The Obligation of Mental Health Services to the Least Well Off

Beginning in the 1970s a series of reforms in U.S. mental health services policy ushered in an era of high-priority concern for individuals with severe and persistent mental disorders (1). These new "community support" initiatives constituted a fourth cycle of policy reform, which followed the three major earlier cycles of reform—the moral treatment movement of the early 19th century, the mental hygiene movement of the late 19th and early 20th centuries, and the community mental health movement of the 1960s.

The fourth cycle of reform focused particular attention on the complex social welfare needs of a population with psychiatric conditions who often lived at the margins of the society (2). Placed in the community during the prior cycle of reform, individuals with severe and persistent mental disorders often were among society's least well off. In harmony with a set of values that suggests that the highest obligation of a society is to its least well off, the fourth cycle of reform emphasized the needs of those individuals who were most disabled by mental disorder and who had complex psychiatric and social welfare needs (1,2).

A series of government and private-foundation service initiatives were developed to address the needs of this population. In addition, mental health policies that affected the least well off were introduced. Some of the service demonstrations provided resources to create new services; others attempted to reorganize the service system and promote service systems integration. New policies addressed the financing of mental health services, disability payments, and housing subsidies (3). Many of the demonstrations were evaluated, and the policy changes were the subject of research (4,5).

This paper briefly examines the key service demonstrations and policy changes of the past 20 years in the light of society's obligation to the least well off. The superficial analysis establishes the connection between policy and the obligation, outlines what we have learned from this connection, and what we have done—and not done—about addressing our concern about the least well off among us.

Establishing a priority for the least well off

Before the start of the community mental health movement in the 1950s and early 1960s, the focus of government mental health policy, particularly at the state level, had been on individuals with severe and persistent mental disorder. The concept of the community mental health center (CMHC) was sold based on the centers' potential for reducing the societal burden associated with chronic mental disability, although CMHCs were also intended to foster preventive services and provide treatment for individuals with less severe emotional problems (1,3).

In the mid 1970s some states criticized the federal shift of focus away from the chronically ill and disabled population, and the General Accounting Office wrote a critique of the CMHC program charging that the federal government was not doing enough to return persons with severe mental illness to the community (6). The National Institute of Mental Health (NIMH) responded to these criticisms by developing the Community Support Program in the late 1970s (7), ushering in the fourth cycle of reform. The program fostered the creation of community support systems, broad networks of services that included health care, social welfare support, and housing and transportation services, all of which were integrated at the individual level by case management services. States resonated with this services strategy and put extensive resources into community support systems (4). In addition, most states clarified that priority for public resources would be given to individuals with severe and persistent mental disorders.

Federal government efforts reinforced this priority. Led by NIMH, the Department of Health and Human Services, including the Health Care Financing Administration, in 1980 released the National Plan for the Chronically Mentally Ill (8). The plan dealt with the status of individuals with severe and persistent mental disorders as society's least well off and focused on their need for social welfare support, subsidized housing, and medical and mental health care. It addressed a wide range of programs designed for the poor and disabled, including Medicaid and Medicare, Social Security Administration (SSA) disability programs, and housing programs sponsored by the Department of Housing and Urban Development (HUD). Although the plan was supported by the Carter Administration, the recommendations were controversial in a time of cost containment, and only 300 copies of the plan were released in 1980.

The Mental Health Systems Act, passed in 1980, established chronic mental illness and concern for the least well off as the principal focus of mental health policy (9). The legislation called for a partnership between federal and state government to develop and administer community support services for this target population. The act also recommended a substantial appropriation of new resources for the expansion of community support programs as well as support for the CMHCs.

In 1980 two major challenges remained for mental health policy focused on individuals with severe and persistent mental disorders. Full implementation of the National Plan for the Chronically Mentally Ill and the Mental Health Systems Act would require substantial new resources as well as a range of strategies for improving the integration of the system of services to meet the complex needs of the least well off. The advocacy efforts of the newly formed National Alliance for the Mentally Ill (NAMI) helped ensure that public mental health policy would continue to be focused on the needs of individuals with severe and persistent mental illnesses. However, lack of new resources and lack of service system integration were powerful impediments to progress as the decade of the 1980s opened.

Policies threatening the least well off

When the Reagan Administration and its new Congress took office in 1981, many of the supportive federal mental health policies of the previous administration came to an abrupt end. Furthermore, the hasty implementation of a review of the SSA disability rolls formulated in 1980 had especially adverse consequences for individuals disabled by mental disorders, who were disproportionately terminated from their disability benefits (10). For the most part the Mental Health Systems Act was repealed, and the National Plan for the Chronically Mentally Ill had no official support.

The new administration put in place a series of policies that threatened the society's least well off, including persons with severe and persistent mental disorders. However, much to the surprise of many observers, the population of persons with severe and persistent mental illness retained its priority for a shrinking supply of resources even as support for the least well off generally dwindled. Chronic mental illness retained its status as a condition "worthy" of social welfare support. Many of the objectives of the National Plan for the Chronically Mentally Ill were implemented by the decade's end (11). Most states also continued a policy of community support.

Many of the reforms in the mainstream health and welfare programs during the 1980s posed a threat of one kind or another to individuals with severe and persistent mental illness. Concern about the potential for adverse impact modified several of these reforms. For example, the Medicare prospective payment system and its case-mix adjustments based on diagnosis-related groups (DRGs) were viewed as unsuitable for use in psychiatric hospitals (12). This conclusion was reached partly because of expected disproportionate harm to patients with higher-than-average needs in the form of premature discharge or other practices reflective of undertreatment.

Further, Medicare's coverage for outpatient services was improved to assist severely impaired beneficiaries (13). Benefit limits were perceived as inappropriately applying concerns about "moral hazard"—arguably a sensible consideration for a population of employed adults—to disabled and elderly retired workers. SSA's disability policies for claimants with severe mental impairments were extensively revised in response to the aggressive nature of the continuing disability reviews (14). HUD's restrictive housing programs began to recognize severe mental illness as a special condition, leading to modification of program policies, especially those governing the Section 8 rental subsidy program (15).

Mental health services researchers and policy analysts began to introduce model mental health benefit plans in response to early conversations about health care reform (16). In an era of cost containment, mental health advocates feared a worsening of benefit restrictions. To preserve coverage for individuals with mental illness, the benefit plan proposals focused on insurance against catastrophic loss to ensure that the least well off would be protected and covered for appropriate mental health services. Benefit design efforts underscored the priority for individuals with the most severe mental disorders. This priority was reflected in health care reform policy recommendations from NIMH (17).

As policy reform improved the outlook for the least well off, it became clearer that the mental health system still lacked effective strategies for serving individuals with severe and persistent mental disorders. The system of mental health services was fragmented and poorly coordinated with the diverse social welfare and other human service systems on which its target population depended to have its complex needs met. The next stage in the focus on the least well off among individuals with mental illness called for development of ways to coordinate services and research on the effectiveness of these strategies.

Service demonstrations

As noted, the NIMH Community Support Program was the first major service demonstration focused on the least well off in community settings (4,7). From the 1970s mental health service programs followed two parallel tracks—one emphasizing integration of services and the systems of services designed to meet the needs of individuals with severe and persistent mental disorders and the other developing specific treatment, rehabilitation, and support services. The Community Support Program proceeded along both tracks simultaneously, although integration was viewed as the unique feature of the program approach. Several service innovations were associated with the program, including assertive community treatment and various less intensive forms of case management, crisis supports, and, later, supported housing.

When the Robert Wood Johnson Foundation decided to initiate demonstrations in the mental health area in the mid-1980s, it chose severe and persistent mental illness among adults and children as its focus (18). The least well off were viewed as an appropriate target for the foundation's philanthropy in its very first venture in mental health. Like NIMH, the Robert Wood Johnson Foundation proceeded along both service demonstration tracks. The foundation launched an initiative in service development, directed by Leonard Stein, M.D., as well as two system integration efforts. The first one, aimed at services for adults with chronic mental illness, was the Program on Chronic Mental Illness, directed by Miles Shore, M.D., and Martin Cohen, M.S.W. The other, aimed at services for children with severe emotional disturbance, was the Mental Health Service Program for Youth, directed by Mary Jane England, M.D., and Robert Cole, Ph.D.

Together with the Community Support Program, the programs sponsored by the Robert Wood Johnson Foundation demonstrated the utility of integrating service systems and offered the field a range of strategies. The evaluation of the Program on Chronic Mental Illness, however, illustrated the difficulty of linking system development to individual client improvements without adding state-of-the-art treatment, such as assertive community treatment, or without offering specific benefits, such as housing rental subsidies (5,19,20).

After the reorganization of NIMH in 1992, the Center for Mental Health Services (CMHS) initiated ACCESS, or Access to Community Care and Effective Services and Supports, a systems integration program for individuals who are homeless and mentally ill (21). Again, the focus was on the least well off population, including homeless street people and others who had been resistant to help. ACCESS incorporated the lessons of the Community Support Program and the Johnson Foundation's Program on Chronic Mental Illness into its design and combined service systems development strategies with state-of-the-art assertive community treatment services at each demonstration site. In addition, CMHS has sponsored a series of service development demonstrations on specific interventions for the least well off, including supported housing, jail diversion, and employment services.

Implementing policies for the least well off

Although many lessons for the care of the least well off were learned in the demonstration programs from the 1970s into the 1990s, society has been much slower in translating these lessons into policy and practice. A detailed analysis of this phenomenon is beyond the scope of this essay and is offered elsewhere (22). However, a few comments should be made here.

One common public response to a complex problem is inaction, caused by lack of a plan or strategy to address the problem. This state of affairs is the putative reason for the conduct of service demonstrations and their rigorous evaluation. According to the logic of service demonstrations, we should compare various service and policy strategies and scientifically determine a best course of action.

Another public response is paralysis in the face of demonstrated solutions to difficult problems, due to a lack of public commitment and political will to apply the solutions. Sometimes the price of action is considered too high. At other times failure to implement the lessons learned in services demonstrations simply reveals a lack of commitment to the problem and to the least well off, a failure in our society's actual commitment to stated social values.

Policy and program paralysis has been a particularly apparent barrier to implementing the changes in the social welfare, housing, and criminal justice systems on which the proper care and support of the least well off depend. Community care is not possible without broad support for human services.

Policies in the 1990s

The related issues of health care benefit reform and managed care have dominated mental health policy in the 1990s. Although both managed care and health care benefit reform, with its drive for parity between mental health and physical health care benefits, include all individuals in the covered population within their scope, recent policies have focused attention on the needs of the least well off and the most impaired.

Managed care

Concerns about the excesses of managed care practices center on their effect on beneficiaries with the greatest problems and greater-than-average costs (23). The policy debate centers on the impact of managed care on individuals with severe and persistent mental disorders. Will they be excluded from plans or systematically underserved? Who will provide the incentive for managed care organizations to care for the least well off? Historically, the private sector avoids serving the least well off or dumps them into the public sector. Will appropriate services be made available for the most impaired and least well off in public-sector managed care initiatives? Discussion of this question must also consider that Medicaid and the public mental health authority barely "managed" in the immediate past, before managed care restricted resources further.

During the 1990s the health care reform debate has emphasized the need to protect the least well off, as reflected in the 1993 Report of the National Advisory Mental Health Council (17). This concern about "vulnerable populations" was echoed by the 1997 President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (24). It is likely that the commission's two psychiatrist members—Herbert Pardes, M.D., and Steven Sharfstein, M.D.—were particularly concerned about the potential for harm from overly aggressive managed care for individuals with severe and persistent mental illness when they supported the commission's recommendation for a health care consumer's bill of rights.

Parity

Similarly, legislation to ensure parity between benefits for mental health care and physical health care in health insurance coverage has made the least well off a priority. State initiatives have either extended mental health benefits to individuals with the most severe disorders or have shaped benefits so that the care of the least well off is protected. Limited resources and cost concerns have restricted parity to less than full coverage for all mental disorders. The federal parity legislation echoed this strategy, providing financial protection against catastrophic losses and guaranteeing equal annual and lifetime dollar limits for somatic and mental disorders. Like state policies, federal parity legislation focused on the most impaired and least well off (25,26).

Future prospects for the least well off

Bad news

As noted, state and federal policies have reflected the societal commitment to a stated policy of priority for the least well off. Unfortunately, at times the commitment was a matter of principle rather than meaningful practice. Numerous "national plans" focused on severe and persistent mental illness, service demonstrations gave the least well off priority, and policy initiatives reflected concern about their well-being. Yet the least well off remain the least well off. We have not succeeded in achieving our goal of implementing the lessons of the past two decades during the fourth cycle of reform. Conditions are better, at least for those who can avail themselves of state-of-the-art practice and the benefits of scientific advances in treatment, rehabilitation, and support services, but they remain the least well off in society.

Recent changes in social welfare policy have threatened further the status of the least well off, reflecting a conservative shift in domestic policy (27). Local communities have abandoned general relief at the same time the federal government has reformed welfare policy. Specific changes in federal policies addressing disability, particularly the elimination of drug abuse and alcoholism as a basis for compensation, have made it more difficult for the least well off to be supported in the community and to receive treatment. Housing policy has also limited the supply of public housing and rental subsidies for individuals with mental illness, despite demonstration of the successful application of these approaches to individuals with severe mental disorders (20).

Better news

Perhaps the most impressive recent change affecting our thinking about mental health policy is the drive for self-advocacy among individuals with a history of mental illness. Some advocates may eschew the concept of the least well off as paternalistic and anachronistic. Consumerism, self-determination, and self-management shift the terms of the debate about the least well off. Rather than focusing on a status conferred by a society ambivalent about providing assistance, consumers of mental health services have organized politically to address these issues on their own.

Current policies are attempting to broaden the mental health agenda to be more inclusive. Recent rhetorical advances, such as those achieved with parity legislation, have emboldened some to favor policies that focus on the integration of mental health into the mainstream of health care. The impulse to broaden the scope of mental health initiatives affects thinking about health care financing, research funding, and service development.

The danger of such a broadening of the agenda is a loss of special status and concern for the least well off. In managed care organizations, mental health carve-out plans protect narrow mental health interests at the expense of integration of health and mental health care. In research, subsuming all investigations of mental health under neuroscience presents the risk that efforts to understand the most severe illnesses will be overshadowed by interest in elucidating day-to-day behavior. Mainstreaming housing for the least well off may result in lack of needed supports for those who are most impaired.

For decades the mental health policy field has been concerned about the downside of mainstreaming and the loss of a special focus on mental illness or on the least well off. The time has come to take what we have learned about the least well off and our established commitment to them and broaden our scope. The report on mental health expected from the Surgeon General is confronting this very issue. The principal message of this report is likely to be that mental health flows in the mainstream of public health. The details of the report, reviewing the state of current knowledge about mental health and mental illness, will lay the foundation for policy in the future. The perspective will be broad, but concerns for the least well off are likely to remain a priority (Center for Mental Health Services and the Office of the Surgeon General, unpublished background documents, 1998). The commitment of more than two decades to the interests of the least well off should not be drowned in a broadened public health mainstream.

Acknowledgments

The author thanks Robert Rosenheck, M.D., for helpful comments. This work was supported by grant MH-43703 from the National Institute of Mental Health.

Dr. Goldman is professor of psychiatry at the University of Maryland School of Medicine in Baltimore. Address correspondence to him at 10600 Trotters Trail, Potomac, Maryland 20854. This paper is one of a series of three papers in this issue on care of the least well off in mental health services.