Don't miss the great piece "Recent Changes in Medicaid Policy and Their Possible Effects on Mental Health Services” by Jeffrey A. Buck, Ph.D., Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, in the November issue of Psychiatric Services. If you were one of the few remaining people in the field who didn't think that Medicaid funding has come to indelibly change public mental health systems—and will continue to do so—this is a great synthesis of the current and future market effects.

On the system side, Dr. Buck identified the following Medicaid-driven system effects that have already occurred:

• A larger role for state Medicaid authorities in state mental health services and a corresponding decline in the role of mental health authorities;


• Service delivery privatization via Medicaid managed care arrangements which privatize many functions previously provided by public entities


• Increased funding for community-based mental health care


• Increased difficulty in using Medicaid funds for areas not clearly defined within the program;


• Increased accountability of individual service providers via the Medicaid Integrity Program


• Movement away from incentivizing psychiatric institutionalization
  

Dr. Buck also looks ahead to future policy changes. A few are ‘more of the same’—an increase in the role of Medicaid authorities and the growth of community-based services, with continued promotion of deinstitutionalization. In addition, he points to two other developments that are on the horizon. The first is increasing convergence of mental health policy with those that are the norm in primary care. The second is more meaningful consumer participation in treatment plan participation and choice of professionals and provider organizations.

I read not long ago that the State of Georgia is sending released sex offenders to live in a camp in the woods near Marietta, Georgia—even those who own their own homes. There are a myriad of factors that have lead to this situation—zoning laws, parole requirements necessitating these individuals to stay a certain distance from children, and lack of suitable housing (the Associated Press reported that "there is only one homeless shelter in Georgia that fulfils the residency requirements for sex offenders, but it only has two beds, which are usually occupied."). I don't think it's acceptable for our leaders to throw up their hands about the inevitability of this situation, as if they were powerless to effect change.

I find this to be part of a troubling change in our view of the acceptability of treating ‘undesirable’ fellow citizens inhumanely. I think this change in thinking is a threat—a slippery slope in the floor of acceptable treatment—for the consumers we serve. One day it's okay to send people to jail because they have no mental health treatment (they need to exhibit some self control and not act in ways that will land them in jail); the next day it's acceptable to close critical health care services that will result in the death of uninsured persons (who should work hard enough to have insurance); and then we can sentence people (dastardly people who prey on children) to living in encampments without even the human supports of leper colonies of old.

In the behavioral health and social service niche, we serve and advocate for a group of individuals unattractive in popular culture. Runaway teens living on the streets, drug addicts, "the retarded", and more. I caution us all to not stand by when this growing acceptance of inhumanity occurs. For those of you who are not swayed by dewy-eyed humanitarian thinking, you can ponder the immortal words of Ronald Reagan who said, "Protecting the rights of even the least individual among us is basically the only excuse the government has for even existing…”

Policy shifts in the detention of illegal immigrants could offer new opportunities for behavioral health and social service provider organizations. I read with interest the October 6 report by Dr. Dora Schriro, former Special Advisor on Immigration and Customs Enforcement (ICE) and Detention & Removal, "Immigration Detention Overview and Recommendations," where she announced new recommendations to revamp the currently fragmented, insufficient immigrant detention system. The basis of her recommendations is that using jails and prisons is costly—and often unnecessary—for detention, and that specialized privately-run facilities might be the answer.

In total, the U.S. government spends $2.4 billion annually on its current ‘detention and removal' system. Even a diversion of a small part of that budget for community-based and situation-appropriate settings could be a big opportunity in the field. Some of the specific recommendations that caught my eye include:

• Non-governmental organizations and non-profit agencies should be invited to assist eligible individuals in special populations, as well as the general population, to establish community ties and develop viable release plans to qualify for placement in ATD programs
• ICE should develop specialized caseloads of aliens including those chronically, medically, or mentally ill or have been detained a significant length of time to improve case management and expedite removal, release, or relief.
• More ADA-accessible facilities should be available to house detainees with special needs. Specialists to diagnose and treat each of these populations, specialized case management, and prescription reviews are all needed.
• Aliens with mental illness would benefit from improved staffing, appropriate housing, access to step down services, and specialized case management.
  
  You can read more on this in "U.S. Moving Away From Correctional Model for Immigrant Detention; New Ideas Include Expanded Use of Hotels & Nursing Homes." As the plans for restructuring the immigration detention system become more concrete, look to our team at OPEN MINDS for continued coverage of new opportunities.