Institutions, programs, and services for the care, treatment, education, or rehabilitation of those inhabitants who are physically, mentally, or otherwise seriously disabled shall always be fostered and supported. Article 8 § Section 8; Michigan Constitution of 1963
Michigan’s managed care program for specialty services has been from the start: value-based, policy oriented, and consumer-focused. The selection process to be used for specialty pre-paid health plans endorses and is constructed around four major goals or purposes for managed specialty care. These goals are freedom, community, accountability, and efficiency. The department expects that CMHSPs will take the initiative and responsibility for embracing and implementing these goals and that there will be evidence of their commitment in the applications they submit to become PHPs. Implementation Guide: Revised Plan for Procurement of Medicaid Specialty Prepaid Health Plans; August 2000.
A New Vision for Michigan: Michigan’s children and adults enjoy good mental health and are served by a mental health system that responds effectively to the needs of individuals with mental illness and emotional disturbance while promoting resiliency and recovery. Michigan Mental Health Commission Report, October 15, 2004
Pursuant to Executive Order 2013-6, the members of the Mental Health and Wellness Commission have assembled this report to detail the findings and recommendations we believe are necessary to improve both the lives of and the outcomes for individuals and families living with mental illnesses, developmental disabilities and substance use disorders in our state.
The charge to the Commission:
“…to address any gaps in the delivery of mental health services and propose new service models to strengthen the entire delivery spectrum of mental health services throughout the state of Michigan.” State of Michigan Mental Health and Wellness Commission Report, 2013.
The Section 298 Initiative is a statewide effort to improve the coordination of physical health services and behavioral health services. The Michigan Department of Health and Human Services (MDHHS) launched this initiative in response to legislative language in the Fiscal Year 2017 approved budget. The language, known as Section 298, calls upon MDHHS to form a workgroup “to make recommendations regarding the most effective financing model and policies for behavioral health services in order to improve the coordination of behavioral and physical health services for individuals with mental illnesses, intellectual and developmental disabilities, and substance use disorders.” Final Report of the 298 Facilitation Work Group, March 2017.
The idea that persons with serious mental illnesses could be better served in their communities as opposed to being warehoused in large, sprawling and overcrowded institutions whose Gothic Victorian architecture often inspired more fear than healing arrived in the United States in the early 1960’s. Given the dire images evoked by Mary Jane Ward’s portrait of life in a “snake pit” that were often validated by individuals who found it necessary to be placed in a state asylum, the movement toward “deinstitutionalization” was commenced. Since that time, community mental health has become a political football that has suffered from underfunding and ongoing rhetoric about “how” and “who” should be providing behavioral healthcare to the most vulnerable citizens in Michigan. Promises have been made by politicians and policy makers who voice support for the most vulnerable citizens in Michigan, but their actions have tended to invalidate those promises by failing to actually implement policies that would have made improvements to mental health care.
In 1963, when President John F. Kennedy signed into law the “Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963”, Public Law 88-164, the intention was to give Americans with mental illnesses the opportunity to live in the community as opposed to being warehoused in large state psychiatric hospitals that were overcrowded and often abusive. At the time, over 560,000 Americans were in state psychiatric facilities across the United States. The possibility of providing community treatment became a reality when Thorazine, the first anti-psychotic, was introduced in 1954. PL 88-164 was the last bill that Kennedy signed into law, three weeks before his death on November 22, 1963.
Kennedy’s vision included the development of 1,500-2,500 community mental health centers across the nation that would reduce the number of individuals in state hospitals by 50%. In an October 20, 2013 article entitled, “Kennedy’s vision for mental health never realized” that appeared in U.S.A. Today to commemorate the 50th anniversary of the Mental Health Act, it was reported:
The legislation did help to usher in positive life-altering changes for people with serious illnesses such as schizophrenia, many of whom now live normal, productive lives with jobs and families. In 1963, the average stay in a state institution for someone with schizophrenia was 11 years. But only half of the proposed centers were ever built, and those were never fully funded (Retrieved online: ttps://www.usatoday.com/story/news/nation/2013/10/20/kennedys-vision-mental-health/3100001/January 23, 2019).
The public mental health system in Michigan was formalized in 1974 with the enactment of Act 258 of 1974, as amended. Known as the Michigan Mental Health Code, this set of laws covers the development and functions of the public mental health system in Michigan. Since that time, mental health has continued to be a political football. In the past 20 years, community mental health in Michigan has been the subject of at least four (4) major efforts on the part of the state to “redesign” and improve it. The genesis of each of these efforts may have been different and may have occurred under diverse political circumstances, but the goals for each of the commissions and reorganizations are eerily similar and have common themes. The problem is that, despite having lengthy processes that included convening groups of individuals to obtain input about “what needs to be done differently”, with the exception of changes in funding models and the addition of some services, the fundamental deficiencies in public mental health remain relatively unchanged. The lack of action on the part of the state and its policymakers in spite of multiple commissions and reports speaks loudly about the lack of support for those individuals that are served by community mental health.
The Mental Health Association in Michigan (MHAM) has been a participant in many of these public policy enterprises over the years. MHAM has been around for over seventy-five years and is the oldest advocacy organization representing the interests of individuals with mental illness and children with serious emotional disturbances in Michigan. In those years, MHAM has witnessed the evolution and, at times, the devolution of the mental health system in this state. Over the past 20 years, the state has emphasized community services and has moved away from warehousing individuals in state hospitals. At the same time, there are common impediments that have afflicted the community mental health system for years. Initiatives, commissions, task forces and reports have been born out of the various barriers and although well-intentioned recommendations have been offered, little to no action has been taken to actively pursue implementation of the observations about what “needs” to happen for the system to move beyond its limitations.
MHAM will be taking a look at the common goals that each initiative sought to achieve and will then write about whether or not the goals have been or were realized. To that end, MHAM is writing a series of blog posts that will examine the various initiatives, commissions and reports that have occurred over the past 20 years. MHAM has chosen to write about the past 20 years because behavioral healthcare has been under tremendous external pressure to reinvent itself. The state has made enormous strides toward helping the most vulnerable in Michigan live their lives as independently as possible. At the same time, however, funding for services has been reduced and services, themselves, have radically changed over the years. Our goal for writing these blogs is to bring an awareness to the failed promises that have been made to fix an ailing and wounded mental health system. At some point, the state needs to live up to the promise it made to its disabled citizens in Article 8, Section 8 of the Michigan Constitution.
The blogs will cover these significant events that have occurred over the past over 20 years: the movement toward Medicaid managed care that began in 1998; the Michigan Mental Health Commission report from 2004; the Mental Health and Wellness Commission report from 2013; and the Section 298 Facilitation Work Group report from 2017. This list is not all-inclusive and does not include the Medicaid-Medicare Dual Eligibles in 2011-2013 and it does not include the HOUSE C.A.R.E.S Task Force that was created by Rep. Tom Leonard in 2017. This blog is intended to provide an overview of the aforementioned projects and subsequent blogs will focus on the failure to keep the promises that were made as a result of these efforts.
Project 1: Medicaid Managed Care and Specialty Supports Waiver
Beginning in 1998, the state of Michigan Department of Community Health (MDCH) embarked upon a new model for public mental health funding by adopting Medicaid managed care. As part of the process, the 49 existing county mental health agencies were required to competitively bid to retain their status as managers of Medicaid funds. In August 2000, the MDCH issued a “Revised Plan for Procurement of Medicaid Specialty Prepaid Health Plans” that outlined the competitive bid process for what would eventually become known as the Prepaid Inpatient Health Plan (PIHP). The specialty supports waiver was intended to provide an array of services to individuals with developmental and intellectual disabilities; individuals with mental illnesses and addictions and to children with Serious Emotional Disturbances that would allow for greater freedom and the ability to live in the most integrated settings. James Haveman was the Director of the Michigan Department of Community Health when the state chose to move toward the PIHP system. The adoption of Medicaid managed care and the implementation of the eighteen PIHPS initiated the current structure of the public mental health system in Michigan.
According to the “Revised Plan”, the rationale for restructuring community mental health was summarized as follows:
The implementation of managed care for specialty services and the utilization of CMHSPs as Prepaid Health Plans were consistent with long held values and reform objectives in Michigan. For more than 30 years, the state has pursued the development of community-based specialty care systems to facilitate the integration, inclusion and recovery of persons with mental illness, developmental disabilities and addictive disorders.
“… the goal of unified system management was a means to a much larger end: that of enhancing the capabilities to function, the freedom to choose and the opportunity to achieve for persons with behavioral or developmental disabilities.”
Project 2: The Michigan Mental Health Commission, 2003-2004
In 2003-2004, Governor Jennifer Granholm convened a task force known as the Michigan Mental Health Commission that was charged with “creating a new vision” for behavioral healthcare. The final report was divided into two parts and contained seven goals for “transforming” the Michigan Mental Health System. The seven goals that were adopted by the Commission:
Goal 1: The public knows that mental illness and emotional disturbance are treatable, recovery is possible, and people with mental illness lead productive lives.
Goal 2: The public mental health system will define clearly those persons it will serve and will address the needs of those persons at the earliest time possible to reduce crisis situations.
Goal 3: A full array of high-quality mental health treatment, services, and supports is accessible to improve the quality of life for individuals with mental illness and their families.
Goal 4: No one enters the juvenile and criminal justice systems because of inadequate mental health care.
Goal 5: Michigan’s mental health system is structured and funded so that high-quality care is delivered effectively and efficiently by accountable providers.
Goal 6: Recovery is supported by access to integrated mental and physical health care and housing, education, and employment services.
Goal 7: Consumers and families are actively involved in service planning, delivery, and monitoring at all levels of the public mental health system.
Project 3: The Mental Health and Wellness Commission, 2013
Lieutenant Governor Brian Calley was the architect of the “Mental Health and Wellness Commission” that convened in 2013 and released its recommendations in 2014. Nine years later, the Michigan Department of Community Health decided to restructure the Medicaid managed care system that funds community mental health by reducing the number of Prepaid Inpatient Health Plans (PIHPS) from eighteen to ten. The Mental Health and Wellness Commission offered another report that was charged with addressing “any gaps in the deliver of mental health services…” The three “overarching goals” adopted by this Commission:
1.) Advancing more opportunities for independence and self-determination for persons living with a mental illness, substance use disorder or developmental disability.
2.) Better access to high quality, coordinated and consistent service and care between agencies, service providers and across geographical boundaries.
3.) Measuring outcomes and establishing meaningful metrics to evaluate the effectiveness of services provided and to assess the progress of goals set by the individual, state, locals and service providers.
The Mental Health and Wellness Commission was also known as the Calley Commission. The report and its findings were published in early 2014 coming on the heels of the state’s plan to adopt Medicaid Expansion. In late 2013, the state of Michigan voted to implement Medicaid Expansion which created the Healthy Michigan Plan. That same year, in 2014, the state tax dollars that are given to the CMHSPS to provide services to individuals without Medicaid and other health insurances were significantly reduced. Individuals with mental illness were most impacted by the reductions in state General Fund dollars and the need for additional inpatient psychiatric beds has dramatically increased. Then-Governor Rick Snyder dissolved the Mental Health and Wellness Commission in January 2015.
Project 4: Section 298 Facilitation Work Group, 2016-2017
The Section 298 Facilitation Work Group was convened as a result of boilerplate language that was inserted into then-Governor Rick Snyder’s budget recommendations for 2016. 298, as it is popularly known, caused controversy among those in the mental health community because it was suggested that the Medicaid dollars that had traditionally been set aside for the pubic mental health system could be given to the private Medicaid Health Plans. Section 298 came along at a time in which the public mental health system was already reeling from the significant reductions in its state General Fund allocations that occurred in 2014 and 2015.
As previously mentioned, Michigan voted to implement Healthy Michigan in April of 2014. Although Healthy Michigan benefitted many Michiganders, the state reduced the state General Fund allocation to the community mental health services programs by approximately 65%, which negatively impacted individuals without health insurance. The rationale for reducing state general fund on the part of the state was this: Those without insurance who had been receiving mental health services from community mental health would be eligible for Healthy Michigan. This supposition was incorrect and, as a result, many persons with serious mental illness and children with serious emotional disturbance were no longer able to obtain services. Therefore, when Section 298 was unveiled in then-Governor Snyder’s budget boilerplate language in February of 2016, there was tremendous outcry from community mental health and those that it serves. 298 was considered to be another nail in the coffin of a public system that had been traditionally under-funded.
As a result of the angst expressed by recipients of services, their families, providers and advocacy organizations, the Section 298 Work Group was formed and headed by Lieutenant Governor Brian Calley. The Work Group consisted of approximately 127 participants and met only three – four times over the summer of 2016. Eventually, the state formed a smaller “work group” of 23 voting members, which then produced a final report with more than 70 recommendations. Unfortunately, the state of Michigan chose to ignore the recommendations and the feedback from stakeholders who attended affinity groups that were held across the state in the fall of 2016.
In March of 2017, the Section 298 work group put out a report outlining over 70 recommendations with 13 areas that needed being addressed.
The recommendations address the following policy issues:
1) Coordination of Physical Health and Behavioral Health Services 2) Access to Services and Continuity of Services 3) Administration of Complaints, Grievances, and Appeals 4) Protections for Mental Health and Epilepsy Drugs 5) Self-Determination and Person-Centered Planning 6) Governance, Transparency and Accountability 7) Workforce Training, Quality and Retention 8) Peer Supports 9) Health Information Sharing 10) Quality Measurement and Quality Improvement 11) Administrative Layers in Both Health Systems 12) Uniformity in Service Delivery 13) Financial Incentives and Provider Reimbursement.
Each of these initiatives began in order to address real and/or perceived problems in community mental health. To date, very few of the recommendations that were made by any of these initiatives have come to fruition. MHAM’s question is: What happened? Stay tuned.
Next blog post: Whatever happened to serving the people? Or in the words of the Michigan Constitution, whatever happened to the promise that “…care, treatment, education, or rehabilitation of those inhabitants who are physically, mentally, or otherwise seriously disabled shall always be fostered and supported?”