1. Changes and Constants in Behavioral Health
Ron Manderscheid, Ph.D.
Executive Director,
National Association of Counties Behavioral Health and Development Disability Directors and National Association for Rural Mental Health
Adjunct Professor, BSPH, JHU
© NACBHDD
The views, opinions, and content of this presentation are those of the presenter and do not necessarily reflect the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.

2. Time for a Thrilling Ride!
Image: Person zip-lining at an amusement park.

3. Introductory Comments on Behavioral Health Workforce Issues
The Behavioral Health Workforce is in crisis:
Baby boomers are retiring.
Baby busters are not there.
Opioid crisis has vastly expanded demand.
We are not training clinicians in sufficient numbers.
We are training people with yesterday’s knowledge.
Clearly, we need a new strategy going forward. The University of Michigan Center on Behavioral Health Workforce Research is a breath of fresh air!

4. Very Recent Developments—1
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 reentry funds on appropriate services.
Grants will be available to build reentry infrastructure between corrections and mental health.

5. Very Recent Developments—2
21st-Century Cures Act (cont’d)
$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 2018 Funding Bill.

6. Very Recent Developments—3
Medicaid Managed Care Regulation (Spring )
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—4
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.
Governors are now discovering the power of these waivers.

8. The Factors Have Become More Complex
Image: Roller coaster.

9. Key Game Changers POLICY: Healthcare reform is in question.
RESEARCH: Early intervention with first- episode psychosis.
PRACTICE: Trauma as a causative factor in most mental illness.

10. 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.

11. Key Responses
MOVING UPSTREAM: APHA has a major 5-year initiative on altering the negative social determinants of health. Goal: Health for all society!
MOVING DOWNSTREAM: The United Nations has set personal and community “well-being” as a worldwide 15-year objective for 2030.
REBUILDING THE STREAM: Major U.S. corporations are beginning to embrace a “culture of well-being” in the workplace (e.g., Carter Center Summit).

12. Let’s Begin Our Adventure
Image: Road sign reading “Thrills.”

13. 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.

14. 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.

15. 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

16. How? Population Health Management.
Integrated Care Systems that bring together mental health, substance use, and primary care services AND incorporate disease prevention and health promotion strategies.

17. Our Dilemma

18. Health and Well-Being—1981
VERY HEALTHY
NO DISEASE SEVERE DISEASE
VERY UNHEALTHY

19. Viewed as Population Health
VERY HEALTHY
NO DISEASE SEVERE DISEASE
VERY UNHEALTHY
Pop 1
Pop 2
Pop 3
Pop 4

20. Tomorrow’s Well-Being Model

21. 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

22. Integrated Care Services

23. Importance of Social Services

24. The Incarceration Crisis

25. Tonight: City and County Jails
About 730,000 persons in these jails:
182,500 (25 percent) persons with a mental illness
365,000 (50 percent) 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).

26. Linkage With Public Health: 1,943 County Public Health Departments

27. Change Is in the Air
Image: Four-way street sign, with each sign reading “CHANGES.”

28. 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.

29. 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 versus change everything.

30. Commentaries
My commentaries on all of these issues are available at

31. So, Which Will It Be?
Image: Two-way street sign reading “BORING” and “Interesting.”

32. Contact Information
Ron Manderscheid, Ph.D.
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!