Politics & Policy

Paul Ryan Commits to Mental-Health Reform

(Vedran Vidovic/Dreamstime)

Once again Speaker Paul Ryan has committed to mental-health reform, recently telling USAToday, “I think there’s promise in that area, because there are some Democrats who are agreeing with us on that.” He’s right. Forty-nine Democrats co-sponsored the Helping Families in Mental Health Crisis Act (HR-2646), which was introduced by Representative Tim Murphy (R., Penn.). Many of the bill’s co-sponsors are members of the Congressional Black Caucus who, rather than giving a knee-jerk “no” to a law associated with a Republican, recognize that Murphy’s proposals will improve services and reduce incarceration. It has 149 Republican co-sponsors who support the same goals as well but also want to save money and use federal funds more efficiently.

What makes the bill unique are its five provisions — frequently championed in National Review, the Wall St. Journal, the Washington Post, and elsewhere — to reduce homelessness, arrest, incarceration, and violence by people with untreated serious mental illness by using existing mental-health funds more effectively.

‐It saves money and comports with conservative principles by eliminating the Substance Abuse and Mental Health Services Administration (SAMHSA), which drives federal mental-health dollars away from the seriously ill and toward the worried well. SAMHSA’s failure has been well documented. It replaces SAMHSA with an assistant secretary of mental health, who will focus existing spending on the most seriously ill and require programs to be evidence-based before the government funds them. This will help end SAMHSA’s funding of anti-psychiatry, pseudo-science, and pop-psychology “treatments.”

‐It promotes family values by carving out a well-defined and minor exemption in current privacy law so that families of seriously mentally ill loved ones who provide housing, food, clothing, and care out of love will no longer be prevented by federal law from getting the same information that paid caregivers receive. This will enable more families to keep loved ones at home, because they will have access to information they need to make sure, for instance, that prescriptions are filled and transportation to doctors is arranged.

‐It returns the focus of the Protection and Advocacy Program (PAIMI) to its original congressionally mandated mission, which is to prevent abuse and neglect of the most seriously ill. Over the years, this federally funded legal-aid program has grown wildly out of control, such that it now spends much of its time lobbying against treatment for the most seriously ill; this is the opposite of what Congress intended.

‐It reduces the use of jails, rather than hospitals, to treat the seriously mentally ill. It achieves this by slightly ameliorating an obscure provision of Medicaid (the “IMD Exclusion”) that refuses Medicaid funds to states that have seriously mentally ill patients who need treatment in hospitals. As Representative Eddie Bernice Johnson (D., Texas), a key co-sponsor of Murphy’s bill, regularly highlights, the IMD Exclusion is what forces states to close state psychiatric hospitals and move the most seriously mentally ill out of them; this often results in incarceration of mentally ill people who need intensive medical and psychiatric treatment.

‐Most important, the bill reduces the use of expensive and inhumane incarceration and hospitalization by providing seed money for Assisted Outpatient Treatment (AOT). AOT is the most successful program for those whom police call “frequent fliers” — the seriously mentally ill who regularly and predictably wind up in jails because they refuse to stay on treatment. It allows judges to order those who have already accumulated multiple episodes of incarceration, violence, homelessness, or hospitalization — as a result of their own refusal of treatment — to work with a case manager and stay in mandated and monitored treatment while they live free in the community. Replacing expensive hospitalization and incarceration with community treatment will save taxpayers money and keep patients and the public safer.

Without Assisted Outpatient Treatment programs, case managers can serve only those patients who are well enough to seek treatment.

The Helping Families in Mental Health Crisis Act has many other provisions as well. The five provisions detailed above — the most important ones — might not be the same ones some Democrats are supporting. It is crucial that Representatives Ryan, Murphy, and Johnson not compromise on the proposals at the heart of the bill. At a committee hearing on the bill in November, Democrats proposed about 40 amendments. Unfortunately, many were designed to strike the very provisions — the five above — that help the most seriously ill. Other amendments were little more than candy and giveaways for the mental-health industry.

Democrats took aim at the AOT provisions by claiming that AOT drives people from care, in spite of the fact that assisted-outpatient treatment is only for those who have a history of already refusing care. They claimed that AOT doesn’t work by ignoring 20 AOT studies done in the last 15 years that prove beyond any doubt that AOT works to improve patients’ health. Opponents claim that AOT violates rights, in spite of the fact that 80 percent of patients say they like it and courts have repeatedly ruled it doesn’t infringe on civil liberties. Shockingly, Representative Joe Kennedy even proposed moving funds away from AOT and using them only for case managers. But without AOT, case managers can serve only those patients who are well enough to seek treatment. The paradox is that the sickest people often do not recognize they have a mental illness, and they flee from treatment. AOT allows judges to issue court orders for the seriously mentally ill who don’t have the ability to recognize their illness. Without AOT, case managers often can’t help those who need it most. Both AOT and case managers are needed, as expressed many times by former congressman Patrick Kennedy (Joe Kennedy’s cousin), who suffers from bipolar disorder.

Representative Murphy has shown a willingness to work with Democrats when they are right and to stand firm when they are wrong. He properly rejected many amendments but accepted several, including one from Tony Cardenas (D., Calif.) that would allow states to “suspend” rather than “terminate” Medicaid benefits to youths who get incarcerated; this will make it easier to restart the benefits when incarceration ends.

But the pressure is building. Ryan is now taking up Murphy’s bill, and on Wednesday a Senate committee will hold mental-health hearings against the backdrop of a similar bill (S 1945) proposed by Senators Bill Cassidy (R., La.) and Chris Murphy (D., Conn.). It could be crunch time. The goal must be not to simply to pass any bill that will allow lawmakers to feel they are “doing something.” They must pass a consequential bill that delivers real treatment to the most seriously ill.

D. J. Jaffe is executive director of Mental Illness Policy Org, a think tank on serious mental illness.


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