Advocates see mental health, substance abuse reforms in Cures bill as big step forward

Congress is poised to take an important first step this week in improving the nation's struggling system of care for millions of Americans suffering from mental illness and drug addiction.

The House is scheduled to vote Wednesday on a sweeping package of mental healthcare and addiction treatment reforms as part of broader legislation, called the 21st Century Cures Act, to speed regulatory approval of new prescription drugs and medical devices. The Senate is expected to vote soon after on the legislation, which was crafted by House and Senate leaders from both parties.

The bill would authorize $1 billion over the next two years to address the nation's opioid abuse crisis, and would authorize or re-authorize smaller amounts of funding for a wide range of federal grants for mental health and substance abuse services. But Congress would still have to decide next year whether to appropriate that money.

Mental health advocates expressed cautious optimism that President-elect Donald Trump's administration and congressional Republican leaders will support that funding—even though House Speaker Paul Ryan and other GOP leaders have promised to cut taxes, boost military outlays and reduce discretionary federal spending.

“A lot of advocacy will have to occur around getting some of these initiatives funded,” said Ron Honberg, senior policy adviser at the National Alliance on Mental Illness, a coalition of advocacy groups. “I feel pretty confident a number of them will be funded, but probably not all of them.”

He and other advocates are worried, however, that GOP plans to repeal the Affordable Care Act's Medicaid expansion, turn Medicaid into a state block-grant program, and reduce federal contributions could undercut the benefits of the new legislation. “With Medicaid expansion, a lot of single, adult males who have serious mental illness have become eligible for coverage,” said Frankie Berger, director of advocacy for the Treatment Advocacy Center. If the expansion is repealed, she added, states will have to figure out how to pay for their care.

The pending bill's mental health provisions, drawn mainly from 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 abuse disorders; authorize grants for community treatment teams and assisted outpatient treatment for noncooperative patients; and create a path to allow Medicaid managed-care plans to pay for short-term inpatient stays.

In addition, the bill requires HHS to clarify when providers may share patient 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.

Hospitals and physicians will welcome a provision clarifying that Medicaid is allowed to pay providers for the delivery of mental health and primary-care services to a patient on the same day, ending a source of frustration for primary-care providers.

Providers and families of behavioral health patients also may welcome provisions that require HHS and the Office for Civil Rights to clarify when providers can use patient information protected by the Health Information Portability and Accountability Act for treatment purposes and share such information with patients' family members and caregivers.

On opioid treatment, the new bill resolves, for now, a partisan battle over funding for the Comprehensive Addiction and Recovery Act, for which President Barack Obama and congressional Democrats demanded more money. The CARA bill strengthens prevention, treatment, and recovery initiatives by giving providers and law enforcement officials more tools to help drug addicts and expanding access to a drug to help reverse overdoses.

Rep. Tim Murphy (R-Pa.), a psychologist who was the chief author of the House mental health bill, said the single most important provision is establishing an assistant HHS secretary in charge of mental health and substance abuse to drive and coordinate federal policy in this area. “We have to restructure the agencies to work together and make sure money is spent wisely and we're focusing on serious mental illness, not wasteful feel-good things,” he said in an interview last month, noting that nearly 1,000 Americans die every day from mental health-related events.

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.

A Murphy spokeswoman said her boss didn't get everything he wanted in the compromise package that was included in the 21st Century Cures bill. He wanted to more fully allow Medicaid plans to pay for inpatient psychiatric care and give providers and families greater access to HIPAA-protected patient information to assist treatment efforts. But the legislation requires a study of the benefits and costs of Medicaid paying for inpatient treatment, and creates a path to sharing patient information while protecting the rights of patients, she noted.

Mental healthcare providers and advocacy groups say 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.

They also say Medicaid programs and private insurers need to increase payments to providers to encourage more to serve people with serious mental illness. Without higher payments, they argue, it will be even harder to attract more psychiatrists, psychologists and other clinicians to serve this population.

“The dearth of available clinicians is abysmal,” Berger said. “We need to fix reimbursement rates (for behavioral-care services) to make sure they are on par with medical and surgical treatments.”

Murphy acknowledged the need for greater investment to train more caregivers and encourage them to serve seriously mentally ill people. “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.”

While advocates say the legislation is just a first step, they argue it's a crucial one. “Our whole system was failing, and no one was talking about it unless they had a family member in crisis,” Berger said. “Now the federal government is acknowledging the system is broken and saying we'll try to change some things. This creates a brand-new foundation level for where we can go.”

(This story was updated on Nov. 30, 2016.)