Current headlines in mental health –

especially in New York – illustrate the

risks, problems and even the opportunities

that we face. What sense can we make out

of headlines like "Hospitals to be

downsized and merged," "Government

reorganization of health agencies being

considered," and "Integration of mental

health and medical care is recommended?"

(OK, I made up the headlines, but all of

these developments are either real or

under consideration.)

The supposed Chinese curse "May you

live in interesting times" comes to mind.

These times are at least interesting...

maybe scary. According to Wikipedia, this

curse is probably not Chinese at all, but

possibly of English origins. And

apparently it goes with two other curses:

1) "May your wishes all come true," and

2) "May you come to the attention of the

government (alternatively...'come to the

attention of powerful people')." It seems

as if all of the curses befall us.

How have "we" wished for these things?

Well, it's clear that we have wished for

health care for all, and for parity in mental

health treatment. And both of these forces

are behind the push for "integration" of

health and mental health care; with health

care reform most people will have

coverage and thanks to federal and state

legislation mental health parity is the law

of the land. And everyone from patients to

payers wants care to be "integrated." So

now we have to figure it out.

The Integration of Health & Mental Health

Care in New York State

What the Debt Limit Agreement Means for

People Living With Serious Mental Illness

catastrophe was averted through the

agreement put together by President

Obama and congressional leaders to

increase the current debt limit and bring

about significant deficit reduction over the

coming decade. As is being widely

reported in the press, the agreement will

increase the debt ceiling by $2.1 trillion

and allow the government to continue

meeting all current obligations. The

agreement also includes a 10-year cap on

discretionary spending and formation of a

new bipartisan congressional committee

charged with identifying an additional

$1.5 trillion in deficit reduction through

changes in entitlement programs and

reforms to the tax code.

Integration of Mental Health Care

The trouble is, many of us remember when

"deinstitutionalization" was a positive

vision. Who could be against alternatives to

institutions, especially when institutions

had been neglected in terms of funding and

standards of care? The difficulty of course

was in the execution. Instead of plentiful,

high quality community services,

deinstitutionalization played out as a kind

of cruel societal "bait and switch" game.

While hospitals were downsized,

community mental health centers received

only temporary funding, and community

support often involved only medications

and an SSI check. While many alternatives

were eventually developed in an improved

community mental health system--from

supported housing to ACT teams--the

services developed were a day late and a

dollar short.

We are going to have to work exceptionally

hard, and with unanimity of mental health

vision and advocacy, to have "integration"

play out better than "deinstitutionalization"

in mental health. We will need to maintain

a focus on the people most in need, the

assurance that essential mental health

services are sustained and improved, and on

public accountability focused through the

Office of Mental Health. And probably,

mindful of the nation's historically

uncertain support for mental health, all

advocates will need to watch very closely.

A good place to begin will be to watch the

work and monitor the report produced by

the "Behavioral Health Subcommittee" of

NYS's Medicaid Redesign Team (MRT).

The Behavioral Health Subcommittee, with

appointments just made, will meet over the

Summer, with the following mission:

• Consider the integration of substance

abuse and mental health services, as

well as the integration of these services

with physical health care services,

through the various payment and

delivery models.

• Examine opportunities for the colocation

of services and also explore

peer and managed addiction treatment

services and their potential integration

with BHOs.

• Provide guidance about health homes

and propose other innovations that lead

to improved coordination of care

between physical and mental health

services.

The downsizing of the OMH hospital

system also hits us hard. The reality is that

OMH has been shrinking, at least in terms

of the number of hospital beds, for well

over a generation. So downsizing is scarcely

a surprise. What is happening this year

reflects this long term trend coupled with

something else that "we" (I mean the

taxpayers) wanted: a balanced budget,

finally. What is a little different is that

Governor Cuomo with the Legislature

actually delivered it. One can argue with the

Governor's position that savings were

needed everywhere, and that state

government had to lead by example. But it's

what people want. One can also argue that

downsizing or even consolidating hospitals

isn't right. But the cuts to OMH are

comparable to those in sister agencies that

also care for people: Correctional Services,

Developmental Disabilities, Child and

Family Services. The hard truth is that New

York State has been living beyond its

means.

Integration of Mental Health Care

What must be our commitments going

forward from these painful changes? First,

we must assure that every consumer or

patient affected by downsizing is cared for

adequately. Second, our sympathy and

support must go to every employee who is

affected. Every feasible effort to find

alternative jobs and to support people

through this difficult transition must be

taken. Third, our clinical services must

continue to demonstrate quality and value

by being indispensable resources in every

community we serve. OMH operates the

third largest network of hospitals in New

York State after the Columbia-Presbyterian

and North Shore-Long Island Jewish

systems. We are accredited under the same

national standards maintained by The Joint

Commission. And we do all of this within

the constraints and limitations of multiple

state bureaucracies. We deliver excellent

quality care to very needy people. This

must continue. It will continue. And I

believe we can do even better.

When all three of these old curses apply,

about the only thing we can be certain of is

that no external force will solve these

challenges for us. And we must have faith

that quality work and diligent advocacy will

be recognized. That's what I'm expecting to

work on, and what I expect will happen.

The Debt Limit Agreement and People Living

With Serious Mental Illness

In terms of assessing the impact of this

agreement on people with mental illness, it

is important to note that the increase in the

government’s borrowing authority will

ensure NO interruption in critical safety net

benefits such as monthly cash assistance

under the SSI and SSDI disability benefits.

While media coverage was largely focused

on a government default and protecting

AAA bond ratings, failure to raise the debt

limit would likely have placed these cash

benefit programs at risk. In addition, the

higher debt limit will ensure that quarterly

matching payments to state Medicaid

agencies and payments to housing agencies

for rental assistance programs (tenant-based

and project-based Section 8) will continue

uninterrupted. Even a short-term disruption

to these programs would have had a

dramatic impact on people living with

mental illness who depend on these

programs (SSI, SSDI, Section 8, etc.) for

basic supports.

The Debt Limit Agreement and Mental Illness

As noted above, the agreement creates a

new 12-member bipartisan joint House-

Senate Committee that will be charged with

identifying $1.5 trillion in additional deficit

reduction over the next decade. This panel

will be on a fast track and must produce

recommendations by November 23, 2011,

with a required "up or down" votes in the

House and Senate by December 23.

This $1.5 trillion in savings will come from

changes in entitlement programs and

reforms to the tax code. This new special

congressional committee will be made up

equally of Democrats and Republicans

from the House and the Senate. As a result,

few expect the committee to come to an

agreement on cuts to major entitlement

programs before November. Therefore, the

"sequestration" enforcement mechanism

becomes critical and it is here that critical

protections for Medicaid will kick in.

So, in the strong likelihood that Congress

fails to approve the committee’s

recommendations (or if the

recommendations fall short of the $1.5

trillion goal), the agreement contains an

"enforcement mechanism" designed to

impose automatic cuts, known as a

"sequester." This "trigger" mechanism for

spending reductions would begin in 2013

and would split reductions evenly between

defense and non-defense programs. If this

automatic "trigger" mechanism is imposed,

and Social Security (including SSI and

SSDI). As with the new special

congressional committee, the "trigger"

mechanism can limit payments to Medicare

providers (health plans and hospitals), but

not Medicare benefits or cost sharing. In

addition, any reductions in payments to

Medicare providers are limited to 2% of

total Medicare spending.

during the difficult negotiations over the

past month, as much as $1.2 trillion in cuts

to Medicaid over the next decade were

under discussion. Exempting Medicaid

from cuts--through the "sequestration

trigger"--will help ensure that this

agreement meets the test of protecting the

most vulnerable.

The agreement does impose new

constraints on the growth of federal

discretionary programs that Congress funds

through annual spending bills. Imposition

of a 10-year limit on federal discretionary

spending will generate as much as $900

billion in savings over the next decade –

that is, $917 billion below the baseline

established by the Congressional Budget

Office (CBO). This will reduce

discretionary spending to its lowest level

since the Eisenhower Administration.

While President Obama had proposed

freezing discretionary spending for 2012

and 2013, this new agreement puts these

limits in statute and extends them through

2021.

The Debt Limit Agreement and Mental Illness

The agreement does impose "firewall"

protections between defense and domestic

discretionary programs. It also walls off

"homeland security" spending that will not

be subject to the discretionary spending

limit. This means that Congress will not be

able to raid domestic discretionary programs

to fund critical defense, homeland security

and veterans medical care needs. For FY

2012 and FY 2013, the agreement puts into

place discretionary limits of $1.043 trillion

and $1.047 trillion respectively.

For NAMI’s priority discretionary

programs, this could have far reaching

implications. Keeping current funding

levels in place for a decade will mean that

mental illness research, services and housing

programs are almost certain to stay in place.

In order for Congress to increase funding for

a domestic discretionary priority, a

corresponding equal reduction must be made

in another program(s) in order to avoid

breaching the cap. Fortunately, homeland

security (including veterans medical care)

are exempt from the cap.

At the same time, keeping a tight

enforceable limit on discretionary spending

will have significant consequences for

NAMI priorities:

The current (FY 2011) budget for the NIMH

is $1.477 billion (.9% below the FY 2010

level). Keeping this level in place for the

coming decade would seriously erode the

capacity of the NIMH to invest in "new and

competing" grants, while still maintaining

"out year" commitments to large scale

clinical trials and longitudinal studies that

take years to design, recruit and complete.

Each year that the NIMH budget is frozen

in place, the capacity of the agency to

undertake new studies and clinical trials

will be eroded as "biomedical research

inflation" (the annual increase in the cost of

research) means fewer and fewer new

grants. This year, the NIMH "pay line" (the

percentage of accepted and validated grant

proposals the agency can fund) is at risk of

dipping below 15%. In other words, 85%

of the proposals and applications NIMH

will receive in 2011 that meet standards for

sound and valid scientific discovery will

not be funded. Level funding NIMH over

the coming decade will inevitably send that

"pay line" even lower.

As noted above, the vast majority of

publicly funded mental health services are

financed by the Medicaid program, a joint

state-federal entitlement program that

operates outside of the new 10-year cap on

discretionary spending. There are now a

range of smaller discretionary services

programs operated by SAMSHA (the

Substance Abuse and Mental Health

Services Administration) that will be

subject to the discretionary cap. These

include:

• Mental Health Block Grant - $421

million,

• PATH (outreach and engagement

services to homeless people with

mental illness) - $65 million,

The Debt Limit Agreement and Mental Illness

• Children’s Mental Health - $121

million, and

• Projects of Regional and National

Significance (various discretionary

grants and demonstration programs) -

$361 million.

A 10-year cap on overall discretionary

spending will likely have a dramatic impact

on HUD’s rental assistance programs.

These programs, including Section 8,

Section 811 and permanent housing

programs under the McKinney-Vento

Homeless Assistance Act depend on the

discretionary budget for ongoing renewal of

existing rental and operating assistance.

The out year costs of these programs are

driven by a complex set of factors such as

tenant income and rental markets. Any

increase in these costs is certain to erode

the capacity of HUD to invest in

development of new supportive housing

units that serve people with disabilities

(including serious mental illness). This is

especially the case with McKinney-Vento

and Section 811.

The agreement follows the Obama

Administration’s definition of "homeland

security" funding that is exempt from the 10-

year discretionary funding cap. This means

to the discretionary spending limit.

However, other functions of the VA,

including medical research will be subject to

the cap.

So glad I got a roof over my head, I’d rather be dead

Than homeless. The stress would kill me –

To be or not to be is the question, whether tis nobler

To be a man or a mouse

A louse? Cry freedom!!!

Come all ye faithful, and eat cake and

Mom’s apple pie

Misery likes company like crabs in a barrel, so keep our eye on the sparrow-don’t

Do the crime if you can’t do the time

Time marches on and – on marches time

When the saints go marching in, Big Ben is number ten

The world was lost when

The dice were tossed

I feel that PROS has been a very positive part of my present feelings. Over the past five

years, since my fiancé passed away (of lung cancer), the first five months I did nothing

but cry and drink and grieve for him. I couldn’t pay the rent and lost my apartment and

all my possessions. And ended up in the hospital.

For years I was lost and suicidal. No one could help me except one psychologist in

Rockland State Hospital. After I was separated from her, my depression returned.

Thoughts of suicide were always there; deep depression and despair.

But since I’ve been coming to PROS, I find my spirits lifted a bit, and I am not so

despondent. I think it is a positive place full of warm and good feelings. Since I have

been here, I have had a more positive outlook. I have lost my ability to make art, but

maybe it will come back.

Although I am no longer a young child the onset of summer is still one of my favorite

times of the year. The weather is so hot and balmy it makes you want to go outside to

enjoy.

The beach is one of my favorite places. The air at the beach smells good and it is moist

and salty.

At the beach the albatross put on a flying aerial show trying to eat their fill of snacks

from the beach combers. The sand is hot and burns your feet if you do not wear

footgear. Lying playfully on the sand with your umbrella for shade and a blanket you

feel good. So good you run to take a dip in the water. The salty water allows you to

jump the waves or float.

Another place to go in the summertime is the park.

You can take your children to the park with a blanket and listen to the drummers play on

the conga and bongos. Hot dogs, potato chips and sandwiches are also something worth

having when you go. Washing it down with a cold bottle of soda is great.

I would like to incorporate my writing skills with my painting skills. I envision

paragraphs of thoughts and feelings spread across a canvas. And these emotions are

surrounded and engulfed with images in bright and soft colors expressing the rhythm

and flow of the words.

I see the canvas almost as a musical score that vibrates with sound and can be

interpreted in many ways.

The possibilities of this creation are infinite and express the universality and unending

limits of art. Art is forever unfinished.

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Morningside-Westside

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Checks should be made out to:

“Morningside-Westside”

Help With Your Generous Support

Nancy Walder, M.A., Bulletin Director

Steve Schimmele, M.B.A., Editor

Andrew Sperling, (Dir. of Federal Legislative Advocacy)/ NAMI, National Editor

Harris T. Schrank, Ph.D., J.D., Contributing Editor

George Aquila, Assistant Editor

We are privileged to be receiving many contributions. We urge you, to submit

your work, personal experience, opinion piece, statement of fact, poem or letter to

us at the Morningside-Westside Bulletin. We generally consider contributions of

500-1500 words.

Thank You for your cooperation. Contact us at mwcac@mail.com for editorial

guidelines and more information.

TBD

XXX

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