The next big reform challenge is mental health

After decades of taking a back seat to other social issues, fixing the nation's broken system of care for millions of Americans suffering from mental illness and drug addiction has risen to the top of Congress' agenda.

Lawmakers are poised to pass a sweeping package of mental healthcare reforms during the lame-duck session next month, following enactment in July of legislation to address the epidemic of opioid addiction. They and advocacy groups are optimistic the Senate will follow the House in approving bipartisan legislation to revamp the government's mental healthcare efforts and increase funding for prevention and treatment.

“There are 959 deaths every day related to mental illness—suicides, overdoses, homicides, mentally ill homeless people dying prematurely,” said Rep. Tim Murphy (R-Pa.), a psychologist who is the chief sponsor of the House bill. “Under any other circumstance, we would consider that an epidemic that would panic us. We have to do something.”

The big question is whether Congress will have enough time during the 20 days of the lame-duck session following the November election to pass the legislation, given the need to approve a continuing budget resolution and potentially address tough issues such as the Trans-Pacific Partnership trade agreement and a revamp in the federal approval process for prescription drugs and medical devices. There's also the chance that partisan rancor after the election could derail across-the-aisle cooperation.

“I remain optimistic because we've talked to the leadership in both parties in the House and Senate, and they want to make this a priority,” said Paul Gionfriddo, CEO of Mental Health America, a coalition of mental health advocacy groups. “Even if it doesn't pass this time, we've laid good groundwork for next year.”

Lawmakers such as Sen. Bill Cassidy (R-La.) say broad consensus has developed after hearing constituents' heart-wrenching stories about people struggling with mentally ill or addicted relatives who are unable to get adequate treatment. “Whenever Sen. Cassidy asks people, 'Who has been touched by mental illness?' hands shoot up around the room,” a Cassidy aide said.

Legislators are also increasingly aware of the costs of housing thousands of severely mentally ill people in prisons and jails, of the stresses on hospital emergency departments of holding patients for lack of psychiatric beds, and of growing numbers of mentally ill and addicted homeless people wandering the streets and occasionally having tense encounters with police. Also grabbing their attention are the painfully regular cases of mentally ill people engaging in incidents of mass violence, though only a small percentage of mentally ill people commit violent acts.

Mental disorders top the list of the most costly conditions in the U.S., accounting for $201 billion in healthcare spending in 2013, far more than was spent on heart disease or cancer, according to federal data.

An estimated 8.1 million adults have schizophrenia or bipolar disorder, and 3.9 million go untreated in any given year, according to data from the National Institute for Mental Health. Fifty-seven percent of adults with a mental illness received no treatment in 2012-13, while 64% of youth with major depression were untreated, according to the Substance Abuse and Mental Health Services Administration.

The pending legislation would build on a number of other measures taken during the Obama administration to improve funding for and access to mental healthcare. Those actions include Medicaid expansion under the Affordable Care Act; the ACA's requirement that health plans cover mental healthcare as an essential benefit; a separate law mandating equal coverage for behavioral and physical care; and a law funding creation of innovative behavioral health centers in eight states.

These policy changes come as a growing body of research shows that early intervention and treatment can significantly improve the long-term prognosis for people with serious mental illness.

“There's been more done for mental health in the last eight years than there has been since 1972,” said Richard Frank, a professor of health economics at Harvard University who served in a top HHS post in the Obama administration. “The new legislation will continue the momentum.”

The Helping Families in Mental Health Crisis Act, which passed the House 422-2 in July, would create a new HHS assistant secretary in charge of mental health and substance use disorders; authorize grants for community treatment teams and assisted outpatient treatment for noncooperative patients; and allow state Medicaid managed-care programs to pay for short-term inpatient stays.

In addition, the bill requires HHS to clarify when providers may share information. It would also step up enforcement of rules for insurers to cover mental healthcare on parity with physical health; boost support for training more mental health professionals; help providers more easily track available inpatient beds; support a wide range of programs to combat suicide and improve screening, early diagnosis and early intervention for mental illness in children; and push to reduce incarceration of nonviolent, mentally ill offenders over the next decade.

In the Senate, the Mental Health Reform Act contains some similar provisions but is not as comprehensive. Still, supporters see broad consensus between the House and Senate bills and express confidence the chambers can reach agreement if congressional leaders make this a priority. A compromise is in the works to strip out a Senate GOP provision making it easier for mental patients to regain gun-ownership rights, which had threatened to torpedo the legislation.

Still, mental healthcare providers and advocacy groups say the legislation would be just a first step toward overhauling the nation's broken behavioral health system and that much more money needs to be invested in expanding services and training more mental health professionals. The pending legislation would authorize only modest increases in grant funding.

“We won't have enough treatment support for all the people who need it,” said Heather O'Donnell, vice president for public policy at Thresholds, a large community-based agency serving seriously mentally ill people in the Chicago area.

What's really needed, she said, is a significant increase in Medicaid payment rates to providers and broader insurance coverage for mental health services.

Murphy acknowledged the need for greater investment, urging the Senate to authorize more spending. “Absolutely,” he said. “Over half the counties in America don't have a psychiatrist or psychologist or other mental health professional. You can't get services even if you want them.”

Bernard Tyson, CEO of Kaiser Permanente, agreed that health plans and providers need to rethink how they cover and treat mental illness and addiction. Kaiser launched a broad initiative to improve coverage and care, following sanctions against Kaiser during the past two years for alleged deficiencies in behavioral-care services.

Kaiser has hired more mental health providers and added telehealth sessions, and it is experimenting with deploying behavioral providers in primary-care clinics. On the insurance side, the system is restructuring its benefits to ease access to care. It's also running public-service announcements to increase awareness of mental health issues in children and reduce the stigma of seeking treatment for people of all ages.

“This is one of the few areas where there is universal agreement that we need to do something in this country,” Tyson said.

That's not to say there aren't continuing differences over many issues, including the most effective treatment approaches and how to share sensitive patient information with families and among providers. There also are sharp partisan differences in Congress over expanding Medicaid under the ACA or turning the program into capped state block grants. Advocacy groups fear the latter approach would roll back crucial coverage gains for people with behavioral disorders.

But experts say the legislation would create a badly needed framework for trying out different innovative approaches and setting the U.S. on a more effective course of preventing and treating the terrible scourge of serious mental illness.

“It would lay a nice foundation for building a better system of care that we all expected to happen decades ago,” Mental Health America's Gionfriddo said. “I'd love it if things moved quicker; but we didn't get here overnight and we're not going to get out of here overnight.”