Insight Matters
Summer, 2003

A Response to the President's Commission Report
by Mark R. Munetz, M.D., OPA President

"We envision a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when everyone with a mental illness at any stage of life has access to effective treatment and supports - essentials for living, working, learning and participating fully in the community." Vision Statement, Achieving the Promise: Transforming Mental Health Care in America, July 2003

Late last month The President's New Freedom Commission on Mental Health released its final report. This is the first Presidential report on mental health issues in 25 years. Knowing Commission Chair, Michael F. Hogan, Ph.D., Director of the Ohio Department of Mental Health as we do, it is not surprising that the report is comprehensive, clearly written and in its own words "conveys a bold vision for transforming mental health care in America". The vision statement in the report is certainly bold, perhaps even utopian.

In response to the report, APA President Marcia K. Goin, M.D. released a statement commending the President and the Commission "for their strong efforts to improve our nation's mental health delivery system". APA in anticipation of the Commission report released a task force report - A Vision for the Mental Health System - which Dr. Goin describes as a far-reaching blueprint "to reform our and rebuild our crumbling mental health system amidst the deepening funding crisis in state and local mental health services".

Both reports are worth reading and studying. The Commission Report can be found in its entirety at www.mentalhealthcommission.gov and the APA report at http://www.psych.org/news_stand/visionreport040303.pdf. The Commission Report contains six goals with 19 recommendations to achieve the goals. The APA Report includes 12 guiding principles that were published in the last issue of Insight Matters.

A major difference between the two documents are assumptions about resources. The Commission emphasizes improving efficiency; APA believes that will not be enough, that "additional funding is required to improve the mental health service delivery system."

The Commission emphasizes the fragmentation and lack of flexibility of the many federal programs that serve the mentally ill. Many of these programs are outside the traditional mental health funding streams per se, such as funding for disability and housing. Key recommendations are to "Align relevant Federal programs to improve access and accountability for mental health services" (Recommendation 2.3) and then to give the states added flexibility of their use of Federal funds as part of each states requirement to "Create a Comprehensive State Mental Health Plan" (Recommendation 2.4). The implication is that if existing funds can be used more efficiently dramatic improvements can occur in our system of care.

The APA Report points out that "in the U.S. the burden of disease accounted for by mental disorders is 20%, whereas only 5-7% of all health expenditures are directed toward treatment of these disorders". Furthermore, in recent years the proportion of funding for mental disorders has been decreasing. The report argues that funding should more closely reflect the disease burden. Put simply, we need substantially more money to adequately address the needs of people of with mental disorders. As the Commission Report points out mental illnesses are the leading cause of disability worldwide.
Would we gain enough efficiency from better coordination of funding streams to make up the large disparity in funding? It seems very unlikely to me.

The Commission Report is 98 pages long, with not a great deal of detail on how its recommendations might be implemented. The real work starts now. It is expected that a number of subcommittee reports will follow which will be more detailed. Giving the states more flexibility to use Federal dollars from many sources to serve people with mental disorders sounds good on first glance. Wouldn't it be nice, for example, to take all the money we spend on people with mental illness in our jails and prisons and move it to treatment in the community. Clearly in determining how such things might happen, the devil will be in the details. The Federal government has never wanted to take on responsibility for serving people with serious mental illness. Over the past half-century the states and the feds have been playing major cost shifting games over the care of the mentally ill. The states have successfully shifted much of the cost to the Feds through programs like Medicaid, Medicare and Social Security. We all agree what we have right now is a mess. Should the Commission recommendations all be followed, will we have Utopia? Or will the Federal government have successfully shifted the burden back to the states. If that happens without significantly more funding the already crumbling state mental health systems will deteriorate further.

We can hope for Utopia. But OPA and our partners in advocacy must remain vigilant and vocal as the impact of this important report reveals itself.

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