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PERSPECTIVEMental Health In The Mainstream Of Health Care
Mental health policy making has moved steadily into the mainstream of health policy. The phenomenon has expanded the resources available to people with mental disorders. It has also led to decisions that are based on inadequate understanding of mental illnesses and their treatment. Continued progress in the well-being of people with mental disorders requires expanded engagement of the mental health community with mainstream health policymakers.
THE EARLY 1980s, when Health Affairs arrived on the health policy scene, was the time of a decisive shift in mental health policy. Deinstitutionalization demanded a new configuration of mental health services. Throughout the 1960s and 1970s, policymakers aimed to build an organized, community-based mental health service system. The Carter administration’s Mental Health Systems Act and a set of categorical federal mental health programs offered a fiscal centerpiece for this structure. However, in 1981 the Reagan administration orchestrated the repeal of the Mental Health Systems Act, consolidated the categorical mental health programs into a block grant, and cut spending on those programs about 25 percent.1 The vision of an organized, community-based, and dedicated mental health system ended. The effect—intended or otherwise—was to thrust mental health policy making into the mainstream of health policy. Since the early 1980s, the decisions that have most affected the well-being of people with mental illnesses have been those taken by mainstream health and disability insurance programs. One such move came when the Reagan administration changed the eligibility criteria for Social Security Disability Insurance (SSDI) in 1982. SSDI, and its sister program, Supplemental Security Income (SSI), provide a stable, though often minimal, source of income for people disabled by mental illness. Absent these programs, survival in the community for people with severe mental illnesses would be nearly impossible. The Reagan administration’s changes to the SSDI criteria disproportionately affected people with mental illnesses. They made up 11 percent of SSDI recipients at the time but represented 30 percent of the people losing program eligibility. The resulting public outcry led to the revamping of all disability criteria and, ultimately, to expanded enrollment of mentally ill people.2 Participation in these public disability insurance programs carries with it eligibility for Medicare, for those with SSDI, and Medicaid, for those with SSI. Today, mental health care for most people with severe mental illnesses is paid for by one or both of these programs. Mental health policymakers have come to recognize that changes in these programs can have powerful effects on the well-being of the population with mental illness. Medicare PPS. Consider the implementation of the inpatient hospital prospective payment system (PPS) for Medicare in 1983. In the years preceding its introduction, the mental health advocacy and provider communities became concerned about two of its features. First, evidence was emerging that the diagnosis-related group (DRG) classification system did not account for heterogeneity among psychiatric cases as well as it did among cases with other health conditions. Second, advocates were concerned that the strong incentives for early discharge would harm vulnerable patients.3 Based on the strength of the empirical evidence on both points, Congress exempted specialty psychiatric units and specialty psychiatric hospitals from the PPS. In the wake of this decision, the research community turned its attention to strategies for improving the workings of prospective payment in the mental health context. Their conclusions, which involved the use of declining block pricing (based on length-of-stay), were incorporated into a new psychiatric payment system for Medicare about twenty years later. Private health insurance design. This move into the mainstream also affected the design of private health insurance. Since President John F. Kennedy’s directive that federal employees’ insurance cover mental health care on a par with other medical conditions, mental health parity has been a central concern of advocates.4 The mental health community most often treated the issue as a matter of fairness or civil rights. Policymakers questioned whether there were not more efficient ways to incorporate mental health coverage in public and private health insurance. Efficiency of mental health insurance coverage became an especially strong concern during the late 1980s as the specialty inpatient psychiatric industry grew and, for the first time, spending growth in mental health rivaled overall health care spending growth.5 This fueled the development of the managed behavioral health care (MBHC) industry and the research program studying its effects.6 This research suggested that utilization could be managed, costs controlled, and quality maintained.7 The rise of MBHC, in turn, made parity in private health insurance coverage affordable. States and the Federal Employees Health Benefits (FEHB) program responded by establishing parity coverage for mental health in the context of mainstream care. Congress appears to be slouching toward parity legislation. Medicaid mental health dollars. The shift of mental health policy into the mainstream means that Medicaid directors and administrators of other mainstream programs now control most mental health dollars.8 For mental health policy advocates and researchers, this change in the locus of responsibility makes it imperative to reach mainstream policymakers. The forum for this outreach has often been the pages of Health Affairs and the special sections and issues on mental health policy published periodically since 1990, with funding from the MacArthur Foundation. THE SHIFT TO THE mainstream precipitated twenty-five years ago was largely inadvertent. Our research suggests that despite the real fears of advocates at the time, most people with mental illnesses ultimately benefited from this shift. Nevertheless, mental health care has suffered serious and notable failures. Continued progress requires the expanded engagement of mental health advocates, experts, and researchers with the health policy mainstream.
Richard Frank (frank{at}hcp.med.harvard.edu) is the Margaret T. Morris Professor of Health Care Policy at Harvard University, in Boston, Massachusetts. Sherry Glied is a professor of health policy and management in the Mailman School of Public Health, Columbia University, in New York City. The authors are grateful to the John D. and Catherine T. MacArthur Foundation for financial support.
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