In 2006, Harvard Professor Richard Frank and Columbia Professor Sherry Glied published Better But Not Well. Taking into consideration economics, treatment, living standards, rights, and stigma, they came to the conclusion that wellbeing improved for people with mental illness in the latter half of the 20th century in the US. However, they also cautioned that although things were better, they were not well.
Fast forward to this past Tuesday, when President Obama signed into law the 21st Century Cures Act, widely lauded as the most significant mental health legislation to pass in the US in more than a decade. The Cures Act isn’t just about mental health but mental health is prominently addressed, and after a groundswell of passionate lobbying – including letters that many of you submitted to your Senators and Representatives – it received near unanimous support in the Senate and a large majority in the House.
The Cures Act promises to make things better still. But how much closer to well do we get? What are key mental health priorities in the 21st Century Cures Act, and is the glass half full or half empty?
1. Increase research funding. The Cures Act provides $4.8 billion over 10 years to the National Institutes of Health for the Precision Medicine Initiative and the Brain Research Through Advancing Innovative Neurotechnologies Initiative, among others. This is fabulous – $4.8 billion is a lot of money – but when we divide it over 10 years and across all the research and training programs that will receive a piece of the pie, covering hundreds of health conditions, this windfall likely will fund only a few studies per year on mental health.
2. Focus on the opioid epidemic. Opioid addiction is a crisis that is savaging huge segments of our population. The Cures Act provides $1 billion over 2 years for grants to states to supplement opioid abuse prevention and treatment activities – the focus is fabulous. But again, $1 billion will probably land well below the threshold required to have real public health impact after it is spread across 50 states and over 2 years.
3. Ensure parity for mental health with other health conditions. The Cures Act increases mental health parity requirements by authorizing the Department of Health and Human Services (DHHS) to issue compliance guidelines to health plans and produce an action plan for improved federal and state coordination. I am afraid we have heard this tune before. The 1996 Mental Health Parity Act, championed by Senators Paul Wellstone (D-MN) and Pete Domenici (R-NM), was riddled with loopholes ensuring that parity remained a dream. In 2008, President Bush signed legislation that made parity the law once again, but again, it didn’t close the gap. In 2010, President Obama passed The Affordable Care Act, promising parity once more. Despite the legislation of 1996, 2008, and 2010, the gaps in care are so great that personally and professionally I have known individuals with mental illness and substance use disorders that bounce from inpatient care to rehab to the street and back around – because of lack of coordinated care, limits on length of stay and inadequate insurance coverage. Maybe this time our aspiration for parity will become a reality? Hope springs eternal.
4. Improve access for mental health care. The Cures Act eliminates the Medicaid “same day” exclusion, which prohibits separate payment for mental health and primary care services provided to a Medicaid enrollee on the same day. This will promote integration of mental health and primary care and make it a lot easier for people to access the care they need in one place – BUT, we do not have enough trained providers. Integration of mental health and primary care has proven efficacy around the globe, including in many low and middle-income countries. If we intend to deliver on this promise, we need to take a page from the playbook of places places like Mozambique and Kenya to expand our mental health workforce.
5. Keep people with mental illness out of jail. The Cures Act increases funding for the Justice and Mental Health Collaboration Program and supports law enforcement training on de-escalation, crisis intervention teams, and alternatives to incarceration. A dear friend was recently told that her best chance of getting help for her brother (who believed there was nothing wrong with him while also believing that he had special powers to communicate with aliens and the CIA) was to wait until he broke the law so the police could arrest him. Clearly a sub-optimal strategy, and one that the Cures Act has the potential to address.
As someone prone to optimism, I have to say that I was thrilled to watch President Obama sign the 21st Century Cures Act into law (with multiple pens, following an obscure White House tradition dating back to FDR). The Cures Act offers exciting promises to make things better. Now the challenge and opportunity is to translate those promises into reality. This will require ongoing vigilance and conviction – thank you for joining us in this work.
So, is the glass half full or half empty? Yes. Both.