1. Higher Mortality of SMI – 29 years 2. ACE Study & Long-term Implications 3. Large Increases in Texas’ Population 4. Increased Diversity in Population 5. 10 Mental Hospital Beds per 100,000 6. Overall Size of the State 7. Slow Science to Practice Transition 8. Highest % of Uninsured 9. Major Workforce Shortages 10. Major Innovations: service & research 11. Significant Federal Dollars for Innovation 12. Difficult to Qualify for Medicaid 13. Emphasis on Integration, Recovery, Resilience

1. Put ACA in Historical Context 2. Summarize the Contents of ACA 3. Tie ACA to Disparities 4. Illustrate the Role of Public Policy 5. Offer a Challenge to Create a

Different Future 6. Be done by 4:00!

Virginia House of Burgesses

What policies should the state develop to manage mental illness?

1760

Policy Solutions:1. Invest in Institutions2. Limit State Funding3. Segregation______________Assumptions: 1. Family Responsibility2. Immune Populations3. Commerce as Cause4. Recovery & CureImplications1.Structural Disparities2.Delayed Help Seeking3.Silos4.Institution Centered

1760187019121933194519631965197319932010

The Affordable Care Act: 2025

1. Why are so many in need of Medicaid? Who are they?

2. What causes the early mortality of SMI? 3. Why are so many uninsured? 4. Why did 27 states sue to prevent the ACA? 5. Where does Texas rank on other measures? 6. What is the state of our science? 7. Do we need different policy direction? 8. What role does university education & research

play? 9. How much profit in health care is enough? 10. Is state funding for mental health adequate?

InstitutionsInstitutions1760-19631760-1963

1st1st

CMHC/FFSCMHC/FFSMedicaidMedicaidMedicareMedicare

1963-19801963-19802nd2nd

Managed CareManaged CareFee for ServiceFee for Service

1973-20091973-2009

33rdrd

Integrated CareIntegrated Care2000 -20132000 -2013

4th4th

Patient Protection &

Affordable Care20105th

State ControlCounty ControlPastoral CareState

HospitalsCounty Hospt.SegregationWarehousingMortality RatesLength of StayRecidivismEmployer Ins.Poor Services

Community ControlStates RightsFederalismNon-profitsCompetitionFederal FundingPrivate ProvidersInsurance NAMIConsumersRacial IntegrationHomelessnessUninsured

Private ControlFederal FundingCMHC Human RightsProfit OrientedState AuthoritiesAdvocacyConsumer Organiz.NAMIUninsuredAccreditationCulturalCompetenceJailsHomelessnessCult. CompetenceService Information

Collaborative CareSchool Based CareHealth Care Ins.Use of Primary CareGeneral HospitalsEarly IdentificationMedical HomesUse of TechnologyPsychiatric RecoveryLong Term Care

PoliciesFamily Support Peer SupportEvidence Based Serv.

Incorporates AllHealth ExchangesMedicaid ExpansionPre-existing Condit.ParityChildren Up to 26 YrAccountable CareMandated CareIncreased Demand

Prior ReformsPrior Reforms

1. Long Term Disparities by class, race, language, ethnicity, residence, employment, region;

2. Limited availability of quality treatment; 3. Insufficient focus on culture in care; 4. Limited content in university education &

research; 6. Limited understanding of help-seeking

behavior; 7. Fewer people in institutions for life; 8. Medicaid and Medicare as primary sources; 9. Conflicting policy directions at federal &

state levels over role of government; 10. Increased recognition of the relationship

between all aspects of physical health, mental health, social determinants, and public policy.

Theodore Roosevelt1912

Universal Health Insurance

The Social Security ActNational Health InsuranceThe New Deal

National Health Insurance

Hill Burton Act

Medicaid MedicareCommunity MentalHealth Centers

The Health Maintenance Act

The Health Security Act

The Patient Protection and Affordable Care Act

MH as an Essential Benefit Dependent Coverage Medicaid Expansion Pre-existing Conditions Health Homes No Rescission of Care Interdisciplinary Care Teams New IT Efforts Medicaid Home/Care Option Workforce Support Co-Location of Services Evidence Based Care Collaborative Care Services for Children Extends Insurance Emergency Services Reimbursements Access to Health Care Co-Morbidity Coverage

Barriers to Change

Commodification of Health Care Unhealthful Life Styles Workforce Shortages

Profit Orientation & Potential Social Determinants State Hospital

% of GDP Status of Science Housing

Opportunity for Fraud Corporate Interests Dated Concepts

Focus on Treatment/Sickness Lobbying Influence Complexity

Professional Silos Ineffective Policy Process Insurance/Employer

Corporatization of Health Care Professional Education

Absence of Prevention State Federal Conflict

Understanding of Disparities Absence of Racial Dialogue

1. Recognize that the Affordable Care Act is but a partial victory in health care; there is a critical need to build on the current ACA as the basis of a more comprehensive policy by 2025;

2. Petition for a White House Conference on Health/Mental Health Care in 2014;

3. Close State Mental Hospitals and Shift Care to General Hospitals and Funding to Communities;

4. Re-examine education in mental health in all the disciplines and move towards more cross disciplinary education;

5. Identify what it would take to move Texas’ per capita expenditures in mental health from 49th to 40th in 5 years;

6. Insist on the expansion of Medicaid as an investment in the population and as a means of lessening long term costs;

7. Automatic provision of health insurance for individuals who are diagnosed with severe mental illness;

8. Address the issue of early mortality of persons with severe mental illnesses; Texas is leading on this issue;

9. Address the issue of jails that have become the mental institutions of the 21st century;

10. Change the delayed help seeking and non-belief in the value of mental health care within minority populations.