Changes and Constants in Behavioral Health Ron Manderscheid, PhD Exec Dir, NACBHDD and NARMH & Adj Prof, BSPH, JHU © NACBHDD

Time for a Thrilling Ride!

Very Recent Developments - 1 Report of President Obama’s Task Force on Parity for Mental Health and Substance Abuse Report: https://www.hhs.gov/sites/default/files/mental- health-substance-use-disorder-parity-task-force- final-report.pdf Observations: More training and technical assistance Focus on consumer reporting of violations Recommendation of penalties

Very Recent Developments - 2 21st Century Cures Act (an authorization bill) Includes the Mental Health Reform Act of 2016 Increased grant funding for services integration Some funding for human resources, particularly in the National Health Service Corps Includes the Mental Health and Corrections Collaboration Act DOJ will be permitted to spend re-entry funds on appropriate services Grants will be available to build re-entry infrastructure between corrections and mental health

Very Recent Developments - 3 21st Century Cures Act (Continued) $1 billion authorization for the Comprehensive Addiction and Recovery Act (CARA) $500 million has been appropriated in the current Continuing Resolution We now are working to get the other $500 million appropriated as part of the next Continuing Resolution or 2017 Funding Bill

Very Recent Developments - 4 Medicaid Managed Care Regulation (Spring 2016) Permits the use of federal Medicaid IMD funds for restricted inpatient and residential treatment care (up to 15 days in a month) CMS Letter to the State Medicaid Directors (Spring 2016) Federal Medicaid funds can be used for persons in the correction system if the person is not actually in a cell

Very Recent Developments - 5 New 1115 Medicaid Waivers CA Systems of Care for Substance Use Clients: The length of residential services range from 1 to 90 days with a 90-day maximum for adults and a 30 day maximum for adolescents; unless medical necessity authorizes a one-time extension of up to 30 days annually.

NJ and Medicaid Expansion TRENTON - Gov. Chris Christie boasted the success of expanding the Medicaid program in the state, arguing the "naysayers" have been "proven wrong" and that 566,000 additional New Jerseyans have insurance coverage.  ""We made a deal with the federal government. If they keep their deal, we'll keep our part of the deal," he said. "I am for Medicaid expansion ... but I am not for Medicaid expansion at any price."

The Factors Have Become More Complex

Key Game Changers POLICY: Affordable Care Act implementation is in question. RESEARCH: Early intervention with first episode psychosis. PRACTICE: Trauma as a causative factor in most mental illness.

Key Underlying Trends From “deficit” to “strength-based” approaches e.g., NAM panel. From “separate” to “integrated” services. From “clinical only” to “clinical and community” together.

Key Responses APHA has a major 5 year initiative on altering the negative social determinants of health. Goal: Health for all society! The UN has set personal and community “well-being” as a world-wide 15 year objective for 2030. Major US corporations are beginning to embrace a “culture of well-being” in the work place, e.g., Carter Center Summit.

Let’s Begin Our Adventure

Our Model is Changing-1 Old Model: Focus: Disease is a personal characteristic Role is to treat disease Goal is to restore functioning Focus: Clinical intervention Care system management Care policy

Our Model is Changing-2 New Model Focus: Disease is a principally a community characteristic Role is to change communities Goal is to improve community functioning Focus: Community intervention Community management Community policy

Our Model is Changing-3 Our current task is to blend the old and new models to achieve the Triple Aim: Better population health Better quality care Reduced care costs

How? Population Health Management Integrated Care Systems that incorporate Disease Prevention and Health Promotion Strategies

Our Dilemma

Health and Well-being --1981 VERY HEALTHY l I NO DISEASE -----|-----SEVERE DISEASE VERY UNHEALTHY

Viewed as Population Health VERY HEALTHY Pop 1 l Pop 2 I NO DISEASE -----| -----SEVERE DISEASE l Pop 3 l Pop 4 VERY UNHEALTHY

Tomorrow’s Well-Being Model

Public Health Reports - 1978

Integrating Care and Well-being

Our Model is Changing-4 Your Tasks as a Manager: Manage old and new systems across these chasms Effectively manage blended models Train and lead a new generation in a new way of thinking and working

Let’s Go!

Pervasive National Concerns in Behavioral Health Move to Integrated Care Services Developing better linkages with social services Incarceration of persons with mental and substance use conditions Linkage with public health

Integrated Care Services

Importance of Social Services

The Incarceration Crisis

Tonight: City and County Jails About 730,000 persons in these jails: 182,500 (25%) persons with a mental illness 365,000 (50%) persons with a substance use disorder Major co-morbidity between the two groups The two groups (547,500) actually approximate the total number in state mental hospitals in 1955 just before deinstitutionalization started (559,000).

Tonight – Juvenile Justice Facilities Juvenile Justice Facilities: About 70,800 (more than 500,000 in one year) NCSL: “As many as 70 percent of youth in the system are affected with a mental disorder.”

Some Observations The actual incarceration rate in the US is about 1 person in 100. The actual rate of involvement in the criminal justice system, including probation and parole, is about 4 in 100. US is generally thought to have the highest rates in the world!

NACBHDD Decarceration Initiative Goal: To reduce the number of persons with MH, SUD, and ID/DD conditions who arrive at the jail. Major foci: Intercept “0”: Improving county behavioral health crisis response capacity Direct TA to small and medium size counties Initiation of a small pilot with corporate sponsors

NACBHDD and NACo NACBHDD is partnering with NACo on its Stepping Up Initiative

Linkage with Public Health: 1,943 County Public Health Departments

Change is in the Air

Thoughts on the Future Repeal and Replacement of the Affordable Care Act (New Bill: American Health Care Act) Block-granting of Medicaid Privatization of Medicare

Repeal and Replacement of ACA Concerns: Health insurance coverage (good benefits) and access to care (good care for all). Concerns: Medicaid Expansion? Persons covered through the Marketplace with subsidies? Understand: repeal, rename, replace. Avoid: Trap about labels, such as “ACA” or “Obamacare”

BILL: American Health Care Act Would repeal the Medicaid Expansion at the end of 2019. Would change Medicaid to a per capita block grant at the end of 2018. Would reduce subsidies paid to persons insured under the State Marketplaces at the end of 2018. Would end the “individual mandate”, and would promote Health Savings Accounts. Would increase insurance costs for all, especially those who are older. BOTTOM LINE: A bad bill for mental health and substance use care.

Block-granting of Medicaid Concerns: Financial implications for the states and coverage for those insured by Medicaid. Understand: Fixed amount per state?; Per person in population? Per person covered? With what baseline: Now? 2013? Other? Avoid: Discussions about the federal and state roles

Privatization of Medicare Concerns: health insurance coverage (good benefits) and access to care (good care for all). Understand: Benefit variability from plan to plan? Fixed payment plans? Health savings accounts for premiums? Coverage of other age groups? Avoid: Change nothing vs. Change everything.

So, which will it be?

Comments?

Contact Information Ron Manderscheid, PhD Executive Director NACBHDD – The National Assn of County Behavioral Health and Developmental Disability Directors NARMH – The National Assn for Rural Mental Health 660 North Capitol Street, NW, Suite 400 Washington, DC 20001 (V) 202 942 4296 (M) 202 553 1827 The Only Voice of County and Local Authorities in the Nation’s Capital!