Mental Health Reform is dead. Long live Mental Health Reform!

by Richard Edwards

Today, at a press conference, NC DHHS Secretary Lanier Cansler stated that the era of mental health reform was over. You can read about it here, here and here.  That’s a bold statement, to say the least, bordering on hyperbole, but I suppose it depends upon how you define reform and set the boundaries for the era itself.

Strictly speaking, mental health reform ended when Local Management Entities, previously community mental health centers, divested their mental health, intellectual and developmental disability and substance abuse services in an effort to increase efficiencies by privatizing the system. The vast majority of this transition occurred years ago, from 2004 to 2006 or so. So, yes, that era of mental health reform is over.

Another focus of mental health reform was to bring people living in institutions back into the community–a move that would be supported by the development of community services. This part of reform never happened–there are still many people living in institutions, and there doesn’t seem to be any inclination to support the community-based service capacity necessary to assure a safe transition. So, also, that era of mental health reform is over–in fact, it ended before it ever began.

So, I suppose, the processes that were supposed to bring about system transformation are over, if they ever really began. But the era of mental health reform is emphatically not over.

The establishment of Critical Access Behavioral Health Agencies (Kah-bas), described in the articles and press releases, is a response to the failures of mh reform, but it’s not the end of it. Far from it.

CABHAs are, in many respects, private mental health service providers who provide an array of services to a given population (adults and/or children) in at least one area of the state. Certain services can only be provided by a CABHA-certified agency, including case management and peer support, but also intensive mental health and substance abuse services. Ostensibly, the goal is to create a more professional, more competent provider network. See, when the state ordered the LMEs to divest their services, they didn’t order them (or pay for them) to divest their clinical and medical oversight. Consequently, some providers had it, and some didn’t. There was no requirement to have it, and there was no funding to support it. The CABHA certification requires that level of clinical and medical oversight to be held within the provider agency, and there is a lot of hope–as evidenced by today’s press conference–that oversight will address many of the problems in the system.

And I would agree, it might, but here’s the rub–there is no guarantee as to how many of the some 175 certified CABHA entities will survive the next 6 months. Consider the following:

Each CABHA must have a Medical Director, for which there is no additional funding.

Each CABHA must have a Clinical Director, for which there is no additional funding.

Each CABHA must have a Quality Improvement/Training Director, for which there is no additional funding.

Each CABHA must provide Outpatient Therapy and Psychiatric services, both of which are loss-leaders in the field and are inadequately supported by state rates.

The cost of the three unfunded positions could easily top $300k annually, and even if you take into account that many agencies may have had a Clinical Director or a QI Director, most small agencies were doomed from the start. Out of some 600+ provider agencies, only 175 or so made it through the certification process. Of that 175, it is almost certain that a third to a half will not survive the next year.

You could argue that the 11-12 budget will actually be to blame for that, and that’s not unfounded, but my angle is this…

In trying to assure mental health reform went over smoothly, the state made it too easy for a business to get into the mental health industry, and for the last four years, has been trying to clamp down on this proliferation.  So, call it what you will, but we are still dealing with the effects of mental health reform.

The era of mental health reform may be over, but the vision is still a long way off.

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