|
PERSPECTIVE‘How Do You Pay Your Rent?’ Social Policies And The President’s Mental Health Commission
Mental health policy involves broad social policies related to housing, education, work disability and rehabilitation, welfare, and criminal justice. The modern era of community care has moved patients, clinicians, and policymakers from closed institutions into the mainstream of society and its health and human service systems. The importance of knowing about the broad array of human services and their policies is reflected in the deliberations and policy recommendations of the President’s New Freedom Commission on Mental Health. It is hoped that these recommendations will provide a roadmap for further change to enable people affected by severe mental illness "to live, learn, work, and participate fully in their communities."
The president’s New Freedom Commission on Mental Health has made key recommendations related to welfare, education, social security, labor, housing, and criminal justice policy. It also has made recommendations related to mainstream health programs, such as Medicaid, Medicare, and the Department of Veterans Affairs (VA), reflecting the importance of these programs and the participation of those agencies on the commission. In addition to the expected commissioners from the health and mental health fields from both inside and outside government, the commission had ex officio representation from the Departments of Education, Labor, and Housing and Urban Development (HUD).1 The commission’s interim report hinted at the reasons for this broad social policy agenda when it focused on a fragmented mental health system "in shambles," disconnected from the many agencies on which people with mental illness depend for service and support.2 Both the interim and final reports cite a series of human and social problems associated with mental illness: homelessness, unemployment and work disability, school failure, minor crime, and incarceration. The final report makes recommendations to address these areas. This Perspective was written in response to the paper by Margarita Alegría and her colleagues, which provides details on several specific mainstream social programs and their relationship to mental health disparities among racial and ethnic minorities. Here I describe the interest of the President’s New Freedom Commission on Mental Health in some of the same social policies, and some related ones. Whereas the Alegría paper concerns the full range of mental health problems in ethnic minority populations, I focus on adults and children with severe and persistent mental disorders. I do not, however, focus on the commission’s recommendations that pertain to the health and mental health systems and to more traditional considerations of treatment for mental illness. My own exposure to these matters originates with my earliest clinical experiences as a psychiatrist. I learned to ask each patient, "How do you pay your rent?" It was a simple question, but the answer was always revealing. Over time, in an effort to assist patients, I learned about housing authorities and HUD policies and programs, local disability determination service offices and Social Security Administration regulations and guidelines; schools and child welfare; and criminal justice, juvenile justice, and corrections policies. These excursions of clinical practice into other human services are commonplace in mental health practice and its service system. Now they are an explicit part of mental health policy.
The President’s New Freedom Commission on Mental Health commissioned a series of issue papers on topics such as housing and homelessness, employment and income supports, schools and mental health, and mental illness and the criminal justice system. The Executive Order creating the commission charged the commissioners "to conduct a comprehensive study of the United States mental health service system...and to advise the President on methods of improving the system." It further called for the commission to make recommendations to enable people affected by severe mental illness "to live, learn, work, and participate fully in their communities."3 This focus on a broad set of individual outcomes led the commission to consider a broad set of health and social policies and the agencies that make and enforce them. This Perspective briefly explores each of these human service areas as they relate to mental health. It provides a look at the recommendations of the President’s New Freedom Commission on Mental Health that are addressed to the broader social policies. The information about the commission’s recommendations is derived from the public reports of the subcommittees mentioned above and from draft versions of the final report, prior to the report’s expected release.4 In the final report some of the recommendations discussed in this paper might not stand alone but could be embedded within other broader recommendations. Further, some of the recommendations remain somewhat vague, without specific details related to implementation.
Key issues. Historically, the public mental health system housed people with long-term mental illnesses in hospitals; now it has been asked to house them in the community. With a decline in categorical mental health resources, this has meant relying on mainstream housing resources, such as Section 8 Housing Choice Vouchers and other programs, such as HUD’s Shelter Plus Care. Sandra Newman has reviewed the research literature on housing and mental illness.5 While there is much we still don’t understand about the relationship between housing and mental illness, she concludes, we do know that people with even the most severe mental disorders prefer to live in independent settings in the community and that the Section 8 rental subsidy program has been used successfully with this population.6 People with mental illnesses do better when they receive treatment and supportive services while living in settings with fewer occupants, in buildings that are in better condition, and in "welcoming" neighborhoods.7 Newman suggests that these findings might help in the targeting of rental subsidies and in deciding where to develop new housing for mentally ill people. The issue paper on housing and homelessness prepared by Ann O’Hara and Lynn Aronson-Napolitano for the commission focuses on policies for people with severe mental illness who are also homeless.8 Estimates vary for the proportion of the homeless population who experience a severe mental disorder. Different studies use different definitions and sample different populations. The commission’s interim report cites a review article by Barbara Dickey that places the figure at about 25 percent of the population on any given day.9 Other estimates place the figure at 18–22 percent.10 When sampled on a single day, this population is more likely to be chronically homeless. Although rates of severe mental illness are much lower in the population of people who are episodically homeless, mental illness is also a problem for this group.11 For example, almost half of the two million people who have at least one episode of homelessness in a year also report mental health or substance abuse problems, or both.12 Recommendations. The commission’s recommendations included several directed at ending chronic homelessness among people with serious mental disorders. The commission calls for more affordable housing to be made more accessible to mentally ill people. Specifically, it suggests facilitating access to 150,000 units of permanent supportive housing and improving other housing opportunities such as the Section 811 Supportive Housing program.13 The issue paper and report of the commission Subcommittee on Housing and Homelessness also recommend changes to current policy to make it easier to use Section 8 vouchers and to provide evidence-based treatment and services to people who are homeless, particularly through improvements in the use of Medicaid.14 To fulfill all of these recommendations, the Bush administration will need to allocate new resources and retain the rental subsidy programs. Regardless of the exact dynamics that result in the association of high levels of mental illness with chronic homelessness, it is clear that these people are poor.15 Improving work-force participation by this population might help to solve the problem of residential instability and provide meaningful daily activity to promote recovery.
Key issues. Adults typically define their social roles by their occupations. People who are disabled tell us that they want to work but that programs to help them return to work fail them. They take too long with ineffective prevocational counseling, and they place them in jobs that are not commensurate with their interests and skills. New and more effective interventions, such as supported work, are not available or are difficult to fund. Furthermore, the incentives in income replacement programs do not encourage the return to work, and those who do go to work risk the loss of health insurance coverage.16 Even though there now are programs to prevent losing Medicaid immediately upon return to work, patients still tell their clinicians and policymakers that they want to work but can’t afford to lose Medicaid if they give up their Supplemental Security Income (SSI) in order to take a job without health benefits.17 Most of the entry-level jobs sought by these people early in their return to work do not provide health benefits. Even new programs such as Ticket to Work do not overcome the barriers for people with a history of having a mental disorder, who often are left out.18 The incentive structure favors enrolling people who quickly return to full-time work and retain their jobs. That encourages adverse selection and the further exclusion of people with mental illness.19 Community mental health practice and policies that focus on recovery must address the vocational needs and preferences of every person under care.20 According to the issue paper on income support and employment prepared by Judith Cook, labor-force participation is extremely low for people with serious mental disorders.21 She reports data from the National Health Interview Survey–Disability Supplement (1994–1995) indicating that 61 percent of people reporting mental disabilities are out of the labor force entirely; 33 percent of working-age adults with mental illness are employed, and only 17 percent of those with severe mental illness are working. David Mechanic and his colleagues also analyzed this data set and three others and concluded that employment rates of people with mental disorders, particularly people with severe impairment, compare unfavorably with the general population, in which only about 20 percent are not working.22 Furthermore, people with mental disorders have employment rates twenty percentage points below rates for people with physical disorders.23 Cook also reports that those who do work are underemployed.24 This situation is particularly frustrating since people who experience even severe mental illness want to work, and there are effective, evidence-based supported employment programs that return people to the workforce at rates much greater than previously experienced in traditional rehabilitation programs.25 For example, in some programs as many as 60 percent of people with serious mental illness have competitive jobs after one year, compared with more typical results of around 20 percent in traditional vocational programs.26 Recommendations. The commission has recommended a comprehensive plan to ensure that every working-age person in the mental health system has access to supported employment.27 The details of the recommendation include a coordinated employment strategy within the federal government and with the states and localities. The commission also recommends improving funding for evidence-based supported employment programs through Medicaid and providing technical assistance to service providers about how to use Medicaid to accomplish this goal. Even in current difficult financial times, states can reallocate Medicaid resources from ineffective vocational programs to those that have been shown to produce results. In addition, the commission recommended a campaign to encourage states to make greater use of the Medicaid buy-in program and to inform SSI beneficiaries who wish to return to work about how to retain their Medicaid coverage. The commission also suggests that some way be developed for states to share in the savings to the Social Security disability programs when beneficiaries return to work, as a way of providing a financial incentive for them to participate in the Medicaid buy-in program. It should be remembered, however, that even supported employment programs do not return most people with mental illness to full employment and financial independence. Even proponents of supported employment admit that it is extremely difficult for many clients to retain their jobs for a variety of reasons.28 Job opportunities are limited, most are part time, and about half of supported-employment clients leave their positions within six months.29 Based on the few studies that permit a rigorous assessment of the economic impact of supported employment, Eric Latimer concludes that compared to traditional vocational rehabilitation programs, supported employment would be cost-saving or at least cost-neutral from the perspective of the program or the government supporting the program. Further, he concludes that from a societal-cost perspective, reductions in benefit costs and increases in tax revenues cannot be expected to fully offset new investment in supported employment. As Latimer says, these efforts must be "motivated by the value of increasing the community integration of persons with severe mental illness."30 For the immediate future, disability income replacement programs and welfare will be necessary for many people. Welfare. Some patients—adults and their children—fall through the cracks in the mainstream systems for housing, work, and disability insurance into the safety net of the broader social welfare system. Health-related impairments often account for entry into the welfare system, when the other assistance programs in mainstream institutions (such as rental subsidies or vocational rehabilitation) are ineffective. Even private insurance and personal resources cannot save some children and families from entry into the child welfare system. According to reports from the Bazelon Center for Mental Health Law and the U.S. General Accounting Office (GAO), some parents relinquish custody of their children to get specialized public mental health services after exhausting private resources and the limited mental health benefits in their insurance while trying to meet the needs of their children.31 The commission offers no specific solution but recommends a process to find a way to end this practice.32
Key issues. School is the workplace of every child. Every pediatrician learns to routinely ask about school performance, but few regularly screen for the early stages of mental health problems. These problems are premonitory and can be apparent even before school failure calls attention to the impairments of young students. Often schools and pediatricians are involved in the care of an impaired child.33 Child health care workers are concerned about the success of every child, but children with mental disorders are those most likely to be "left behind." Data reported to Congress in 2001 by the U.S. Department of Education indicate that the high school graduation rate of only 42 percent for children with emotional disturbance is the lowest rate of any other disability group—the same rate as for children with a developmental disability. Half of all children with disabilities graduate from high school, compared with 78 percent of all children. School dropout rates of 48 percent for children with emotional disturbance compare with 30 percent for children with all disabilities and 24 percent for all children.34 Educational policy is a vital part of mental health policy for children. Pediatricians and child mental health care professionals must learn about special education programs and services for children with "severe emotional disturbance" (SED)—such as the Individuals with Disabilities Education Act (IDEA). First enacted as P.L. 94-142 in 1975 and subsequently renamed, IDEA was designed to make sure that children with disabilities have access to appropriate public education. It is one of the most important programs at the interface of schools and mental health. IDEA is undergoing scrutiny as it heads into reauthorization. The President’s Commission on Excellence in Special Education, which released its report in 2002, made general recommendations on IDEA but none specific to children with mental illness.35 Mental health organizations are calling for specific changes in IDEA (such as a more appropriate scientific definition of the target population for mental health services) when it is reauthorized.36 Recommendations. The President’s New Freedom Commission on Mental Health focused on several aspects of children’s mental health and the schools, including recommending early screening for developmental problems and mental disorders and expansion of school mental health programs.37 Half of children with SED get no mental health treatment, but those who do are identified most frequently in the schools.38 There are several models of providing school mental health programs.39 To expand on them, the commission calls for collaborative programs that would involve a wide range of collaborators, including parents, teachers, and local mental health and child welfare agencies. The focus is on screening, early case identification, and treatment in schools or referral to appropriate mental health services in the community.40 These recommendations will succeed only if community services are available and affordable.
Key issues. The criminal justice system is perhaps the last stop on the fall from the mainstream through the safety net to the rocks below. In many cases, however, the criminal justice system is not the appropriate place to address these problems of deviance; when it is the appropriate place, it is essential that people also receive required care and treatment. This is one of the main conclusions of the issue paper prepared for the commission by Henry Steadman.41 As society increasingly resorts to criminal proceedings and incarceration, the number of people with severe mental illness involved in the criminal justice system also grows.42 The problem affects both children and adults, as there is increasing contact between the mental health and juvenile justice systems.43 Recommendations. Models for criminal justice diversion and community reentry have been developed and their feasibility assessed over the past decade.44 No single approach has emerged with sufficient evidence that it is considered more effective than any of the other models.45 Furthermore, the objectives of jail diversion programs, whether based in law enforcement, courts, or jails, and specialty mental health reentry programs are different. The commission identified a number of efforts at diverting people with mental illness from the criminal justice system into the mental health system and recommended that they be expanded. It also recommended several policy changes to facilitate reentry of inmates who have a mental disorder into the community when they are released from custody.46 The Consequences Of Complexity There are consequences of the complexity associated with interactions between the mental health system and the rest of the human service system. The fragmentation of these social systems and the discontinuities between agencies and their policies is characterized as the central problem by the Executive Order creating the mental health commission and by its interim report.47 Fragmentation remains a challenge to progress. To address the problems of fragmentation, the commission recommended that each state develop its own mental health plan and that federal policies be aligned to facilitate the coordination of programs within the state mental health plans. The state plan is designed to bring together all of the agencies whose responsibilities include providing services used by people with serious mental illness, to avoid duplication of effort and to coordinate the use of resources. These agencies were not created to specifically address the needs of people with a mental disorder, and often their policies work at cross-purposes.48 It is critical for health and social policy to keep pace with these needs if everyone is "to live, learn, work, and participate fully in their communities."
Howard Goldman is a professor of psychiatry at the University of Maryland School of Medicine and was a consultant to the President’s New Freedom Commission on Mental Health. The author acknowledges financial support from the John D. and Catherine T. MacArthur Foundation and helpful comments from Richard Frank, Joseph Morrissey, David Salkever, and two anonymous reviewers, as well as personal communications from commission consultants Lynn Aronson-Napolitano, Judith Cook, Ann O’Hara, and Hank Steadman.
This article has been cited by other articles:
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Top
Of Presidents And Paying...
Housing
