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Change is coming!

December 1, 2008
by Ronald W. Manderscheid, PhD
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We must ensure our agenda is on lawmakers' radars

During the fall presidential campaign, it was very hard for many of us to reconcile concern with a rapidly failing economy and concern with Gov. Sarah Palin's clothes. How dare the national media consider these two stories with the same intensity and seriousness! Now that the campaign is a fading memory, we need to regain our perspective, take stock, and set our future course into the uncharted waters of the Obama administration and a new Congress.

The election of Barack Obama and Joe Biden signals that our national government will be concerned about middle-class, working-class, and poor people during the next four years, and that it will have empathy for the very poor, the downtrodden, and those who are homeless. Biden is from a traditional working-class family; Obama's mother was a single parent who hovered near poverty for years.

The strengthened Democratic majorities in both the Senate and the House suggest that the relationship between the administration and Congress will be vastly different than during the troubled waning years of the Bush administration. Clearly, many more opportunities will exist to build and move a joint national agenda. We need to ensure that mental and substance use health and care are part of that agenda.

Concern about our economy, with a rapidly spreading recession and the potential for a 1929-style depression, will be riveting to both the Obama administration and Congress. However, we must remember that Franklin D. Roosevelt created his most innovative programs during the depths of the Great Depression. These programs—Social Security, employer-based health insurance coverage, and community general hospitals, among others—endure today, more than 75 years later.

Promoting national health reform

We hope that the Obama administration will take on national health reform, involving universal coverage, system reform, and financing reform. However, if this happens, we will need to develop “new arguments” about health. For starters, we must ask how national health reform can help us rebuild the American economy. How would have FDR approached this issue? To my knowledge, no one has yet asked this question. We must.

Taking the same point of view, we must ask what the mental health and substance use care fields can contribute to the recovery of our economy. I believe we already know the answer. Mental and substance use conditions sap economic performance at the personal and community levels. Good care improves worker performance. Hence, the issue for us becomes how to link national health reform with good care to improve our economy's overall performance. This will not be an easy task, but neither will it be “mission impossible.”

We also know that mental and substance use conditions are strongly correlated with major chronic diseases, such as diabetes and heart disease. Good mental health and substance use care can reduce these diseases' severity and long-term costs. We must collaborate more closely with our primary care colleagues to provide incontrovertible evidence to support this assertion.

In practical terms, we really need this evidence today. Chronic illnesses consume 75 cents of every dollar spent on healthcare. Reducing this fraction only slightly, say by 5%, would reap an enormous economic return of about $115 billion. This is more than the total direct public and private expenditures for mental and substance use care today!

As part of this agenda, we also must begin to focus on health rather than disease, and we must ask how we can prevent diseases before they occur. True health reform must encompass health, not just healthcare.

Reforming our healthcare system

An equally important future national agenda is reforming the healthcare system to regain the American people's confidence. For us, this implies that much more work will be required on integrating mental and substance use care with primary care.

Some obvious steps can be taken to begin this task. We can work to:

  • reduce barriers (e.g., permitting Medicaid to pay for a mental health and a primary care encounter on the same day);

  • expand care coordination (e.g., rewriting CMS case management definitions); and

  • embed coordinated, integrated care into SAMHSA's and HRSA's grant programs (e.g., requiring that block grant plans address integrated service delivery).

Integrated care will improve consumer outcomes, and it will lead to financial savings.

A right to good health

As a people, we need to become emboldened and explicit about good health as a human right for everyone. This is not simply a pie-in-the-sky concept, but one grounded in economic realities. The United States cannot be competitive in the global economy without a healthy population. This right must include good mental health and a healthy approach to substances. Our thinking will need to expand beyond disease and recovery to embrace wellness, not only for individuals but also for populations.

Final thought

We must not be cowed by fear, but act with courage. I can see FDR smiling.

Ronald W. Manderscheid, PhD, is Director of Mental Health and Substance Use Programs at the consulting firm SRA International.

To contact Dr. Manderscheid, e-mail

Behavioral Healthcare 2008 December;28(12):36-37