Update on Mental Health Policy Issues June 2007 Presentation by Rusty Selix Executive Director California Council of Community Mental Health Agencies (CCCMHA)

Congress – Mental Health Parity  Chance to pass Mental Health Parity  Impacts large employers exempt from state laws  Full Mental Health Parity  Substance Abuse Parity  Senate Bill Pre-empts State Laws  No adverse impacts in California  House bill is more certain but unacceptable to interests needed to get 60 votes in Senate

CMS/Rehab Option  Restrictive Medicaid Philosophy  Rehabilitation Option Definitions  Telephone advice to states  Rehab limited to improvement to a former state of being  Can’t be maintenance  Can’t be a skill you never had  Proposed Regs expected soon  Home and Community Based Services Option – Iowa example gives hope!

Home and Community Based Services Option -HCBS  Authorized in deficit reduction act (DRA)  Available January 1, 2007  No guidance regs yet  Iowa just approved  Broader benefits for defined pop - SMI/SED  States can cap # eligible  Not a waiver – need not be cost neutral  Permanent state plan amendment  DMH-CMHDA Interested

Services to Veterans?  Iraq war returnees with PTSD overwhelming VA capacity  Funding and authority to refer to other providers  CMHCs doing this in other states  Contract or fee for service  CCCMHA north and south committees

California Healthcare Reform  Six million uninsured  Schwarzenegger, Kuehl, Perata, Nunez  All have legal and political problems  Pressure to do something  Mental Health benefits protected  Guaranteed right to coverage –pre- existing condition limit overcome

Prison Overcrowding  170,000 in system – double capacity  # and % of California prisoners with serious mental illnesses growing faster  80% Recidivism Rate  1998 – 16,000 – 11%  2003 – 25,000 – 16%  2006 – 34,000 – 20%

Prison MH Reform – SB 851  Prop 63 will eventually serve everyone in harm’s way  Provide AB 34 Recovery Services  Homeless Outreach to Prevent Crime  MH Courts - Diversion to reduce incarceration  In Prison Rehabilitation,  AB 2034 for parolees phased in  State pays for parolees – counties fearful

Co-Occurring Disorders?  Alcohol and drug with mental illness  Expectation not an exception  Fully cover in public and private plans?  Bill A/D under EPSDT?  Train professionals to be able to do both  Require integrated services  Co-locate with Primary Care?  Report to MHSOAC in July

Budget  Estimated permanent $5 Billion Deficit  Prop 63 Revenues Exceed Projections  $55 million AB Restored?  SSI/SSP COLAs?  AB 3632 fully funded – not discussed  EPSDT back payments over 3 years  EPSDT $$ up -  Realignment $$ up?

AB What is funded?  $69 million formula via Dept of Education for  Add’l Funds to fully pay claims for  Add’l Funds to pay most claims  Total won’t be known until several months into and not due until  No new Funds for 00-01, 01-02, and claims to be repaid over 15 years

EPSDT Audits  Extrapolation limited to error rate over 5%  Retroactive to 04 and 05 audits  75% of audits – no extrapolation  New appeals to address clerical errors and other adjustments – not yet settled  Cases kept open  Each audit only one service function Extrapolation to 90% confidence-  Final guidance manual nearly done

Proposition 63 Revenues Up!!! Revenue by Year Prop 63 estimates in 2003 Current State Projections Excess above estimates Available Funds 05-06$680 m$1.1 B$420 m$ $690 m$1.6 B$910 m$ $730 m$1.8 B$1.070 B$1.15 B

Future Resources to spend  Three year plans to  Estimated average - $2.4 Billion  More than double original projections  Assumes 10% annual revenue growth  Conservative compared to current trends  Original Projection was 7% annual growth  Cuts in other funding and programs  Supplantation??

Realignment – Adult CSS/other

Supplantation Issues  MHSA says only for increases - no cuts  No exceptions  DMH emergency regs - “required” $$  Exempts overmatch + realignment transfers  Permanent regs pending  Office of Administrative Law review  Legal challenges  MHSOAC says it could withhold $$

Adult CSS Revenues

Adult CSS $$ - MHSA vs Realignment

Prop 63/Mental Health Services Act (MHSA) Community Services and Supports Capital Facilities and Technology Education and Training County Planning Prevention and Early Intervention State Administration County Administration Innovative Programs Reserves

Full Service Partnerships  Not well understood by some counties  24-7 and include dually diagnosed  Housing for those not clean and sober  Outcome oriented  Independent living and employment  Not limited to high need clients  Physical health and wellness  early death, smoking, diet, exercise

FSP for Kids + EPSDT/3632  Most high need kids get EPSDT/3632  Won’t pay for all needs  Respite care and other family support  Alcohol and drug?  3632 Crisis care  Case rate to supplement EPSDT/3632  Can have risk/reserve factor

Education and Training  Stipends to attract/retain  Loan Forgiveness  Academic program expansion and improvement of curriculum  Attract high school students  Employ consumers and family members  Retraining staff  Fair share for private providers!

Education and Training  $500 million through  Some Funds remain with state  Based upon county needs  State prepares five year plan  Draft state plan due in June  Some funds available in  Additional funding for future years

Capital Facilities and Technology  $500 million through  Formula distribution –not yet announced  Very flexible eligibility  Must relate to providing eligible services  Technology likely to be web based open system that can be used in all counties and by all providers  Additional funding through plans for future  Fair share for private providers!!

Innovative Services  5% of what a county receives for CSS + PEI  County proposals must be approved by Oversight and Accountability Commission  Commission Developing Guidelines  Funds expected in 2008  Ideas may be developed locally or at state  Can’t be something already widely done

Prevention and Early Intervention  PEI State first draft guidelines/regs out soon  OAC – jump start Higher Ed/Schools  Respond to Virginia Tech  Broad competitive grants to institutions  Develop strategic plan?  Stigma and Discrimination  Statewide media campaign informed by political consultant  Suicide Prevention Committee and set aside

Prevention and Early Intervention - concepts  Take steps to get help as soon as possible after someone exhibits symptoms that could be or become a severe mental illness or a serious emotional disturbance  Make sure it happens before someone has hit rock bottom or been hospitalized  Requires education and outreach to those in a position to recognize that someone near needs help

Changing Attitudes through Early Intervention  Identify and treat schizophrenia in first few months – “Early Psychosis” began in Australia  Back to work or school within a year  Save $$ and shift to private insurance  Educate year olds, their families and primary care about symptoms and value of treatment and how to access it  Outreach/education $1 per capita per year  Expanding to Bipolar and Depression

Help for schools and kids  Teachers know who SED/at risk kids are  Need referral system/on campus help  Early treatment costs hundreds vs thousands  Increases attendance and graduation  Reduce teacher burnout  Reduce out of home placements

Prevention and Early Intervention  Minimum 20% of funds – starting in 2008  $200 per year for 2 years  $ m after  Formula distribution  State must develop new program  State process through summer  County planning in fall/winter  County plans must be approved by Oversight and Accountability Commission

This is totally new  What are the most likely programs?  Who will be the providers?  What other funds will be leveraged?  What will each program cost?  How many people can be served?  What results are we looking for?  How will we measure what is achieved?

Planning process (1) State establishes program and planning requirements – statewide stigma reduction and suicide prevention $$ and plans (2) Develop County Plans with expanded stakeholder participation  Within each community each setting and age group may require a different set of strategies  Not all expected to be included at first (3) Review and approval by Commission

CCCMHA Priorities?  Early Childhood?  Early Psychosis?  School Based Programs?  Suicide Prevention?  Outreach to elderly/primary care?  Outreach to Latino/Asian communities?  Other??

 Situation constantly changing  Unprecedented level of stakeholder participation  All materials posted on DMH website  Sign up to get notice of new materials  – county specific info

Remember how special this is  Transformation of a large public mental health system won’t happen overnight  Take the time to get it right  Don’t delay the things we know should be done  Appreciate the broad and diverse participation  Be assertive and patient