Mental healthcare legislation gives boost to inpatient care

More than two years ago, a mentally ill young man shot 20 children and six adults to death at Sandy Hook Elementary School in Newtown, Conn. Many experts blamed an underfunded and inadequate behavioral healthcare system at least partly for the tragedy, and there were widespread calls for national reform. But it hasn't happened.

The mentally ill still face major barriers to accessing care years after states and municipalities slashed their mental health budgets, resulting in sharp cuts in capacity at inpatient and outpatient treatment facilities. There's also a dwindling supply of behavioral health professionals.

The Newtown murders, along with the horrendous 2011 shooting spree in Arizona by another mentally ill young man that killed six and severely wounded former Rep. Gabrielle Giffords, did not convince Congress to pass a comprehensive overhaul of the nation's mental health system. And mental health providers and advocates say any action remains a long shot.

But behavioral health stakeholders are gearing up for another push for legislation in 2015, uniting behind a bill first introduced in 2013 by Rep. Tim Murphy (R-Pa.), a psychologist who spent more than a year holding hearings on mental illness after the Sandy Hook shootings. But while many professional and patient-advocacy groups back the measure, others fear the proposal will shift the focus away from relying on community-based mental healthcare providers and undermine the years put into deinstitutionalizing the mentally ill in the U.S.

“We're concerned about moving in that direction,” said John Head, spokesman for the Washington-based Bazelon Center for Mental Health Law, which opposes the Helping Families in Mental Health Crisis Act sponsored by Murphy. “We want to incentivize states to provide more community-based services, make them more accessible so that people have the care they need, when they need it, where they need it.”

Murphy's bill would sharply reduce the power of the Substance Abuse and Mental Health Services Administration, or SAMHSA, which provides federal funding for states to provide mental health services. The bill would create an assistant secretary for mental health within HHS to oversee all federal mental health spending, and, most significantly, allow Medicaid for the first time to pay providers for inpatient mental health stays so mentally ill patients don't languish on emergency room gurneys.

The legislation also requires states that receive federal mental health funding to make it easier for courts to order treatment for people with mental illness. Current standards on involuntary treatment vary from state to state, with 23 allowing courts to make the determination only when they deem a person an imminent danger to themselves or the public. Under the bill, courts could order treatment for those who have been hospitalized or jailed repeatedly, or lack the capacity to make informed medical decisions.

While the legislation opens the door for increased inpatient treatment, it also authorizes $60 million for expanded outpatient treatment programs as well as provides for expanded use of telepsychiatry in rural areas. It would also earmark $40 million for the National Institutes of Health's Brain Research through Advancing Innovative Neurotechnologies initiative, which seeks to identify the molecular pathways of mental illness and dementia.

In announcing plans to reintroduce the bill this year, Murphy on Jan. 7 said: “In the face of this growing crisis, we must approach serious mental illness as a medical emergency that engages the community and (offers a) medical response to help people and families trapped in this system that is misguided, in denial and disconnected.” The bill, which had more than 100 co-sponsors last year, is expected to draw bipartisan support in Congress again this year, as well as the endorsement of a number of mental health advocacy organizations.

Yet some contend the measure focuses too heavily on initiatives meant for the severely mentally ill, who represent only 9 million of the estimated 44 million adults in the U.S. living with mental illness.

According to Head of the Bazelon Center, focusing more resources on community mental health would reach more people and prevent them from getting to the point where they would need the kind of interventions Murphy's bill proposes.

“We want to make sure that there are services, and the services are available for people to be appropriately treated in a community setting and they don't have to be put into a facility or anything that even resembles warehousing people,” Head said.

The likelihood of competing approaches emerging in the current session of Congress is slim. Legislation introduced in 2014 by then-Rep. Ron Barber (D-Ariz.), who was wounded in the shooting incident in which Giffords was shot, would have increased mental health funding for veterans and active-duty service members, as well as created a White House Office of Mental Health Policy. But Barber lost his bid for re-election last November.

Some of the provisions in Murphy's bill are controversial, especially the focus on involuntary treatment and the reduced role for SAMHSA. Critics contend the bill is an attempt to circumvent the agency by taking away its authority to distribute nearly $500 million annually in community mental health services block grants.

Murphy has been critical of SAMHSA, saying the agency's grants and programs do not use the most effective medical treatments for the care of those with serious mental illness. His bill would give the new HHS assistant secretary the power to allocate mental health block grants.

“A few of the things in the bill that were problematic for us last year included the treatment of SAMHSA,” said Paul Gionfriddo, CEO of the patient advocacy group Mental Health America. The organization came out against the bill last year over concerns about the proposed SAMHSA changes, as well as what it viewed as too little focus on early interventions.

But the nation's largest mental health advocacy group, the National Alliance for Mental Illness, is throwing its weight behind the legislation. “It's not trying to solve every problem in the mental health system,” said Andrew Sperling, director of legislative affairs for the NAMI. “It's really focused on people with the most severe mental illnesses who are not getting access to treatment and are experiencing very bad outcomes.”

According to Sperling, provisions that would increase access to inpatient care offer a better alternative than leaving those with serious mental illness on the street, in jail or temporarily housed in hospital emergency departments.

In a practice known as “psychiatric boarding,” a hospital may be forced to hold a psychiatric patient while waiting for the patient to be admitted to a certified mental health facility. Boarding has been widely recognized as an unsuitable option for patients, who face delayed evaluation and treatment.

Psychiatric boarding at hospitals grew as states and municipalities cut their mental health budgets, which began long before the Great Recession shrank budgets. The number of psychiatric beds at public mental health treatment facilities declined from 50,509 in 2005 to 43,318 by 2010, according to a 2012 report by the Treatment Advocacy Center.

The report found that as many as 13 states had closed 25% or more of their beds between 2005 and 2010. Since 2010, the number of beds has been further reduced to about 38,000 nationwide, well below the recommended 50 beds per 100,000 people that advocates say is needed to provide adequate inpatient psychiatric services.

The decline in inpatient facilities has also led to a rise in the number of mentally ill housed in the U.S. penal system. Roughly 17% of the nation's 2.3 million prisoners are individuals who fit the criteria of having serious mental illness, according to a 2012 report by the Justice Department. Since most are housed in state and local jails, state Medicaid directors are backing Murphy's efforts to “advance the discussion on this topic.”

“If it gets bad for patients who need that level of services, we are limiting the scope and location of where they can receive appropriate treatment,” said Andrea Maresca, director of federal policy and strategy for the National Association of Medicaid Directors.

Under Murphy's bill, the Medicaid restriction, known as the IMD exclusion, would be removed for psychiatric hospitals, which Sperling and others say would give states a financial incentive to provide greater access to such facilities.

A repeal of the exclusion could have a big effect on acute-care hospitals, many of which have inpatient psychiatric-care units that could address patients' mental and physical health needs.

Even if the bill passes Congress, it may be vetoed by President Barack Obama because of its proposed changes to SAMHSA. Paying for the legislation represents another roadblock because it would involve more Medicaid spending.

The most likely pay-for targets are existing block grants that support community mental health facilities.

“We believe the end result would be less support for community-based services,” Head said. “If you're going to do these things, the money to do them has to come from somewhere. We're concerned that it's going to come from money that is already budgeted for mental health services.”

Follow Steven Ross Johnson on Twitter: @MHsjohnson