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Parity Panel A funding crisis threatens the future of the mental health system in California, and specifically its goal of parity with the physical health system, a panel on mental health funding and party led by Economist Richard Scheffler concluded. Dr. Scheffler called upon the state's leadership to marshal the intellectual, political and economic forces to provide parity for the mentally ill. He chaired the Funding and Parity Panel, one of four at the Mental Health & Public Policy symposium presented jointly via video teleconferencing from UC Berkeley and from UCLA. Assemblywoman Helen Thomson, a panelist, Chair of the Assembly Health Committee, and a Registered Nurse, said, "California spends billions and billions on the consequences of untreated mental illness. If we applied the same policies to other illnesses, we would tell the cancer victim to come back when the tumor has metastasized." Richard Scheffler, Ph.D., is Professor of Health Economics, School of Public Health, and Policy Director, Nicholas C. Petris Center on Health Care Markets and Consumer Welfare, UC Berkeley. Other panelists were Stephen W. Mayberg, Ph.D., Director, Department of Mental Health, State of California; and Ralph Catalano, Ph.D., Professor of Public Health, Division of Health Policy & Management, UC. Berkeley. But Dr. Mayberg noted that while the amount of monies the provided local governments is growing, the share provided by the state will be cut. Assemblywoman Thomson, the author of major mental health reform legislation, issued a call for action to overcome the status quo and provide the programs and funding so desperately needed. She said every level of government finds a rationale to short change mental health on dollars and as a result "we are practicing systematic discrimination against those with mental illness." Overwhelmingly, she said, the people of California, when polled, support parity in funding for mental illness, are willing to see their taxes increased to meet this need and opposed cuts in mental health programs. Dr. Catalano said there is another type of mental health problem that concerns public policy: "That," he said, "is the problem of caring for severely and persistently mentally ill persons who have no insurance. "The real or imagined threats and incivilities associated with these very ill people have diminished the residential, cultural, and commercial amenities of great cities," he said. "These persons are often dangerous to themselves or others. They typically consume expensive emergency treatment that represents a large fraction of the cost of mental health services provided at public expense." The scope of mental illness is broad, Dr. Scheffler continued, noting that within the next 20 years depression will be the second leading cause of disease in the world -- and that globally one out of four persons will have a mental health problem, citing the World Health Organization report as his source. Dr. Scheffler ranked managed care as more important in mental health care than in health care overall. He said this is because 90 per cent of the insured with mental illness are dealt with in managed care while more than 30 per cent of the mentally ill go untreated and lack any insurance coverage. Calling parity for mental health the issue most central to progress, Dr. Scheffler explained that this meant that a mental illness would be treated on a par with any other illness. But he said that parity laws imposed by states did raise costs, but the increases were small. He said that clever insurance companies figured out a way around parity by differentiating the number of visits and setting the limit for mental illness at half that of other illnesses. Assemblywoman Thomson said that state law provides treatment "to the extent funds are available," but added: "Nothing less than an entitlement to care" is fundamental to a solution. She said we cannot discuss mental health without noting that these policies are marked by discrimination and the misunderstanding. Adequate funding of outpatient services, she said, would reduce the cost because the criminalization of mental illness costs $1.2 and $1.8 billion annually and when the mentally ill are kept in hospitals longer than needed this too adds great expense which could be avoided by spending more dollars on out patient services that would reduce costs. Dr. Catalano reported that three interest groups have dominated mental health policy formation, the civil libertarians, social reformers, and clinicians, adding: "The interests of these groups coincide only on the belief that the patient should be the sole client of public mental health services. Is this bad? Should we not assess mental health services solely by their effect on the patient? "This question goes to the larger issue of whether any public policy should be driven only by those most affected. Our political culture has long held that public policies deserve public support only when they value the general welfare over that of the most affected interest groups.... Public policy regarding mental health has traditionally been too captured by those most affected. "The notion that the public at large has a right to expect that mental health services will reduce the threats and incivility associated with the SPMI (Severely and Persistently Mentally Ill) is increasingly accepted by elected officials and will begin to influence public policy by opening the door to a wider debate and broader participation." Noting evidence of improvement, Dr. Catalano attributed this to the emergence of a fourth interest group ( the families. The families have increasingly asked for public policies that reduce the burden put on them by their ill relatives, he said, adding: "That burden includes not only the physical, financial, and emotional commitment required to care for very ill persons, but also the incivilities and threats alluded to above," Dr. Catalano explained. "Families agree with civil libertarians that very ill persons should not be subjected to a hostile state, but disagree with the notion that state cannot coerce the SPMI into treatment. "Families, like reformers, want 'good' care for their ill members but good means not only that the patient is satisfied but that the family is also safer and less burdened. They may agree with providers that more funding would be good but families would like to see the funds available used in the most creative and effective way possible. "Family involvement has opened the door to a view of publicly funded mental health services that was traditionally rejected by other participants in the policy struggle. That view is that the client of service providers is not just the patient, or his or her family, but the community at large." When families forced the debate to include the effects of policy on persons other than the patient this line of reasoning has been extended to yield the argument that the community should be the client of public mental health services. "The adherents of the argument would have mental health policy evaluated on whether it reduces violence and other incivilities committed by the SPMI in the community. "This argument, combined with capitated financing, may lead to more efforts at prevention including those that involve coerced participation by the patient." In the first public report on the 2002 State of California mental health budget for 2002, Dr. Mayberg said overall mental health assistant to local governments would rise from $1,517,289,000 in 2002 from $1,416,274,000 in 2001. The state fund component of that money, he said, would fall to $385,340,000 for 2002 compared with $419,307,000 in 2001. He cited these key factors:
His department, like other departments in state government, would take the hit because of reduced revenues. But he said that state funding had nearly doubled between 1997 and 2001.
Dr. Mayberg listed a number of state mental health expenditures not in his budget, including $250 million for a new state hospital. He also said that payments for all anti-psychotic drugs were the fasted growing expense, and that these are in the Medical budget. Noting a heightened degree of public interest and media attention, he said "money drives what we do rather than good programming." In summary, he said some strategies have been developed that work, but the state finds it very difficult to expand pilot programs statewide. Education and awareness has made a big difference, he said, discrimination is the remaining major barrier. If you are an older adult, he said, it is very difficult to get into a program that works. Programs, he said, follow the money instead of the need, with great pockets of excellent but many pockets of unmet need. It's the rank and file Californians who require these services, he said, but unfortunately mental illness lies hidden with too many of the mentally ill languishing in silence or in places where we cannot see them. |
