When President Obama signed the 21st Century Cures Act on December 13th, he signed into law one of the most sweeping efforts to provide additional programs and funding for health conditions and innovation in America, including cancer, Alzheimer’s disease, opioid addiction, medical devices, access to new drugs, and mental health. The Cures Act includes the major provisions of the Senate mental health compromise bill, Mental Health Reform Act of 2016, as well as a few additional provisions from the House’s over-reaching Helping Families in Mental Health Crisis Act of 2016 bill.
While the bill goes a long way in helping fix certain components of mental health care in the nation, it does little for the vast majority of people who suffer from mental health concerns and receive outpatient treatment. Here are the highlights of what just became law.
Assistant Secretary for Mental Health and Substance Use & Chief Medical Officer
The old Senate S.2680 bill declined to burden the system with even more federal bureaucracy by creating a new Assistant Secretary for Mental Health and Substance Use. The bill that was just passed, however, does create such a new position, though — largely replacing the Administrator for SAMHSA. This was an unfortunate change that takes away control of SAMHSA from the experts and instead gives it to politically-appointed leaders. Time will tell whether this actually strengthens mental health leadership in this country, or simply makes it more political.
The Mental Health Reform Act of 2016 did include a newly-created position of Chief Medical Officer, and this position is included in the Cures Act. The chief medical officer must be a physician who is licensed to practice medicine. Unfortunately, this limitation will likely result in the emphasis of the psychiatric perspective over a more balanced biopsychosocial approach.
Interdepartmental Serious Mental Illness Coordinating Committee
The new law establishes a coordinating committee of 23 individuals in order to provide “a summary of advances in serious mental illness and serious emotional disturbance research related to the prevention of, diagnosis of, intervention in, and treatment and recovery of serious mental illnesses, serious emotional disturbances, and advances in access to services and support for adults with a serious mental illness or children with a serious emotional disturbance.” It will also seek to determine what impact federal programs have on “rates of suicide, suicide attempts, incidence and prevalence of serious mental illnesses, serious emotional disturbances, and substance use disorders, overdose, overdose deaths, emergency hospitalizations, emergency room boarding, preventable emergency room visits, interaction with the criminal justice system, homelessness, and unemployment.”
Oddly, only two representatives of the committee will be patients (up from one patient representative in the Senate bill), while the rest of the committee members will be taken up by mental health professionals and federal bureaucrats. This seems like a token for this important interdepartmental effort.1
National Mental Health and Substance Use Policy Laboratory
In the law that was passed, this existing Office of Policy, Planning, and Innovation was changed to that of a “laboratory,”2 a none-too-subtle effort to imbue “science” into whatever this office does.
The newly-named Laboratory also has an additional new mandate — to identify programs the agency administers that are not “evidence-based” and to “promote innovation” (as well as evidence-based programs). This is the effort to defund peer-support programs that have long been a mainstay of SAMHSA grants. Unless, of course, they do more research to prove their scientific validity.
I’m all for evidence-based programs. My objection to this is the same one I noted years ago — medicine is generally not held to the same evidence-based standard that is now being required for mental health programs. This is yet another example of the unequal treatment given to mental health concerns.3
Mental Health Parity Enforcement
Despite being the law of the land for years now, insurance companies have still found ways to limit people’s equal access to mental health treatment. They currently do this by systematically limiting the number of providers that serve specific geographic regions, ensuring long wait times to be seen by a mental health professional — especially psychiatrists — under certain plans. They also pay rates well below the going rate (as defined by Medicare or other specialty professions for similar services), dis-incentivizing professionals from taking certain kinds of health insurance. The new law provides for further guidance and compliance efforts in mental health parity, to ensure insurance providers meet the spirit of the law.
Early Intervention Programs
Early intervention programs remain a focus of SAMHSA, and the new law requires states to use at least 10 percent of their annual block grants of funding for mental health to be directed to such programs (or ask for a waiver). According to USA Today, these programs — called coordinated specialty care — provide “a team of specialists to provide psychotherapy, medication, education and support for patients’ families, as well as services to help young people stay in school or their jobs. Research from the National Institutes of Health shows that people who receive this kind of care stay in treatment longer; have greater improvement in their symptoms, personal relationships and quality of life; and are more involved in work or school compared to people who receive standard care.”
Assisted Outpatient Treatment (AOT) and Assertive Community Treatment (ACT)
Thankfully, the new law doesn’t significantly expand or change the federal government’s stance on forced treatment — also known as “assisted” outpatient treatment (AOT). It does make AOT available as an alternative option to those facing jail time in civil court, and reauthorized continued funding for existing AOT programs. The earlier House bill mandated AOT treatment options for all states receiving SAMHSA funding — a provision luckily absent from the final law.
New grants will be available to expand the use of assertive community treatment (ACT) programs. ACT programs are far less coercive than AOT programs, and can help keep people in their own community, living independently and free from government intervention (such as incarceration or AOT programs). The new law provides funding for states to pursue more of these kinds of programs to help those with mental illness live independently.
Everyone acknowledges the big winners in the bill are pharmaceutical companies. As the New York Times noted:
In considering whether to approve new drugs or new uses for medications, the bill says, the F.D.A. shall pay more attention to “patient experience data” showing the impact of a disease or treatment on patients’ lives, and their treatment preferences.
The legislation does not include provisions to to rein in prescription drug prices, a significant victory for the pharmaceutical industry. Consultants to the industry said that drug makers had kept a low profile in their lobbying on the legislation, knowing that any conversations on Capitol Hill could turn quickly to drug prices.
Sounds like pharmaceutical companies’ lobbying efforts — money that supports both parties — on Capitol Hill were very successful. My sources in these companies tell me they are very happy with the final bill, which is ultimately bad for taxpayers as drug prices continue to skyrocket. Unless these companies do something to combat this problem soon, they are likely to face an ugly backlash from consumers.
Suicide Prevention Technical Assistance Center
Instead of focusing on just youth and young adult suicidal behavior, the new law refocuses federal resources on those at highest-risk for suicide, no matter what the age group. Programs for helping to deter youth suicide, however, remain in place.
HIPAA Patient Privacy Protections to Be Re-evaluated
In an effort to gut individual’s rights and patient privacy protections under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the new law demands the issuance of new guidance that takes into account the wants of a family member to gain access to a patient’s mental health record. It is unclear what guidance will eventually be issued, but the “Sense of Congress” clearly indicates what they want to see — families gaining access to patient’s confidential mental health records.
Medicaid Same-Day Billing Glitch Fixed
Due to the way a previous law was written, if one was covered by Medicaid, he or she could not see a primary care physician and a mental health care professional on the same day. While both services could bill Medicaid, only one of them would get paid. This resulted in a huge hassle for Medicaid patients who had to schedule services — often times in the same building — on different days, just to get around this rule. (Medicaid is the program that caters to those who are poor and often lack basic resources — such as transportation or means to get around.) The new law fixes this glitch and allows Medicaid patients to see multiple professionals on the same day for different services.
While the Cures Act authorizes funding for its many new provisions, such funding must still be appropriated by annual budgets from Congress. Which means that although Congress has authorized the spending, it hasn’t actually provided the money for any of this yet. While many components of the bill will likely be funded as authorized, other components may find their funding cut as Congress continues to wrestle with the ever-increasing federal deficit.
While this bill goes a long way to addressing some of the problems with the mental health care system in the United States, it does little to fix the underlying issues — or to “fix the broken national mental health system” (as one organization claimed). It does not significantly increase the actual funding to states that provide public mental health care to the indigent and poor. And it doesn’t really do much to help bridge the divide between physical health care (delivered through primary care physicians) and mental health, although the new bill does carry a number of provisions to start addressing this issue.
The bill provides virtually nothing for how most poor Americans receive their mental health treatment, via outpatient care. Its focus on specific groups of people with specific issues (psychosis, suicide, people who are in jail or homeless, etc.) means it will have little impact for most people. Furthermore, some of the sections of this new bill actually cut authorization funding for their respective programs (such as grants for substance abuse prevention and treatment, treatment and recovery for homeless individuals, transition from homelessness, and jail diversion programs, as just a few examples).
In short, this is yet another bandaid on the national mental health system, designed to alleviate some immediate problems. Will the fix last? Time will tell, but many of the major issues facing patients today — lack of timely access to mental health professionals, lower drug prices, primary care integration of mental health needs — were not meaningfully addressed by the new law.
For Further Information
- Furthermore, no money was authorized to organize and hold regular meetings of this committee, apparently suggesting that everyone who serves on it will be a volunteer. [↩]
- Laboratory definition: a building, part of a building, or other place equipped to conduct scientific experiments, tests, investigations, etc., or to manufacture chemicals, medicines, or the like. [↩]
- This effort was driven largely by a single politician’s dislike of some of the peer programs funded by SAMHSA. [↩]