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

2. Time for a Thrilling Ride!

3. Very Recent Developments - 1
Report of President Obama’s Task Force on Parity for Mental Health and Substance Abuse
Report: 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

4. 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

5. 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

6. 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

7. 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.

8. 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."

9. The Factors Have Become More Complex

10. 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.

11. 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.

12. 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.

13. Let’s Begin Our Adventure

14. 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

15. 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

16. 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

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

18. Our Dilemma

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

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

21. Tomorrow’s Well-Being Model

22. Public Health Reports - 1978

23. Integrating Care and Well-being

24. 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

25. Let’s Go!

26. 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

27. Integrated Care Services

28. Importance of Social Services

29. The Incarceration Crisis

30. 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).

31. 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.”

32. 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!

34. 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

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

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

37. Change is in the Air

38. 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

39. 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”

40. 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.

41. 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

42. 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.

43. So, which will it be?

44. Comments?

45. 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) (M)
The Only Voice of County and Local Authorities in the Nation’s Capital!