A subtle shift has occurred during the 17 years that this column has appeared. In the 1990s, leading Washington-based representatives of the behavioral health community confidently lectured members of the press on their strategy to advance their objectives on Capitol Hill. Those strategies changed over time, as objectives changed from ensuring a role for behavioral health in President Clinton's comprehensive healthcare financing plan to convincing a newly elected Republican congressional majority of the cost-effectiveness of mental health spending. At that time the people who lobbied for mental healthcare and substance abuse treatment felt that they understood the game and how to win it.
This is no longer true. Policy advocates for behavioral healthcare at the midpoint of George W. Bush's presidency generally appear grumpy and cynical. Behavioral healthcare scores occasional victories on Capitol Hill and in the courts, but these occur (literally) on a case-by-case basis. As a result, supporters of greater access to affordable, quality behavioral healthcare privately look toward a major electoral revolution in Washington as the best hope for substantive progress.
Advocates for changes in the behavioral healthcare system are running against barriers imposed by long-term realities governing U.S. mental health policy. Regardless of who is in power in the White House, Congress, and state legislatures across the country, laws and policies affecting mental healthcare are strongly influenced by beliefs and principles inherent in our society.
Recently, I invited several longtime students of behavioral healthcare policy initiatives to join in developing a short list of these governing realities of behavioral healthcare policy. There was surprisingly little dissension in this task, except for the question of how the stigma of mental illness affects policy making. Leaving aside that one debatable point, the following represents a consensus on the seven most important principles driving government action (and inaction) in the mental health field.
It's all about the money. Ten years ago, a keynote speaker entertained the Washington meeting of a professional association by proclaiming that he had finally discovered exactly what the American people wanted from national healthcare policy: “universal access to comprehensive, high-quality prevention and treatment services… paid for by Germany.” The joke's punch line rests on the simple truth that all healthcare issues really focus on how much quality costs and who should pay for it.
This is hardly new. When Massachusetts and Virginia were still colonies of British North America, their legislatures debated whether the cost of care for the mentally ill should rest with the entire colony or with local parishes. The debate continues today because there is no consensus on what part of government should bear the primary cost of mental health services. Even the idea that Washington should share responsibility for paying for mental healthcare for other Americans is barely 50 years old and is still not universally accepted. Well into the 20th century, the national government had financial responsibility for mental healthcare only for a small number of wards of the state: armed forces personnel, veterans, residents of Native American reservations and overseas territories, and residents of the District of Columbia.
The question of who should pay for quality care might be easier to answer if there were a clear measure of the size of the bill. Behavioral health advocates in Washington are quick to dispel the widespread image of lifelong weekly psychotherapy for millions of prospective patients, but they cannot define a plausible cost for effective care for everyone in need. We know that current spending on treatment and outreach fails to reach a large percentage of the population who could benefit from behavioral healthcare, but we don't know how much more those patients would cost. We also don't know how much society overall would benefit from paying for care and prevention services for an additional two, four, or ten million Americans. For this reason, every government appropriation for mental health services will probably fall short of someone's definition of adequate effort.
Because government doesn't try to meet the mental health needs of all residents, the real policy question tends to center on the choices that must be made in spending. Do we pay for the greatest good for the greatest number of people, even if it means skimping on quality? Do we pay for care for those with the greatest need, such as people with severely disabling conditions, at the cost of providing benefits to people who have a greater likelihood of maintaining recovery from mental illness? Do we focus government efforts on populations who have the greatest claim on government largesse, such as incarcerated prisoners, war veterans, first responders to natural disasters, and the poor and helpless? Or do we concentrate national government spending on support for scientific and medical research? There is little likelihood that the behavioral health field can hammer out a compromise to present to elected officials. And, in the absence of a compromise, elected officials will continue to make decisions on behavioral healthcare financing that will leave most of our field unsatisfied.