From 2009-2012, states cut $4.35 billion from their mental health care budgets. Cost-cutting strategies mostly occurred without regard to cost-effectiveness or the need for strategic reorientation of the mental health system.
Last year, 37 states began reversing the trend, but the damage has been done. It will be a long time before what was lost will be regained. The challenge now is to transform the system while rebuilding it. One in four adults experiences a mental health problem in any given year. One in 17 lives with the most serious conditions. As many as one in five children also experience mental disorders.
Unlike many other chronic conditions, mental illness begins at an early age. Fifty percent of lifetime cases of mental illness begin by age 14 and 75 percent by age 24. Treatment from the time of onset is delayed on average eight to 10 years. The mental health care system is rigged to respond to crises, rather than early screening, sustained treatment and social supports. Structural choices involve costs, but instead of providing continuity of care, the system is fragmented and uncoordinated.
The mental health care system is rigged to respond to crises, rather than early screening, sustained treatment and social supports.
Policymakers often lack information for making sound choices. Hard data is elusive. Returns on investment — outcomes — are not accurately measured. Analyses across different budget sectors are difficult or non-existent. The system begs for integrated, uniform, and transparent data.
When taxpayer dollars aren’t spent on evidence-based, cost-effective programs, cost-shifting occurs across different systems. The criminal justice system is one of the most dramatic examples. Investing in mental health care at the front end can result in cross-system savings overall. In state prisons and local jails, 20 percent of inmates live with mental illness. In the juvenile justice system, the prevalence is 70 percent.
Correction facilities are probably the worst places to treat mental illness. The goal should be to divert individuals from incarceration into treatment and to provide supports and services so they don’t enter the criminal justice system in the first place.
Police Crisis Intervention Teams (CIT), mental health courts and community services like assertive community treatment (ACT) serve both diversion and prevention purposes. With ACT, teams of mental health professionals visit individuals where they live rather than expecting them to come to an office. This proactive approach helps people stay on a path to recovery — and protects against relapses. ACT programs in the Chicago and Rochester, NY areas have shown savings up to $20,000 and $40,000 per person over the cost of hospitalizations or jail sentences.
Pre-booking diversions, including CIT, can reduce re-arrests by approximately 60 percent. In the juvenile justice system, services such as functional family therapy (FFT), a short-term intervention that focuses on family interaction patterns, reduce crime and recidivism. Savings with FFT are approximately $32,000 per person, but few communities offer such services.
Without early identification and treatment, childhood mental disorders affect how children learn and behave. In turn, school systems confront higher special education costs, increased disciplinary issues and lost education time. At the same time, schools can play an important role in community mental health partnerships. In Minneapolis, community mental health services are delivered in school facilities. For families, the arrangement is convenient, requiring less time away from work. Local agencies engage young people more effectively, and students are better able to integrate learning and coping strategies for school and home.
Supported housing and supported employment services can also reduce cost-shifting. Supported housing costs significantly less than homeless shelters or jails or hospitals. Louisiana, Tennessee and Utah are among states with model programs. Large, urban states do not have a monopoly on innovation.
Only about 20 percent of individuals living with mental illness are employed … The vast majority want to work and would be successful with supported employment services, but only two percent receive them.
Only about 20 percent of individuals living with mental illness are employed. About half of these work full-time. The vast majority want to work and would be successful with supported employment services, but only two percent receive them. Communities lose economic earning power. Costs increase for programs such as Supplement Security Income (SSI), Social Security Disability Income (SSDI), Medicaid and Medicare.
Medicaid is the single largest payer for state mental health services and tends to serve those people with the most severe illnesses. However, many individuals with serious mental illness have difficulty completing the process for obtaining SSI, which is a pathway to coverage under Medicaid. Overall, almost 40 percent of people living with mental illness are uninsured. Expanded coverage will help many of them get care. Cost studies indicate that states will gain resources from expansion and individuals with mental illness will be able to get care earlier.
Even in states that have expanded Medicaid, it is critical to keep co-pays low, since they otherwise serve as significant disincentives for people seeking help when they need it. Mental illness and poverty make it very difficult for some individuals to obtain continuous treatment. It is important to eliminate any financial barrier to getting care. Failure to do so will result in increased costs to criminal justice and emergency providers.
Investing in evidence-based services and supports and providing accessible early care will yield long term benefits. Our current system is spending significant resources for poor outcomes. We can do better.
Mary Giliberti is the Executive Director for the National Alliance on Mental Illness (NAMI).