When you strip away all the fancy words and the tons and tons of rhettoric about what the Murphy Bill says and simply ask yourself “What is the plan?” you get a few core ideas. What does Rep. Murphy think we actually need to do to serve the severely mentally ill? There are many other provisions of the bill that has nothing to do with what I am about to talk about. Many of them are the most positive features of the bill. But this is what I think the essence of the Murphy plan is. These are his bottom lines. These are his “new ideas.”
He believes, in effect, that many of the severely mentally ill suffer from a defiency of psychiatric hospitalization. He seems to see that as the answer to so many people with “mental illness” being in jails and prisons. He thinks that way too many hospital beds are gone and it is time to increase hospitalization radically.
Perhaps I am wrong but I believe that ship has sailed. A mental health system with psychiatric hospitalization as its corner stone is not financially sustainable in this country. Insurance companies pay less and less for it. They do not see it as medically necessary but in the most extreme circumstances and then for brief periods of time. In Tennessee I believe most psychiatric hospitals are struggling to break even and most of them are losing that struggle. States are getting out of the business. They realize that a large hospital system leaves them unable to finance a community system and if you dont have a community system to serve the people coming out of the hospital what is the point of the hospital. If you look at how often and how quickly people leaving the hospital system end up back there you begin to realize the impact of disemboweling the community system. I cant even imagine the circumstances under which Tennessee would act to increase the beds in any kind of dramatic way, indeed in any way at all. It is far too little bang for way too many bucks.
His method for making psychiatric hospitalization possible is to remove the IMD exclusion on medicaid funding. Basically it makes it possible for medicaid to then pay for state psychiatric hospitals. One question comes to me immediately. If Congressman Murphy thinks that medicaid funding is such an important part of mental health reform why did he vote to repeal the ACA over 50 times? That bill through its provisions for medicaid expansion would have given millions of people with “mental illness” access to programs and services that if he has his way they will never access.
A couple of other questions come to mind. What about the people who dont have medicaid access? Many people with “mental illness” and particularly many people who are having serious problems in life simply dont have insurance. Another question is the response of states to finding out now that medicaid funds can pay for psychiatric hospitals. In most states that I am aware the medicaid program eats up a considerable portion of their state budget and I really question, particularly in the states that choose not to expand medicaid, how receptive they will be to finding out that medicaid expenses are about to soar through the roof. In Tennessee the most likely two responses are to adopt the private insurance definitions of medical necessity and decide not that many people need hospitalizations and/or cut benefits and provider payments to pay for any any expenses the increase in hospitalization is likely to cause. The provider rates for psychiatric care, at least in Tennessee, are so low that very few people will even provide services anyway and there is a serious real question about where the professionals to do all this treatment are to come from.
Even if you start to use medicaid funding it does not begin to pay for all the new costs. The state institutions in Tennessee for example are aging. There is a need for new buildings and new spaces if beds are added. Who pays for new hospitals?? What about the cost of new staff?? Who pays? I can only speak to Tennessee but there is no commitment to psychiatric hospitalization, especially on a massive scale, as the answer to anything by state officials, by mental health professionals. by anyone that I know and removing the IMD exclusion is unlikely to change that. The strong perception is that the community system is the most cost effective and effective means to help people meet their needs and that it is defiencies in that system that lead most to people falling through the cracks.
And even if it was possible would it work?? I know of no evidence, that other than providing a place for stabilization, that psychiatric hospitals work in any enduring fashion. They dont, if you look at return rates, even work well enough to keep people out of psychiatric hospitals.
I dont know but would be willing to hazard a guess that many of the “mentally ill” in the prisons and jails have had considerable psychiatric experience with little or no solid gains. Criminal behavior is not a symptom of mental illness and the “put them in the hospital” solution ignores things like poverty, drug addiction, racism, lack of work, homelessness and history of trauma and other adverse events that lead to someone actually committing criminal acts. The other thing to consider is not the degree to which “mental illness” causes criminal behavior but the extent to which incarceration causes “mental illness.” Is treatment needed?? Are mental health resources needed and might for some people those resources be inpatient resources??? Of course. I wonder what percent of those people in jail would even meet the criteria for hospitalization?? I dont know the answers but tend to believe it is the lack of effective and accessible community resources that engender emotional involvement with the people they serve that is the root of the great numbers of “mentally ill” in jails and prisons.
Another core point of Murphy is that he believes that too many people get mental health services and that it is the “worried well ” that are basically stealing resources that are better used by the severely mentally ill. Given the fact that most mental health systems have been starved and cut back over the last few years it seems a little like telling one person eating bread and water that the the person next to him is eating too much bread and water and not considering that the problem is the diet of bread and water. It is an argument of little integrity that resorts to an us vs. them argument as a pseudo explanation. It ignores totally the fact that state legislature after state legislature has sacrificed their mental health system on the fires of “financial responsibility” over the last few years.
There are without question people who are victims of a psychiatric system eager to diagnose every event in life as an enotional illness. There is a reason that pharmaceutical companies make money. But there are also people who struggle every day with serious mental health issues, trauma, and distress and to dismiss those people as dupes or malingers is stupid, dishonest and evil. If you think the biggest problem in the mental health system is that too many people need or are seeking help then you are a simple minded person not worthy of being taken seriously.
If you take the notion of “worried well” seriously it takes you to some strange places. How do you decide who is “worried well”? Who decides? Based on what criteria? What do you do to the “worried well”? Do you limit their access to services? How? How much and why? If you dont limit their access to services arent you being complicit in the people who need help being hurt?? And how much is all this going to cost?? Do we need programs to make sure that people who need services get them and another program to make sure those that dont are kept out. This is a treacherous notion that if you take serious leads to nightmares.
Another core notion is making assisted outpatient treatment a law in every state. They tell you that aot is a major problem solver but dont really explain why most of the 45 states that have it dont really use it. And they dont really explain why you need to make something a federal law that is already a state law. And they dont really explain why if 45 states can choose to have it 5 states cant.
I think the truth is that most states who are not willing to throw $32 million a year at it like New York find it more irrelevant than anything. It costs too much and does too little and in an environment of increasingly limited resources is not something that a lot of people are going to turn to to solve many things. And none of this even begins to touch on the questions of choice and coercion that so many people find so fundamentally troubling.
Another core notion of the Murphy Bill is that too many people complain about the human rights of people in the system being important and those people need to be quiet. It would basically eviscerate the protection and advocacy programs like Paimi and legislate away their voice. The idea that people in the system dont need protection is naive and self serving and something you might figure a psychologist or psychiatrist might come up with. Ask anybody in the system. See how safe they feel in the system.
The final key element is to do away with the notion of recovery and the best way to do that is to cut the legs out from under Samsha. Samsha is as close to a boogeyman as there is in this play. They are blamed for everything bad that has happened or will happened. The fact that thousands of people have found recovery to be a real thing is explained away by saying they probably didnt need help anyway or that they are in a remission that would have happened anyway regardless of what they did. If you dont like what you see it works really well to convince yourself that it was really something else.
Samsha is blamed for many things it doesnt decide about. The state of Tennessee decides what kind of services it will offer the people it serves….not Samsha.
Like I said at the start there is more to the Murphy Bill than what I have described here. He took a lot of peoples good ideas and made them part of his bill. None of them seem though to be core elements that define the bill and that is a shame. He has told people he will work with them on a better bill but no one knows what that means because he has compromised on nothing. I have been told by a lot of people I know that is bill is in trouble and very unlikely to be passed as written. I dont know how true that is, but know it is in everybodies best interest to know the bottom lines of what he proposes and decide what that means for them and the way they would like to see the mental health system change.