Grading the States 2006: Nebraska - Narrative
In 2004, Nebraska's then-governor Governor Mike Johanns launched his state-of-the-state address by enumerating priorities for the state. At the top of his list was reform of the state mental health system. Johanns then worked collaboratively with Senator Jim Jensen to steer LB 1083 through the Nebraska Unicameral Legislature. The bill, signed into law in mid-April 2004, set Nebraska on a journey toward complete redesign of its mental health system.
LB 1083 seeks to change the state's health system from one based on inpatient, state-operated facilities to a system featuring community-based care and evidence-based practices (EBPs). The bill authorized creation of a division of Behavioral Health Services within the state's Health and Human Services System. All non-Medicaid state-appropriated mental health expenditures were to be directed through this new division. It established the state's first identifiable lead agency on mental health care.
The state faces significant challenges in implementing LB 1083. The legislation requires each of six regional Behavioral Health Authorities to develop specific action plans that addressed needs for inpatient services and for implementation and availability of community support programs. And, as part of the 1083 effort, two of the state's three regional hospitals - those located at Hastings and Norfolk - were to be closed or modified. Another change as a result of the legislation is that the Office of Consumer Affairs was created at the state level. This places a consumer in an administrative level position in Nebraska's Behavioral Health Division.
Only time will tell if the reforms underway in Nebraska will work. To the state's credit, these significant system changes have not been contemplated in a vacuum. The state's website provides credible evidence of efforts to engage family members, consumers, and other constituents in planning strategies. Recent changes provide some evidence that this state is making significant improvements to its system.
Rapid changes create acute challenges to the smooth implementation of any reforms. Implementing the new system will be problematic in a state that rates its behavioral health staffing shortages as "critical." The problem is so severe that 88 of the state's 93 counties are federally designated as Psychiatric Shortage Areas. Efforts to address the gap remain rudimentary at this time and have yet to make a notable impact on the shortage.
Another factor working against successful reform is the amount of new funding generated through the legislative initiative. The proposal took about $29 million that previously was allocated to state hospitals and reinvested it in community services. New resources included $9 million in new Medicaid funds, $2 million in new housing supports, and $2.5 million in newly appropriated money for emergency psychiatric services.
The availability of new resources is paramount to the success of the transition to community services. Historically, however, many states have underfunded such transitions by assuming that redirected dollars would reach the community sooner rather than later. A review of the 2006 state block grant casts significant doubts on the state's chances of success in directing adequate funds to these services: it identifies mental health care as "chronically underfunded." And the most recent infusion of new resources was in 2001, when LB 692 added $8 million annually.
One sector that is currently grossly underfunded is the Nebraska jail diversion program. The state currently lists only one existing jail diversion program. A second jail diversion program is in the process of being implemented in Douglas County - the highest populated county in Nebraska. The initiative is being funded by local private funding. In a state with nearly 100 counties, the needs of consumers who are entangled with the criminal justice system therefore go unmet. While law enforcement was engaged successfully in the implementation of the mental health reform plan; the involvement focused on the process of civil commitment rather than diversionary strategies.
The legislature has been slow to address expansion of the state's parity benefits. The unicameral legislature did enact a good bill in 1999 that addressed people with severe mental illness and provided one of the lowest exemption thresholds in the country - 15 employees. However, efforts by advocates to strengthen the bill by adding substance abuse protections have been rebuffed.
Although some of the programs in Nebraska are underfunded, reform is coming. The new reforms emphasize the development of evidence-based services to meet the needs of Nebraska consumers in communities across the state. The authors of the legislation and those involved in implementing reforms have clearly prioritized critical needs such as Assertive Community Treatment (ACT), supported employment, medication algorithms, and peer-to-peer educational models. Though not implemented fully, evidence suggests that the state is making modest inroads in these areas. New programs are developing, and there is a demonstrated ongoing commitment to SAMHSA's evidence-based models.
Concurrent with its efforts to continue the mental health reforms, Nebraska has joined other states in considering broad reforms to its Medicaid program. While other states have rushed into reform efforts, often making far-reaching policy decisions without analyzing the consequences of the implemented changes, Nebraska's unicameral and executive leadership deserve credit for addressing Medicaid through a "deliberate and deliberative" process. The state is off to a good start by emphasizing data-driven decisions, and giving priority to guarding the interests of participants.
The current reform plan calls for implementation of a medication-prescribing program similar to the partnership developed in Missouri. The proposal, while it seeks expansion of the state's preferred drug list, allows the Drug Utilization Review board to continue to exempt certain classes of medication from prior authorization. While the early indications are promising, developments must be watched closely to ensurethat any such resulting program preserves access to medications.
Other promising, unique components of the proposal suggest broader use of technologies such as telemedicine within the state and disease management strategies for chronic health conditions, known as Enhanced Care Connections.
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