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Congress Won't Act On Guns, But It Might Help Mental Health

The Huffington Post The Huffington Post 11/11/2015 Jonathan Cohn

Remember all that empty political talk about improving mental health care? It may not be so empty after all.

Responding to the outrage over gun violence, both houses of Congress are considering bills designed to make treatment for serious psychiatric disorders more available and effective.

The leading House bill, from Rep. Tim Murphy (R-Pa.), won approval from a key subcommittee last week. In the Senate, a similar bill from Bill Cassidy (R-La.) and Chris Murphy (D-Ct.) will get preliminary hearings before the Health, Education, Labor and Pensions Committee next month.

Both bills have bipartisan support. Both have endorsements from major organizations that work on mental health, including the American Psychiatric Association and the National Alliance on Mental Illness . And while both proposals face significant political obstacles, including opposition from other mental health advocates , some kind of legislation has a real chance of passing Congress and getting the president’s signature by next year.

Whether enactment would actually reduce the incidence of gun violence is difficult to say. The vast majority of people with mental illness, like most people without mental illness, are not violent. But passage of something resembling either of the two bills could mean real improvement for people suffering from serious psychiatric ailments -- people who, traditionally, have gotten a short shrift from the U.S. healthcare system.

At the heart of each proposal is a significant, if seemingly obscure, change to Medicaid, the government-financed program that provides insurance to millions of poor and disabled Americans. Under current law, Medicaid does not cover inpatient care at some psychiatric hospitals. The provision is a legacy of the 1960s, when Medicaid first became law and policymakers were eager to discourage the warehousing of the mentally ill at institutions. Another purpose of the provision, in some tellings, was to stop states from cutting back on their own funding for long-term psychiatric care.

Many experts feel that restriction limits the availability of inpatient psychiatric beds -- at a time when such beds are frequently in short supply. Both the House and Senate bills would modify the existing restriction, allowing more Medicaid money to flow to psychiatric hospitals. Supporters of the bills hope this change would allow the hospitals to provide more care, alleviating the existing shortages where they exist.

A second key feature of the bills is an investment in promising new treatments for severe mental illness, including early intervention services for schizophrenia. Recent studies have shown that the early intervention approach, which provides social and psychiatric supports to people first experiencing psychotic symptoms, can yield substantially better outcomes than traditional care for people with schizophrenia. The federal government has already set aside some money for early intervention, but it’s short-term funding that will soon run out.

The House bill has been a labor of love for Congressman Murphy , who is a trained psychologist. He led a congressional investigation into mental health care following the Sandy Hook massacre and, last year, introduced a preliminary proposal that reflected what the committee found. Following Wednesday’s subcommittee vote, NAMI executive director Mary Giliberti said that her organization “is thrilled that Congress has taken the first crucial step in moving forward comprehensive, bipartisan mental health legislation.”

But the House bill has also been the one to attract the strongest opposition, primarily (but not exclusively) because of two controversial elements. One is a proposal that would offer state governments small financial incentives to introduce and make greater use of "assisted outpatient treatment."  That’s a program in which courts can order people to enroll in treatment programs as a condition for avoiding involuntary hospitalization. Groups like the Bazelon Center for Mental Health Law fear that greater reliance on assisted outpatient treatment would compromise the civil liberties of people with mental illness -- and discourage the kind of community-based care that in many cases produces the best results.

Moving this bill forward is the same as moving backwards on mental health for this country. John Head, spokesman for the Bazelon Center

Murphy’s House bill would also alter existing privacy regulations, loosening restrictions on communication between the providers of mental health care and the families of the mentally ill. Advocates for the bill feel this will make it easier for caregivers to take care of people who are so sick they cannot manage their own treatment. Critics say the changes would violate patient privacy.

“Moving this bill forward is the same as moving backwards on mental health for this country,” John Head, spokesman for the Bazelon Center, told The Huffington Post.

The Senate bill doesn’t have those same controversial provisions, perhaps because Cassidy and Sen. Murphy introduced their measure later and took some of those objections into account. But the Senate bill includes the House proposal to change Medicaid and that could ultimately pose the biggest obstacle to passage, because that provision comes with a hefty price tag. The Congressional Budget Office  predicted that a previous version of the House bill would cost $46 billion to $66 billion over 10 years. Mainly that is because inpatient psychiatric care is expensive and, if implemented, both the House and Senate bills would allow a great deal more of it. 

Congressman Murphy has since scaled back the Medicaid portion of his proposals and the Senate version was always less ambitious. If either bill moves forward, the CBO will likely find it costs less than the earlier House bill -- and maybe a lot less. But even more modest expenditures would require lawmakers to agree on offsetting revenue or spending cuts, or tolerate modestly higher deficits. 

Serious discussions about finding offsets hasn't begun, since the legislative process has just started -- and both proposals are likely to undergo more revision before they go to floor consideration. Some advocates would argue that if Congress is going to spend more money on mental health, the balance between outpatient and inpatient care should tilt more heavily to the former. But the financing question looms and, at some point, the proof of whether Congress takes mental health seriously will be whether Congress is willing to spend money on it.

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