mental Health Budget. In addition, nearly all of those financial cuts are required by budget language to come out of administrative reductions, not from direct services to clients.
- Working together, we successfully eliminated proposed cuts to the Medically Indigent Program and minimized the proposed cuts to General Assistance Unemployed (GAU) Programs.
- In the end, however, there were some cuts that will impact our folks including:
- a 30 bed reduction (at the end of 18 months) in the Program for Adaptive Living Skills (PALS) at Western State Hospital,
- elimination of the small pilot Atypical Medication Access Program that helped bridge the gap for a few people seeking treatment while getting onto Medicaid, and
- slight reductions to the state's Social Security (SSI) supplement program.
One key component of the final budget was not a cut, but will likely have significant impact on community treatment services. There is now a directive to the state's 14 RSN's to significantly trim their Reserve Accounts, a one time "spend down." We have contended that the total amount of money tied up in reserve bank accounts was too much and robbed the system of needed infrastructure. Now, Washington's NAMI members need to watch the decisions to implement this mandate very closely.
How and on what kinds of services RSNs decide to buy are decisions being left to the governing boards of the RSNs. NAMI Washington is encouraging all local NAMI Affiliates and their members and allies to contact their regional RSN and let them know that you want a place at the table in deciding just exactly how to allocate those freed-up reserve funds. In most RSNs, the funds are substantial. Of course, these funds should be carefully invested in the system to improve long term effectiveness because they are only available one time. The final Budget adopted by the legislature this year is currently sitting on the Governor's desk waiting for his signature. He does have the authority to delete specific sections of the bill that, for any reason, he finds offensive, and he still has to trim $40 million more from the total. So, it isn't over until Governor Locke signs it.
Three Particular Policy Issues
- Medication Access "Formulary": HB 2431/SB 6368 Developing a comprehensive prescription drug education and utilization system. This legislation was intended to create a list of preferred drugs from which physicians who treat patience on Medicaid or other state sponsored health care would have had to prescribe. This list would have created classes of medication that treat more or less the same illnesses and symptoms and are therefore considered "therapeutically equivalent." An example of a class would be anti-depressants. All anti depressants would be placed in this class and a panel of doctors and pharmacist would determine which ones were preferred based essentially on the relative cost of the various medications.
NAMI Washington strongly opposed this legislation because not all anti-depressants or anti-anxietals or anti-psychotics or . . . are "therapeutically equivalent." Most differ greatly in effectiveness and negative side effects. A one-size-fits-all cookie cutter approach to medications does not produce effective mental illness treatment. We attempted to get the legislature to amend the bill to have all drugs used to treat mental illness (the whole cocktail) exempted from these provisions. Because 43% of projected savings were on the line, we were unable to persuade them to exempt our meds. In the end, NAMI Washington took the position of vigorous and direct opposition to this legislation. This bill passed out of the Senate, but died on the Floor of the House. We can expect similar legislation to be introduced next session. However, we hope to encourage the legislature to devise a program similar to that jointly developed in Texas several years ago by NAMI Texas and their state Mental Health Division. That cost effective and treatment effective methodology is called the Texas Medication Algorithm Program (TMAP). Reportedly, it works well for all concerned. It is essentially based on the premise that if doctors and patients remain free to employ the medications that work best for them and if the state operates an ongoing feedback loop of information on what medications do work best for which symptoms and diagnoses, everyone will want to choose those medications that are most likely to be most effective. In the end, cost effective treatment is not getting people to take the cheapest pills, but getting them the most effective medications early in their illness.
- Advanced Directives: SB HB 2367/6589 This legislation will allow individuals with mental illnesses to create Mental Health Advanced Directives (ADs) that are legally recognized as guidelines for providers, friends, designated agents of the consumer, and his/her family members when and if a recovery decline calls for treatment intervention.
NAMI Washington strongly supported this legislation and was intimately involved in many meetings and the negotiations surrounding its development. It got mired in controversy in the final days with some provider organization, particularly those dealing with acute crisis treatment begging for a hold. They felt that as presented, the bill would create significant confusion at their facilities and potentially conflict with other laws related to standard medical directives. NAMI and other stake holders were unable to reach a comfortable compromise in the short time left at end of session.
All of the provider stakeholders have pledged to work with us and the bills sponsor during the interim to reconstitute the conflicting language. This bill will have universal support in the next session which begins almost on NAMI Day in Olympia in January of 2003.
- Mental Health Ombudsman Reform: Senate Bill 5522: This legislation passed out of the Senate last year and was taken up by the House Health Care and Appropriations Committee this session. Due to the current budget situation it did not make it out of the House Appropriations Committee in spite of a strong lobbying effort by NAMI Washington and by the Washington Protection and Advocacy Service. Our persistent lobbying did not move the bill forward; however, it did convince the budget writers to include a budget proviso directing DSHS and The Department of Community Trade and Economic Development to develop a plan for mental health ombuds functional independence. To wit: "The department shall cooperate with the department of community, trade, and economic development to develop a proposal to create a structurally and functionally independent mental health ombudsman program. The proposal shall include recommendations about the statutory and administrative changes needed to establish a structurally and functionally independent ombudsman system. The departments shall report to the appropriate policy and fiscal committees of the legislature by November 1, 2002." We didn't get our bill, but we will begin working on the solution to the problem right now with a clear intention by the legislature that independent Ombuds and Quality Assessment become a reality in Washington.
It is not a prudent thing for NAMI Washington to single out a particular legislator for praise. We have too many friends in office to praise just one or two. This was a very difficult year for all legislators. It is always easier to spend the people's money than it is to take it away. Every existing government program is a "sacred cow" to some group of citizens.
Nevertheless, the President of NAMI Washington wants our members to convey our appreciation to the Chairs of two key legislative committees, the Senate Ways and Means Committee and the House Appropriations Committee, Senator Lisa Brown and Representative Helen Sommers respectively. These are the two most important legislators when it comes to the "power of the purse." Everyone always wants something from them in good times and bad. Theirs was a very tough job in this very bad year; a job that no one should want. The budget was way out of balance with the anticipated reduction in revenues coming into the state treasury when this session began; the negative numbers only got worse as the session unfolded.
That social service programs for the most vulnerable citizens of our state were protected from harmful cuts to the degree that they were is largely due to the untiring efforts of these two women. Without some very creative financing agreements and a lot of very hard work to bring it all together into the final budget that now sits on Governor Locke's desk, things would undoubtedly have been much worse for our folks and for others around the state who are mostly poor and powerless. Brown and Sommers didn't give us everything we wanted; not even everything we thought would be in the best interest of all the people of Washington. But, they represent their respective institutions highest promise of public service.
Generally, and perhaps without exception, our state's elected officials are honorable public servants doing a largely thankless job (especially these days) on behalf of all the people of Washington. Give Senator Lisa Brown, Representative Helen Sommers, and your other Senators and Representatives a hug when you see them.
Finally, largely because NAMI members have come to Olympia in large numbers each year and presented their case for better mental illness treatment programs on NAMI Day in Olympia, we now do our lobbying work with many more knowledgeable friends in Olympia that ever before. Legislators are now much better informed about mental illness and about the problems that remain in our state's public treatment system. They have come to look for and expect NAMI members to call or write them with our views on important pieces of legislation. Keep up the good work!