President Obama and Mental Health Policy – the Audacity to Hope

President Obama has no mental health policy – at least not one that has been stated formally. That should come as no surprise, as the outgoing administration did not really have one either. In truth there is no de jure national mental health policy in the United States in the sense of the World Health Organization use of the term to denote an explicit set of national laws focused specifically on the allocation of resources, rights and responsibilities for individuals who experience a mental disorder. Instead in the U.S. there is a de facto federal mental health policy comprised of the de jure mental health policies of fifty states and a handful of territories together with the mental health components of myriad federal health and social policies.

According to a thoughtful analysis by Frank and Glied (2006), over the past half century the mental health of most Americans has improved as a result of the population having gained increased access to mainstream resources and services. A minority of the most impaired and impoverished individuals continue to do poorly, but the majority has benefited from access to financing programs from Titles II, XVI, XVIII, and XIX of the Social Security Act, better known as Social Security Disability Insurance, Supplemental Security Income, Medicare and Medicaid (Frank and Glied, 2006). Other programs assist individuals who have a severe mental disorder to live and work in the community, such as various housing assistance and rehabilitative services programs. The policies of these mainstream benefits programs constitute the core of America's federal mental health policy (Goldman, Glied, and Alegria, 2006; Grob and Goldman, 2006).

Federal mental health policy, such as it is, has achieved these successes through a sequence of incremental changes guided by a vision and recommendations for reform described in a series of high level reports, according to a recent history by Grob and Goldman (2006). Presidential commissions going back to the Eisenhower and Kennedy administrations in the 1950's and early 1960's, followed by another during the Carter presidency in the late-1970's, published reports and recommendations that called for dramatic and sometimes fundamental reform. What resulted, however, was piecemeal change in a multitude of jurisdictions, yielding a fragmented patchwork of policies and services.

Ten years ago during the Clinton administration the U.S. Surgeon General issued the first-ever report on mental health (Department of Health and Human Services, 1999). While not a policy document, the report set forth eight “courses of action” recommended by the review of the research literature about mental health and mental illness. The 1999 report of the Surgeon General and its 2001 supplement on culture, race and ethnicity in mental health (Department of Health and Human Services, 2001) served as the scientific foundation for a presidential mental health commission created by President George W. Bush in 2002. This so-called “new freedom” commission issued it report in 2003 (President's New Freedom Commission, 2003). Its policy recommendations were mostly broad and non-partisan, receiving little attention within the government after the release of the report. A workgroup of federal agency heads met periodically to discuss mental health issues within their organizations. Federal research efforts were directed at evidence-based services. The federal Center for Mental Health Services focused on recovery and transformation of services, making a series of related grants to various selected states (Power, 2009). Advocacy organizations formed a Campaign for Mental Health Reform (Campaign, 2008) to push forward the recommendations of the commission. Advocate focused on “parity,” gaining improved insurance coverage for mental and addictive disorders in Medicare and private insurance, and they succeeded late in 2008 (News & Notes, 2008).

This chain of events sets the stage for the Obama administration, as it considers its domestic policy, with healthcare reform heading the list. No one yet knows the precise contours of healthcare reform proposals. There have been no formal announcements. Work on healthcare reform is underway both within the executive branch, led by members of the new administration, and also within the Congress, where legislation is being drafted. This is different from the healthcare reform effort during the Clinton administration, when the initial policy development was handled almost exclusively by the executive branch. The legislature was only involved after the administration offered its elaborate plan for healthcare reform legislation. As of now, there has been little discussion of mental health issues, although benefit design is beginning to be explored. What then are the key issues that should be addressed with respect to mental health in the healthcare reform activities in the new administration?

A good place to start would be the 2003 recommendations of the President's New Freedom Commission on Mental Health. Nineteen recommendations were organized around six goals or themes (President's New Freedom Commission, Figure 1). Most of the means for “achieving the promise” of these goals are pretty broad and general, including “addressing mental health with the same urgency as physical health” or “promote the mental health of young children.” Other recommendations are specific, such as “advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention” or “develop and implement integrated electronic health record and personal health information systems.” The federal government started work on most fronts but made little headway on any one of the recommendations. A new administration could and should pick up these recommendations and move forward with them. Given the broad support for the work of the Commission, it would be foolish to push the recommendations aside because they were the product of another administration. All of the goals and so many of the specifics fit with what we know of President Obama's ideas about healthcare and human services from the presidential campaign, such as support for evidence-based practices, more research, and the need for electronic medical records.

The members of the Commission also called for improved financing for mental health services, particularly supporting “the President's call for Federal legislation to provide full parity between insurance coverage for mental health care and for physical health care” (President's New Freedom Commission, p. 21). While not officially one of the nineteen recommendations, the call for parity was achieved in the final months of the Bush presidency (News & Notes, 2008). The challenge now is the implementation of this legislation.

Implementing parity in Medicare and in private insurance requires considerable attention and adroitness, particularly in the context of broader healthcare reform. The parity legislation did not create a mandate for mental health coverage in insurance; it required equal coverage to general healthcare, if mental health treatment was covered at all. A health plan could meet the requirements of the parity law by reducing coverage of general health services or more perversely by eliminating mental health coverage entirely. There are numerous provisions of the parity law that require oversight and many adjustments to health insurance coverage. This policy implementation occurs at the same time as broader healthcare reform. It will be complicated to sort out what parity will mean for the mental health benefits in existing health plans and also for health plans newly created as a result of healthcare reform.

The Campaign for Mental Health Reform made “Inclusion of Mental Healthcare in Overall Healthcare Reform” the title of its press release at the time of its initial launch. The Campaign reiterated the recommendations of the President's Commission and has organized the advocacy community to move forward in unity (Campaign, 2008). The new drive for healthcare reform, however, will test this unified front as mental health advocates seek to advance their individual interests now that the more general goal of parity has been achieved. Commission chair and now Commissioner of Mental Health for New York State, Michael Hogan calls for “a new era of mental health advocacy” in the wake of parity to make sure that improve financing results in access to the right amount and mix of services. Not surprisingly, he also calls for a special “point of responsibility on mental health policy in the federal government” (Personal communication; March 2009).

Several other commentators and researchers have gone beyond the recommendations of the President's New Freedom Commission to offer their own ideas about priorities for healthcare reform in the Obama administration:

Longtime policy analyst and advocate, Chris Koyanagi (2009) of the Bazelon Center for Mental Health Law, suggests learning from the lessons of the experience with healthcare reform during the Clinton years. Feeling optimistic about the increased interest in mental health now compared to sixteen years ago, she focuses on implementing evidence-based practices and integrating mental healthcare within general medical care, particularly in primary care. Thomas Smith and Lloyd Sederer (2009) suggest adapting the concept of a “medical home” from primary care to create a “mental health home.” The medical home is as a central point of clinical responsibility for an individual, and the “mental health home” would be responsible for coordinating an individual's health and mental healthcare and connecting with families and an array of community services.

The MacArthur Foundation Network on Mental Health Policy Research developed a series of papers on a policy research agenda for the future, currently being published in the American Journal of Psychiatry and Psychiatric Services (Goldman, Glied, and Alegria, 2008). The focus of this research is on the mental health issues in mainstream social policies, such as housing, criminal justice, education, employment, and welfare, as well as in general health policy. These “inter-sectoral” policy issues are where so much of the progress of the past decades has occurred and where there are the greatest needs for reform in the future. It is often very difficult to implement effective change for individuals with mental illness within mainstream social policies. As a result, the advance of mental health policy will depend on informed and enlightened stewardship, a special form of leadership for complex problems. As noted above, Commissioner Hogan calls for a point of responsibility, similar to the call for a “federal mental health czar” by Frank and Glied (2006).

The current “steward” of federal mental health service activities is Kathryn Power, who heads the Center for Mental Health Services within the federal agency, the Substance Abuse and Mental Health Services Administration. She presents her ideas for transformational change in an essay, “A Public Health Model of Mental Health for the 21^st Century” (Power, 2009). Her recommendations are the product of an internal strategic planning process conducted by the agency involving its many stakeholders. Although she is the agency director within the executive branch of the federal government, she is not a political appointee. The appointed leadership of the Department of Health and Human Services (DHHS), within which the Center for Mental Health Services (CMHS) resides, is still forming. So the CMHS strategic forecast does not represent the official policy of the Obama administration. It does, however, represent the best thinking of a strategic planning process set in motion by the agency in collaboration with a broad array of informed and interested parties. Unsurprisingly, this forecast and its recommendations echo those of the President's Commission: “There is no health without mental health.”“Recovery is the expected outcome.”“Service recipients direct their own care.”“Services are evidence based.”“Performance management drives quality improvement.”“First and foremost, CMHS will embrace the concept and practice of a public health model of health care.”

Exactly what shape (if any) this proposed transformation will take remains to be seen. The plan for CMHS to build the information base and to provide national mental health policy leadership is welcomed and makes sense, but it will only yield results if the agency is empowered by the Secretary of DHHS and by the President, as healthcare reform moves forward. And it will only yield progress if federal healthcare and social policies are aligned with mental health policy in the states and the territories. It is true that the federal government will have strong influence on state policies, but reform will be more effective if the federal government facilitates access to services offered in the states. That is where day-to-day mental policies are enacted and implemented. Care and treatment goes on, while the Obama administration takes its time considering healthcare reform.

Table I.  Goals and recommendations in a transformed mental health system.

Goal 1	Americans Understand that Mental Health is Essential to Overall Health.
	Recommendations	1.1 Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention.
		1.2 Address mental health with the same urgency as physical health.
Goal 2	Mental Health Care is Consumer and Family Driven.
	Recommendations	2.1 Develop an individualized plan of care for every adult with a serious mental illness and child with a serious emotional disturbance.
		2.2 Involve consumers and families fully in orienting the mental health system toward recovery.
		2.3 Align relevant Federal programs to improve access and accountability for mental health services.
		2.4 Create a Comprehensive State Mental Health Plan.
		2.5 Protect and enhance the rights of people with mental illnesses.
Goal 3	Disparities in Mental Health Services are Eliminated.
	Recommendations	3.1 Improve access to quality care that is culturally competent.
		3.2 Improve access to quality care in rural and geographically remote areas.
Goal 4	Early Mental Health Screening, Assessment, and Referral to Services are Common Practice.
	Recommendations	4.1 Promote the mental health of young children.
		4.2 Improve and expand school mental health programs.
		4.3 Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies.
		4.4 Screen for mental disorders in primary health care, across the life span, and connect to treatment and supports.
Goal 5	Excellent Mental Health Care is Delivered and Research is Accelerated.
	Recommendations	5.1 Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.
		5.2 Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.
		5.3 Improve and expand the workforce providing evidence-based mental health services and supports.
		5.4 Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.
Goal 6	Technology is Used to Access Mental Health Care and Information.
	Recommendations	6.1 Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations.
		6.2 Develop and implement integrated electronic health record and personal health information systems.

We have the audacity to hope that President Obama's insistence on healthcare reform will mean significant reform for mental healthcare within the larger reform effort. The roadmap for change has been set forth in various policy documents over the past decade. Whether the change is fundamental reform or a sequence of incremental changes in policy, the expectation is for greater access to quality mental health services, that recovery from mental illness is possible and that mental health is fundamental to health.