Access: The TAC Blog
The number of state institutional psychiatric beds, which were once the primary setting for psychiatric treatment, has gone down dramatically nationwide. Community psychiatric hospitals, private hospitals, and nursing facilities filled the gap in the 1980s and 90s, but inpatient capacity in these settings, too, has recently been on the decline. There is widespread concern — given ample voice by the media — that we need to restore our nation’s psychiatric bed capacity, both to reduce the risk of violence perpetrated by people with untreated mental illness, and for their own safety and health.
In reality, however, inpatient treatment should form only one part of a robust system of mental health care. For comparison, note that treatment for even the most serious medical conditions now frequently occurs in outpatient and in-home settings. However, recent findings from the Healthcare Cost and Utilization Project reveal a widening gap between our country’s approaches to hospitalization for mental and for physical health conditions: Between 2005 and 2014, the rate of inpatient stays per 100,000 people for all causes decreased across all age groups, while the number of hospital stays for mental health/substance use actually increased by 12.2 percent.
To examine these trends and their implications, the National Association of State Mental Health Program Directors recently commissioned a series of working papers on the question: “What is the real need for inpatient psychiatric beds in the context of a best practice continuum of care?” In this series, researchers and policy leaders describe ways to improve mental health and substance use disorder treatment at many different points in a community’s system of care so as to necessitate fewer psychiatric hospitalizations, of shorter duration, with better and more equitable outcomes.
Increasing the number of psychiatric inpatient beds is not the solution in most communities. As my colleague Kevin Martone and I argue in our contributions to the series, investments in care and services can create alternatives to inpatient beds that are both more effective and less costly. “Beyond Beds: The Vital Role of a Full Continuum of Psychiatric Care” lays out specific public policy recommendations to minimize the human and economic costs associated with severe mental illness by building and invigorating a robust, interconnected, and evidence-based system of care. And as “The Role of Permanent Supportive Housing in Determining Psychiatric Inpatient Bed Capacity” shows, stable and affordable housing combined with voluntary services can contribute to improved outcomes in both physical and behavioral health, while reducing incarceration and homelessness. Furthermore, the cost of serving a person in supportive housing is half that of a shelter, a quarter that of incarceration, and one-tenth the cost of a state psychiatric hospital bed.
Advances in medical research and technology, chronic disease management programs, and alternative treatment settings such as walk-in urgent care centers — along with payment approaches that support medical care in outpatient settings — have all helped reduce hospitalizations for physical health conditions. Evidence-based mental health care options, especially when provided in the communities where people live, offer the potential to bring down psychiatric hospitalizations as well. Private insurers rarely cover these services, however, and state and federal mental health funding are drastically insufficient to meet demand. Medicare and Medicaid together fund approximately 60 percent of inpatient care in the United States. Unfortunately, Medicare funds very few evidence-based mental health practices, and Medicaid funding for housing transition and tenancy-sustaining programs — a critical component of permanent supportive housing for people with mental health disabilities — is not yet fully incorporated into services.
We don’t need to re-create massive numbers of psychiatric inpatient beds. Rather, policymakers must prioritize funding for the evidence-based preventive treatment and services that people with mental illness need and desire. With these effective and cost-saving resources available and truly accessible in every community, hospitalization will play an appropriate role in a balanced system.
DEPENDING ON WHOM YOU ASK, an Olmstead settlement agreement can be a blessing or a curse. While the parties typically agree on the principle affirmed by the U.S. Supreme Court — that people with disabilities should live in the most integrated setting possible — costly housing markets and complex service delivery systems are formidable barriers to this goal. More than 15 years after the Supreme Court's landmark Olmstead decision, states still struggle to serve people with disabilities in integrated settings.
Delaware and New Jersey are two states that have recently resolved their Olmstead settlements, achieving significant reforms though years of dedicated effort — Delaware's settlement was originally signed in 2011 with the U.S. Department of Justice, while New Jersey's was signed in 2009 with Disability Rights New Jersey and the Bazelon Center for Mental Health Law.
Thanks to the successes of these states in substantially attaining the outcomes required by their agreements, thousands of people with serious mental illness now have the opportunity to live in integrated community settings. What is perhaps most impressive is that a substantial part of the system reform accomplished by New Jersey and Delaware occurred during the great recession (2007 to 2009) and the following period of slow economic recovery.
Delaware and New Jersey both offer good examples of what is possible when states focus on community integration for people with mental illness and other disabilities.
A U.S. Department of Justice press release describes some of Delaware’s most significant gains. The state reduced the number of bed days in the Delaware Psychiatric Center by 47.2 percent. The number of Medicaid-eligible Delawareans receiving community-based services has increased by 92 percent since the United States began its investigation. The state has seen the growth of a strong peer and self-advocacy movement that is now incorporated into its entire service system. Two statewide mobile crisis teams and a crisis walk-in center divert 70 to 90 percent of the individuals they engage away from hospitalization and criminal justice interaction and toward community-based services.
As a press release from Bazelon details, New Jersey’s settlement also brought about important changes. Between 2005 and 2016, New Jersey invested nearly $104 million in services and rental assistance for Olmstead-related activities. The state also established a $200 million special needs housing trust fund, and created nearly 1,500 new permanent supportive housing units through capital and rental assistance. New Jersey’s state psychiatric hospital census was reduced by a third, patients’ average length of stay went down, and one state hospital was closed — changes that allowed state hospital operating funds to be reinvested in community supports. New Jersey created a Medicaid benefit to fund community support services for residents of supportive housing, and leveraged additional Medicaid money with investments in community-based services.
Both Delaware and New Jersey used their Olmstead settlement agreements as a driver for change, embracing a community integration platform to guide them toward significant behavioral health system reform. These states recognized that without sustainable system reform and new resources, counting numbers to achieve settlement targets wouldn’t bring about the changes needed to serve people with serious mental illness effectively.
Commitment to Olmstead in a Changing Landscape
Across the country, Olmstead stakeholders are raising questions about the future of community integration for people with serious mental illness and other disabilities. Doubt surrounds the capacity and motivation of states to tackle Olmstead in the years ahead; the commitment of the Department of Justice to focus on Olmstead as strongly as it has in the past; and the ability of protection and advocacy organizations to hold states accountable.
Changes to the Medicaid landscape at the federal level could put at risk the types of benefits coverage that makes community integration work for people with disabilities. Looming cuts to non-mandatory discretionary budgets, such as HUD housing assistance programs, may further jeopardize the ability of states to support community integration.
The Department of Justice has been instrumental in the movement toward community integration, enforcing Olmstead by leading investigations, entering into settlement agreements in several states, and intervening in support of class actions. If the Department shifts its attention to other priorities established by the Trump administration, individuals with serious mental illness and other disabilities will be left without civil rights enforcement at the very time when loss of benefits could place them at greater risk of institutionalization. Many state protection and advocacy agencies, as well as legal services organizations, have the authority to bring class action lawsuits on behalf of people with disabilities, and these groups may be called upon to step up their efforts.
Complying with Olmstead will become increasingly difficult if federal policy and budgetary changes reduce support to states in the near future. Federal cuts currently under consideration would put people with mental illness and other disabilities at greater risk of institutionalization and homelessness due to thinner benefits and services and reductions to the rental assistance that can make housing affordable. Our February blog post on budget impacts explained the challenges states will face in making resources available to meet federal requirements. Nevertheless, it is states that are on the hook to ensure that individuals are served in integrated settings.
Community integration mandates in the Olmstead decision, Title II of the Americans with Disabilities Act, and Section 504 of the Rehabilitation Act are still the law, regardless of fluctuations in federal enforcement and support. Furthermore, serving individuals with disabilities in integrated, community-based settings is good, cost-effective policy. With these facts in mind, states should continue to design and implement Olmstead plans that build sustainable, system-wide improvements. The benefits — to individuals, communities, and all who recognize the value of true integration — are well worth the challenges.
Access: The TAC Blog is Launched!
With the addition of Access to TAC’s website, our senior consultants are now able to contribute their unique perspectives from the intersection of affordable housing, health care, and human services policy. Posts so far have included John O’Brien on “The Next Frontier: Care and Service Integration for People with Substance Use Disorders” and Kevin Martone asking “Can States Take On the Fiscal Responsibility that Federal Policymakers Are About to Hand Them?” Watch your email for monthly post alerts.
A New “Practice Profile” on In-Home Therapy
In the fall of 2015, the Children’s Behavioral Health Initiative (CBHI) Knowledge Center, in collaboration with MassHealth, began an extensive effort to develop a “practice profile” for providers of in-home therapy to Massachusetts children and youth receiving publicly funded behavioral health services. After conducting a literature review and a series of workshops with stakeholders, CBHI drafted the new resource and engaged TAC to help produce the final version. Publicly available, the In-Home Therapy Practice Profile offers in-home therapy providers easy-to-use guidance on best practices in cultural relevance, risk assessment and safety planning, engaging natural supports, and other key areas.
TAC Staff in Action
Senior Associate Liz Stewart participated in the inaugural Winter Walk across Boston to end homelessness; Liz and Associate Lauren Knott joined a panel on “Improving Systems in Balance of State and Regional CoCs” at the National Alliance to End Homelessness’ Annual Conference on Ending Family & Youth Homelessness.
We’re happy to welcome Phillip Allen as a new Associate on the TAC housing team. Phil is helping Supportive Services for Veteran Families (SSVF) grantees and communities to develop and implement effective programs.
The Next Frontier: Care and Service Integration for People with Substance Use Disorders - by John O'Brien
THIS MONTH, states are submitting proposals to the Substance Abuse and Mental Health Services Administration (SAMHSA), outlining their plans to address the opioid crisis. While the strategies proposed will vary, SAMHSA’s message is clear: the funds it provides must be used to connect individuals to needed services in communities that have been hit hardest by opioids. Time is of the essence, and states have only a few months — lightning speed for most state bureaucracies — to increase access to substance use disorder (SUD) services.
Many states will no doubt use their awards to expand prevention and treatment programs. That’s terrific — enhancing the services that directly address addiction should be paramount. However, it is of great importance that federal and state agencies also ensure the availability of physical health care and long-term services, such as in-home supports, for individuals dealing with addiction. States should take steps to integrate these forms of care into the continuum of SUD services, rather than relegating them to separate systems.
Awareness has never been stronger of the importance of an integrated approach to treating diabetes, asthma, HIV/AIDS, and behavioral health conditions. Data has helped show the impact these health challenges have on people’s morbidity, quality of life, and health care costs, while also revealing that people who have any one of these conditions often have others on the list as well — or are at significant risk for acquiring them.
The good news is that insurers and health care providers recognize the need to coordinate medical, behavioral health, and long-term services. Over the past ten years, Medicare and Medicaid have laid the foundation for developing integrated care models to help tens of millions of Americans — and private sector insurance companies have followed suit. These insurers have learned from the pioneering work of health care providers in integrated care, and are bringing their efforts to scale.
A Good Use of Resources
Much of the energy powering integration efforts in behavioral health has so far been directed specifically toward mental health. As the opioid crisis intensifies, however, private and public insurers are paying increased attention to the impact of substance use disorders on morbidity. Meanwhile, prompted by federal requirements that many insurance plans cover SUDs, insurers have found plenty of data that offers compelling reasons to integrate physical health care, SUD services, and long-term supports.
Individuals with untreated SUDs and co-morbid medical conditions often incur high medical costs. For instance, $3.3 billion was expended in one year on behalf of 575,000 Medicaid beneficiaries with a secondary diagnosis of an SUD — triple the cost for those without an SUD. Two of the top ten reasons Medicaid patients are readmitted to a hospital within 30 days of discharge are SUD-related. Conditions that occur more frequently among individuals with SUDs than in the general population include respiratory issues, skin infections, and suicide.
Other problems related to SUDs are opioid-exposed pregnancies, drugged driving, and increases in Hepatitis C and in some circumstances HIV. Opiate use during pregnancy increased from 1.19 to 5.63 per 1000 hospital births from 2003 to 2009; seventy-eight percent of these births were to women covered by Medicaid. For newborns with Neonatal Abstinence Syndrome (NAS) and their mothers, the post-delivery costs are seismic — $43,000 per child versus $900 per child who does not have NAS.
To succeed fully, integration efforts must also factor in the social determinants of health. Many individuals with SUDs are homeless or have unstable living arrangements, challenges that often render health care needs secondary to the search for affordable and safe housing.
Meeting the Need
For insurers who are ready to introduce or enhance integrated care, the first task is encouraging recognition of the need. This may also be the easiest task, as insurers already have the data to make a strong clinical and business case for integration. The next step is to use the data to be more precise regarding who, what, and where should be the focus of insurers’ attention.
First, who? While some individuals are at elevated risk of acquiring a substance use disorder, others have struggled with addiction for decades. Insurers can’t assume that a one-size-fits-all integration program is sufficient. Using data analytics, we can identify the specific health care, treatment, and recovery service needs of different populations. These results can be used in turn to develop data-informed integration strategies.
Which leads to the question of what models an insurer might implement as part of an integration strategy. Some approaches are well-researched and proven to be effective. For instance, the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model has proven invaluable in assessing an individual’s SUD risk and providing immediate and short-term interventions. Screening and brief intervention should occur in a doctor’s office; if patients have more extensive treatment needs, the doctor can make a referral to an SUD treatment provider who is either part of the same practice or a member of a network of practitioners and organizations specializing in SUD treatment.
For individuals with more intensive SUD treatment needs, models for integration are still developing. Several states have created partnerships between physical health care providers and SUD care providers to increase access to evidence-based treatment, such as medications coupled with counseling. Other insurers have assembled teams of physicians, nurses, licensed SUD practitioners, and recovery coaches to coordinate the health, behavioral health, long-term supports, and social services needed by people with significant health and SUD challenges. Evaluations are underway to measure the effectiveness of these strategies.
And finally, the where. Where does it make sense for insurers to invest in new and existing models of integrated care for individuals with an SUD or at risk of an SUD? Again, the answer is not immediately clear. The models highlighted above are being tested in primary care settings, emergency departments, and the specialty SUD system. Some insurers have been working with health clinics to increase access to SUD medications (which generally must be prescribed by a physician or other health practitioner). Other insurers have invested in placing physicians, nurses, and physician assistants in SUD specialty agencies, creating teams to help the high need/high cost individuals who often engage with this system.
In these times of uncertainty, it makes sense to prioritize the protection of individuals’ access to insurance coverage and treatment services — but this can’t be our only focus. Excellent progress has been made over the past eight years to introduce and sustain integrated care for people with substance use disorders, and to test models that will improve their quality of care while reducing costs. Let’s keep going.
Can States Take On the Fiscal Responsibility that Federal Policymakers Are About to Hand Them? - by Kevin Martone
A FEW WEEKS AGO, I had the opportunity to explain to a roomful of congressional staffers the profound impact that a repeal of Medicaid expansion would have on individuals with substance use disorders - and on the systems that serve them. In the questions that followed, an underlying theme was evident: Would lost Medicaid revenue and other federal resources be replaced by state funds to pay for such services? This issue has far-reaching implications for all of our nation's safety net programs. Both my current work with state systems across the country and my experience as a former state commissioner of behavioral health make clear to me that states are in no position to absorb the transfer of fiscal responsibility they are about to receive from federal policymakers.
Systems Work Better Together
In every state, there are vulnerable populations whose complex challenges require coordinated solutions that use federal and state funding. In recent years, awareness has grown in both the health care and affordable housing communities of the positive outcomes to be attained by leveraging these resources together. State Medicaid directors have become educated on the costs to their programs of individuals with chronic health conditions who are homeless, at risk of homelessness, or living in substandard housing. Likewise, affordable housing leaders have learned that lack of access to health insurance, and especially to integrated behavioral and primary health care services, jeopardizes housing stability. States are becoming sophisticated in their use of interventions that build on this new understanding, such as supportive housing - an approach that combines affordable housing assistance with wraparound supportive services. Such states have increasingly demonstrated cost savings in their systems.
The availability of federal funding has afforded states the opportunity to improve the lives of millions of children and adults. The option to expand Medicaid through the Affordable Care Act (ACA) allowed states to increase access to care for populations with many health needs, create better health care delivery systems, and save taxpayer dollars. Federal funding was the incentive needed for 31 states and the District of Columbia to expand coverage, while states that did not expand Medicaid still rely on significant federal support to operate their traditional Medicaid programs. Federal housing assistance programs have been a critical resource for millions of seniors, people with disabilities, and people living on very little income - though a significant gap remains between available assistance and need.
Shifting the Burden to States
The imminent repeal of Medicaid expansion and the ACA, and proposals to convert Medicaid to a block grant or per capita program, threaten millions of people's access to health care, with disproportionate consequences for vulnerable populations. While these changes will create significant savings for the federal government, states will in turn experience both immediate and long-term pressures to fill the void - allegedly in exchange for more control and "flexibility." Under a block grant plan previously proposed by former House Budget Chair and Health and Human Services Secretary nominee Tom Price, the Medicaid and Children's Health Insurance Program would receive 34 percent less funding in 2025 than under the current federal law.
Decreases in affordable housing assistance resulting from cuts to non-defense discretionary (NDD) programs like those at HUD will disproportionately affect the same populations impacted by cuts in Medicaid. We don't have to look too far back to see how this plays out: the March 2013 sequestration cuts forced state and local housing agencies to decrease the number of households using tenant-based vouchers by more than 80,000. About half of all voucher recipients are seniors or people with disabilities, most of whom live on fixed incomes such as Social Security or Supplemental Security Income (SSI) and rely on Medicaid. In not a single rental housing market in the country can a person with a disability who is living on SSI afford housing at the "fair market rent" determined by HUD. According to the National Low Income Housing Coalition, the United States has a shortage of 7.2 million rental units affordable to extremely low-income renter households. Yet President Trump has proposed a one-percent reduction to NDD each year for the next ten years. Even a simple freeze, suggested by several members of Congress, would result in the defunding of housing vouchers currently used by more than 100,000 families in 2017 alone.
Faced with such a significant loss of federal support, Democratic and Republican governors, legislators, and mayors will have to make some very difficult budgetary decisions. Will these leaders, as many have suggested, find ways to sustain access to health benefits, affordable housing assistance, and social services once federal policymakers shift the financial burden onto states?
Recent history shows that as resources are squeezed, many states are unable or unwilling to prioritize vulnerable populations. Most Medicaid expansion states were in a position to increase coverage only because of significant federal matching. Without such support, states have generally opted to provide only limited benefits to people who are traditionally ineligible for Medicaid, and several states have established highly restrictive eligibility criteria. Economic downturns can create added challenges for states as tax revenues decrease while unemployment and enrollment in Medicaid increase. According to the U.S. Government Accountability Office (GAO), during the nation’s last recession, Medicaid enrollment grew by 14.2 percent from October 2007 through February 2010. During the same period, total Medicaid expenditures grew nearly 21 percent, from $332.2 billion in 2007 to $401.5 billion in 2010.
To reduce program spending, the GAO noted, states generally make certain changes to their Medicaid programs, such as altering payments to providers, limiting eligibility, eliminating optional services, or reducing the amount, duration, or scope of services covered. Even as need rose, states cut funding for a range of services by 4.2 percent in fiscal year 2009 and an additional 6.8 percent in 2010, according to estimates by the National Association of State Budget Officers (NASBO). In 2011, two-thirds of states cut provider payments, and 18 states reduced Medicaid benefits. The recession of 2009–2012 resulted in losses of over $4 billion from public behavioral health systems across the country, losses from which they have still not fully recovered.
Most states have allocated resources to support housing assistance for low-income populations. A report prepared by the Technical Assistance Collaborative in 2014 indicated that 34 states offer some type of rental assistance or homelessness prevention funds (e.g. security deposits). However, there is wide variation in the number of individuals such programs can support, and program funding tends to fluctuate annually due to state budget pressures. Indeed, a NASBO survey conducted in the fall of 2016 indicated that in 24 states, general fund revenues for 2017 are coming in below projections, the greatest number of states expecting revenue shortfalls at this time in the fiscal year since 2010. Nineteen states reported net mid-year budget reductions in fiscal 2016, a historically high number outside of a recession period.
There is indisputable evidence that the availability of health insurance and access to health care and affordable housing improve people's lives. As lawmakers contemplate dramatic reductions that will hurt people and economically burden states, we find ourselves at a pivotal point. There is little evidence to suggest that state governments can or will assume the financial responsibility offloaded by the federal government under current proposals. Yet, it is state and local budgets that must absorb the preventable economic consequences when individuals engage costly, crisis-oriented health care, correctional, and homelessness systems. Federal policymakers must understand that a cost shift to states under the guise of flexibility and efficiency will have dramatic and unfortunate consequences for vulnerable individuals and their families.