When the President's New Freedom Commission on Mental Health released its final report in July, it issued a document that is likely to shape the nation's mental health care policies for decades. The Commission's charge was to study inadequacies in the current mental health care system and make specific recommendations for addressing these problems without increasing government spending.
After more than a year of coast-to-coast hearings and meetings, the panel released a roadmap that calls for a fundamental transformation of the delivery of mental health care. That transformation rests on two principles:
- Services and treatments must be consumer- and family-centered, designed to give meaningful choices in terms of treatment options and providers.
- Care must focus on increasing the consumer's ability to cope with life's challenges, emphasizing recovery and resilience, rather than just managing symptoms.
"The Nation must replace unnecessary institutional care with efficient, effective community services that people can count on," the report stated. "It needs to integrate programs that are fragmented across levels of government and among many agencies."
While the report targeted public sector mental health care, its impact could be widespread. If the U.S. Department of Health and Human Services (HHS) uses the document to reshape Medicaid policy, for instance, the report's influence will likely extend to private health care plans as well. It is widely acknowledged that Medicaid policy has a major impact on local systems of care that extends beyond the public sector.
The report emphasized a recovery model that would offer options in treatment, housing and employment and other supports to help people with serious mental illness take charge of their lives.
It defined recovery as "the process in which people are able to live, work, learn, and participate fully in their communities." Recovery can mean living a fulfilling life despite a disability or having a reduction or complete remission of symptoms.
The HHS is now conducting an assessment of the report and looking at the model programs that the final report uses as examples of best practices. "Our aim will be to identify ways in which the best elements of these models can be brought to scale nationwide," HHS Secretary Tommy G. Thompson said in a press release.
In 1997--the latest year for comparable data--the United States spent $71 billion on mental health care out of a total health care budget of more than $1 trillion, according to the report. The public sector paid for 57% of mental health care, compared to the public sector's 4% share of general health care expenditures. Mental health care spending did not keep pace with general health care spending between 1987 and 1997, primarily due to drops in private sector spending as a result of managed care and cutbacks in hospital expenditures.
The American Psychiatric Association released its own blueprint for the nation's mental health care system in April titled "A Vision for the Mental Health System." The APA's plan called for an investment in mental health care services that is equivalent to the level of disability caused by mental disorders, an end to behavioral health carveouts, and better integration between psychiatry and primary care. The report was released in the hopes of influencing the Commission's work.
While the report from the New Freedom Commission emphasized recovery and rehabilitation, the APA task force emphasized the role of medical professionals in shaping the nation's mental health care system. The APA blueprint stressed the need for expert diagnosis, an individualized treatment plan, continuity of care and a meaningful physician-patient relationship.
When the Commission released their final report, APA President Marcia K. Goin, M.D., voiced support: "The report describes barriers to the delivery of effective mental health care and provides examples of community-based care models that enable people with mental illnesses to live, work, learn and participate more fully in their communities."
Goin also stated that the APA "believes that a treatment approach based on a biomedical and public health perspective is a forward-looking conceptual foundation for a rational mental health system." Such a conceptual framework ought to include the "global burden of disease" model used by the World Health Organization (WHO) and World Bank to measure the impact of a given disability.
The WHO model--which uses disability-adjusted life years or years of life lost and years living with a disability--offers a way to compare the resources necessary to treat psychiatric disorders in relation to the impact of other medical conditions. The measure showed that mental disorders account for 20% of the total disease burden in the United States. Only 5.7% of health care expenditures go toward the treatment of these disorders.
Overall, mental health trade associations and advocacy groups came out in support of the Commission's final report. The Campaign for Mental Health Reform--a group founded by the Judge David L. Bazelon Center for Mental Health Law, National Alliance for the Mentally Ill (NAMI), National Association of State Mental Health Program Directors and National Mental Health Association--called on the U.S. Congress and the president to act on the report's recommendations.
"Policymakers have a choice," Robert Bernstein, executive director of the Bazelon Center for Mental Health Law, said in a press release. "They can put this report on a shelf and continue the past policies of hopelessness, or they can act on its recommendations and make recovery-focused services a priority for millions of Americans with unmet mental health needs."