With the introduction in August of a new bi-partisan bill in the U.S. Senate that is designed to improve the mental health system, it's apparent that Congress is placing a greater emphasis on mental health policy. However, some question whether the current focus will lead to the meaningful change the system needs.
"This new legislation continues this desire by Congress to do something to improve access to and quality of mental health and addiction services," says Chuck Ingoglia, senior vice president for policy at the National Council for Behavioral Health.
Senator Bill Cassidy, a Republican from Louisiana, and Senator Chris Murphy, a Democrat from Connecticut, introduced the Mental Health Reform Act of 2015 (S. 1945)on August 4.
Described as a "comprehensive overhaul of the mental health system," the bill would establish an Assistant Secretary for Mental Health and Substance Use Disorders within the U.S. Department of Health and Human Services (HHS); create state grants to improve physical and mental health integration; establish a new national mental health policy laboratory; and create several grant programs that would aid in early intervention for children. Under the proposal, HHS, the Department of Labor and the Department of the Treasury would be obligated to conduct audits on implementation of mental health parity efforts.
This is not the only attempt at reform circulating through Congress. In June, Representative Tim Murphy (R-Pa.) reintroduced the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646), an act aimed at refocusing programs and resources to those families and patients with the greatest need. It too has bipartisan support from co-sponsors.
While both bills place an emphasis on evidence-based practices, promoting integrated care and trying to create organizational changes within HHS, Ingoglia says they also have significant differences.
For instance, the House proposal has a greater focus on Medicare and Medicaid. It also includes provisions the Senate bill does not have, such as a policy that would extend meaningful use EHR incentives to behavioral health providers as well as an extension to the Excellence in Mental Health Act demonstration program to additional states (currently set for eight states)and a longer demonstration period.
The Senate bill also does not include some of the efforts related to access to medications for Medicaid and Medicare patients that are incorporated into the House bill.
"If you are going to overhaul public mental health system you need to address Medicaid because Medicaid pays for almost all of public mental health," says Jennifer Mathis, director of programs for the Bazelon Center for Mental Health Law.
Perhaps one of the more contentious issues among reform advocates is assisted outpatient treatment (AOT). Both bills include AOT with some variation in approach. The House bill would create incentives within the mental health block grant for states that have assisted outpatient treatment laws, while the Senate bill calls for incentives for states that have “assertive outreach and engagement” activity but lacks more specific language.
"Certainly the Senate bill doesn't contain the same focus on it that the House bill does. The House bill obviously tries to promote it in a number of ways," says Mathis, who added that Bazelon has always opposed AOT.
Overall, Mathis says that while S. 1945 includes some promising provisions including small grants to do good things like encourage research on suicide prevention, support early childhood intervention and promote integration, she believes both bills only work around the edges of mental health and fail to address some fundamental problems.
"I think any overhaul of public mental health needs to address the gaps in community mental health service," she says. "That is the focus of mental health service system directors: expanding supported housing, expanding supported employment—which is available to less than 2 percent of people in public mental health systems—expanding mobile crisis services, and expanding peer support services. None of that is in here."
She also raised questions about the depth of some of the efforts. For instance, in S. 1945, there's a provision about parity, however, it primarily promotes a reporting and recommendation function.
"Doing a GAO [U.S. Government Accountability Office] report is not going to result in dramatic changes to enforcement of parity," Mathis says.
Context of the Senate bill
S. 1945 has already gained support and endorsement from numerous organizations including the National Association of Psychiatric Health Systems, the National Alliance on Mental Illness, the National Council for Behavioral Health and the National Association of State Mental Health Program Directors.
The Sandy Hook Promise advocacy group has also endorsed the bipartisan bill.
Mathis, however, believes associating mental illness with violence can produce negative outcomes for the industry.
"This seems to be getting attention because of an association with violence—and as a response to Sandy Hook—and I think that is part of the problem," she says. "As long as mental health reform is framed as a response to violence, the debate is going to be about the wrong things. You know the whole frame is that people with psychiatric disabilities are ‘scary, dangerous people who need to be controlled’ and that is why the debate is where it is and why the conversation is about the wrong things."