After a shooter took the lives of 20 children and six adults in Newtown, Conn., policymakers at the state and federal levels called for a re-evaluation of many things. Gun laws, school security and behavioral health treatment topped the list.
One could argue that focusing on mental health care in the wake of that and other mass shootings could cause harm by serving to reinforce stigmas and provide a scapegoat to avoid more controversial questions tied to gun violence. Most of the mental health experts I talked to for an article that ran in the March 2013 Illinois Issues had these concerns. But they were also glad that some attention, and possibly some funding, would be directed toward the state’s threadbare mental health care system.
For years, mental health care had been the target of budget cuts. Almost all care that was not covered by Medicaid — and the federal matching dollars that come with it — was slashed. Low-income residents who do not have children, and therefore do not qualify for Medicaid, have almost nowhere to turn. And some community groups that treat those with Medicaid and private insurance are struggling to keep their doors open. Meanwhile, people who need treatment are using emergency rooms as a last resort or clogging up the state’s jails and prisons after being arrested for behavior that could often be managed through treatment. Everyone interviewed last year painted a fairly dire picture of the state’s support system for the mentally ill. But nearly everyone also said they saw hope on the horizon in the form of the Patient Protection and Affordable Care Act, otherwise known as Obamacare.
Catching up with them recently, as Obamacare begins to roll out in earnest, they still feel that way. However, there have been some hiccups. Mental health care activists say they are working to ensure that the Affordable Care Act fulfills its promise as an opportunity to bring needed care. “This is overwhelmingly going to be a move in the right direction,” says Mark Heyrman, a law professor at the University of Chicago Law School and a legal advocate for the mentally ill. And that is why he says state and local health officials must work to make sure it is handled well.
A primary component of Obamacare is the expansion of Medicaid coverage to anyone who earns up to 138 percent of the federal poverty level, which is about $15,860 for an individual or $32,500 for a family of four. Between that expansion and the new online health insurance marketplace, which will offer federal subsidies to many to help buy insurance, an estimated 800,000 Illinoisans who are not covered now will have insurance starting next year.
After the U.S. Supreme Court ruled that the Medicaid expansion was not mandatory for states to keep the Medicaid funds they already receive, Illinois was one of only 25 states that opted to go ahead with the expansion. Those applicants who are approved will begin receiving coverage on January 1. However, Illinois lawmakers voted to allow Cook County to offer the expanded coverage early, and as of October, an estimated 100,000 Cook County residents had signed up under the program known as CountyCare. But so far, providers say that CountyCare has failed to properly cover some key mental health services.
Assertive Community Treatment (ACT) and Community Support Treatment (CST) are forms of preventive care for mental illness. Both programs meet patients where they live, “whether it’s in their home, whether it’s in the shelter or on the street,” says Heather O’Donnell, vice president of public policy and advocacy for Chicago-based Thresholds, the oldest and largest mental health service provider in the state. Under ACT and CST, teams that include a psychiatrist provide services such as checking in to make sure patients are keeping up with their medication and generally doing all right. Both programs help people maintain their mental health and avoid hospitalization. According to Heyrman, ACT and CST teams “help them solve problems of daily living [such as] making sure that their rent gets paid, that they are staying on their medication, that they are eating properly, that they are taking care of their physical health — all the things that could cause someone to be pushed over the edge into serious illness” and potentially institutionalized. The programs allow mental health professionals to keep open lines of communication with patients who may struggle to make it to office appointments. “Those services are really critical for people who have serious mental illness and are reluctant to come into clinical settings,” O’Donnell says.
ACT is the more intensive version of the concept. These programs are not for everyone. Heyrman says, “Lots of people can do fine with low-level services, and not very expensive services, and not even continuous services.” ACT and CST focus on people who need more care and who may have been hospitalized in the past. They are often used to help people with illnesses such as schizophrenia and bipolar disorder. “They’re intended to be focuses on people who typically do not stay engaged to the mental health system,” he says. “What we have found is that we need to have strategies for engagement.”
WBEZ in Chicago reported in October that providers were struggling to get reimbursements for ACT care from the contractor, PsycHealth, Ltd., which the county hired to administer mental health care under the Medicaid expansion. “We’ve got a big problem in Cook County with the roll out of CountyCare. ... It has been hard for many people to get the mental health services that they are entitled to,” Heyrman says.
Officials from the Cook County Health and Hospitals System and representatives of PsycHealth told WBEZ that the expansion covers ACT and CST. “The community-based facilities are used to getting whatever they want from the state,” Cathryn Shemroske, the provider network manager for PsycHealth, told WBEZ. “The state is bankrupt for a reason. This is definitely something contributing to that.”
However, her opinion of community treatment seems to run counter to Gov. Pat Quinn’s stance of moving away from institutionalization whenever possible. “Often I’m hearing that the model doesn’t necessarily keep members well,” Shemroske told WBEZ. “The treatment outside the hospital isn’t always what gets people healthy.” But as Heyrman points out, such programs are “highly researched, have been around for at least 30 years and are available in all 50 states.”
As of press time, providers were in talks with Cook County Health officials to work out a plan to ensure that ACT and CST are available to those who need them. At the same time, it is still unclear whether they will be covered under the state’s Medicaid expansion. Mike Claffey, a spokesman for Quinn on health issues, says the state hopes to have them both covered under the expansion. But he says it is a matter of working out some things with the federal government and determining whether there will need to be action through the state’s rule-making process. “There’s a lot of hoops to jump through, and we’re trying to work those out,” he says. Providers say they are optimistic that something can be worked out.
“On the state level, the problem is there is a complicated set of federal regulations about this, so it is not that there is some evil person or some stupid person in state government that’s saying no,” says Heyrman. “It looks good going forward.”
O’Donnell agrees. “I think that they are doing their best to try to figure out how to cover these services.”
Once all the details are sorted out, the growing number of people with coverage will likely strain current capacity. “There’s a substantial shortage of psychiatrists in this country and particularly in this state. We need to have more psychiatrists and more psychologists,” says Heyrman. He says that these mental health professionals are especially needed in communities outside of the Chicago area and adds that child psychologists are particularly scarce outside of Chicago and the suburbs. But as Heyrman and O’Donnell both point out, capacity will likely be an issue in many sectors of the health care industry. “Both on the federal and state level there are efforts underway to figure out long-term and short-term shortages of health care professionals,” Heyrman says.
O’Donnell says that Thresholds administrators and staff are having conversations pretty much daily about how they will treat these newly insured populations. “I think all providers are grappling with how do we build the capacity to provide care.” But she says: “I think it’s a good challenge to have. It’s certainly better than no coverage and no access at all.” Advocates and providers say that generally, it’s difficult not to look on the bright side of what the Affordable Care Act could bring in terms of mental health coverage. And it has been awhile since they have had a bright side to look at.
As the one-year anniversary of the Newtown tragedy approaches next month, my wish is that there is follow-through on the calls it spurred for improving our country’s mental health system. I am not certain that the two are related — as mental health advocates point out, people with mental illness are much more likely to be the victims of crimes than the perpetrators. But if part of the legacy of such an awful event can be hope and help for the millions in our country who face mental illness at some point in their lives, I don’t think that would be a bad thing.
Illinois Issues, November 2013
