Grading the States 2006: Michigan - Narrative
You cannot separate what is happening with mental health services in Michigan from what is happening with the state's economy. The state has been in a recession since 2001 and has lost several hundred thousand well-paid manufacturing jobs, a trend that hasn't stopped yet.
Despite loss of tax revenue, the state has committed to level funding for the Michigan Department of Community Health (MDCH) over the past three years. The frozen resources have been stretched more thinly every year, as the number of unemployed and uninsured persons increases.
Governor Jennifer Granholm appointed a special Mental Health Commission in 2003, which released a report in October 2004 with approximately 70 proposals for reform. Over a year later, advocates claimed that 90 percent of them have gone nowhere; only six were acted upon. The administration said that that a "working group" still is working on the rest.
One of the commission recommendations is passage of mental health insurance parity legislation - a measure that is important in helping to stem the flow of people with private insurance into the public system, as well as being central to the fight against stigma and discrimination. Simply put, when middle class families lack mental health benefits under private insurance plans, they often are forced to spend down assets and end up in the public system - or go without treatment. Either way, the cost ultimately is passed on to the state. Untreated mental illness results in more emergency room visits and hospitalizations, and in some cases, costs shifted to the criminal justice system.
In Michigan, auto industry politics are largely responsible for blocking parity. The Michigan AFL-CIO opposes parity out of concern that it will weaken collective bargaining power and benefits. This position overlooks both Michigan citizens who lack union contracts and those costs shifted to the state, as well as being based on an erroneous interpretation of the proposal - seeing it as a mandate, rather than equality between benefits offered within a single plan. To its credit, the AFL-CIO does support other Granholm commission recommendations.
Parity's fate - and that of other recommendations - hinges on leadership and political will. Advocates are concerned for the future because there soon will be no enduring mental health champions in the state legislature. In 1992, the state enacted term limits. It usually takes years for legislators to learn the needs and often complex issues of people with serious mental illnesses. By the time they do, they are gone. In 2006, State Senator Beverly Hammerstrom, who has been one of the leaders in mental health, will have to leave.
A year before the Granholm commission, the state reorganized the mental health system so that 18 Medicaid prepaid inpatient health plans (PIHPs) were created. Using Medicaid, the state contracts with 46 community mental health service programs (CMHSPs) organized by regions. Each CMHSP provides a basic set of services mandated by the state, but each region differs in admission criteria, service array, and service accessibility for ethnic minorities and older adults.
Assertive Community Treatment (ACT) and supported employment programs have undergone "fidelity drift," so that many programs are not what their names imply. As an example, advocates report that one CMHSP-supported employment program consists of a single clubhouse custodian, who does custodial job coaching for three to four people.
To its credit, MDCH has instituted a quality improvement effort. The Improving Practices Committee is working to ensure national model standards and quality services across the state.
Michigan has notably chosen to embrace consumer involvement in mental health care and the recovery model of mental healthcare. The state has established a Recovery Council, and the hope is that some local programs will emerge to serve as models of recovery-oriented care for the rest of the state.
Since 1995, consumer representation on governing boards of local mental health agencies and on the state Mental Health Planning Council has been a statutory requirement. Advocates describe MDCH as accessible overall, with administrators who are caring, skilled, and working to do a good job with limited resources.
Despite funding problems, Michigan reports that many areas are in the process of being improved.
- Michigan recognizes that its data collection system is flawed, and is implementing changes.
- Mental health and substance abuse services have long been separate, but the state has formed several working committees looking to integrate them.
- The state trained 45 peer support specialists in 2005 and plans to train 135 in 2006.
Progress can come incrementally, but it cannot come simply by playing around the edges or without investment. The Granholm commission presented an agenda, but it will take sustained leadership and commitment - and a coming together of diverse interests - to move it forward.
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