TheStruggleToProvide Community-Based Care To Low-Income People With Serious Mental Illnesses

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1 Quality & Access TheStruggleToProvide Community-Based Care To Low-Income People With Serious Mental Illnesses Cutbacks in federal funding have reduced the options available for people with mental illnesses, especially if they are uninsured. by Peter Cunningham, Kelly McKenzie, and Erin Fries Taylor ABSTRACT: This paper describes gaps in services for low-income people with serious mental illnesses as reported by mental health professionals and other observers in twelve U.S. communities. According to respondents, service gaps have grown in recent years especially for uninsured people as a result of state budget pressures and Medicaid cost containment policies. Growing service gaps contribute to the high prevalence of serious mental illness among the homeless and incarcerated populations, as well as crowding of emergency departments. Some states and communities are aggressively addressing these gaps, although funding for new programs remains scarce. [Health Affairs 25, no. 3 (2006): ; /hlthaff ] Communities throughout the united states are finding it more difficult to provide services to low-income people with serious mental illnesses. These people are often dependent on a public mental health system because they are unable to work or obtain private insurance, or because they lack sufficient income to obtain care through private mental health care providers. The public mental health system has evolved during the past fifty years from being a primarily state-financed system focused on providing institutionalized services in state mental hospitals, to an increasingly federally funded system focused on providing services in the community. Medicaid has become the single largest payer of mental health services for low-income people; it accounted for about 40 percent of all public-sector spending on mental health services in 2001, compared with 21 percent in However, not all low-income people with serious mental illnesses are eligible for Medicaid, because they aren t disabled enough to qualify for Supplemental Se- Peter Cunningham (pcunningham@hschange.org) is a senior health researcher at the Center for Studying Health System Change (HSC) in Washington, D.C. Kelly McKenzie is a health research assistant there. Erin Fries Taylor is a health researcher at Mathematica Policy Research in Washington, D.C. 694 May/June 2006 DOI /hlthaff Project HOPE The People-to-People Health Foundation, Inc.

2 Community-Based Care curity Income (SSI); they don t meet other Medicaid eligibility criteria (such as single adults or immigrants); or they are homeless, incarcerated, or too ill to follow through with the enrollment and eligibility process. With states shifting an increasing proportion of their mental health budgets onto Medicaid, fewer state funds are available to provide services for low-income uninsured people with serious mental illnesses who are not eligible for Medicaid. 2 To cope with tight state budgets and Medicaid cost increases, many states have attempted to contain costs through reductions in reimbursements and eligibility, increased cost sharing, and greater restrictions on prescription drug use. 3 State budgets for non-medicaid mental health services, which affect primarily the uninsured, have been cut, or else their growth has slowed to the point at which they barely keep pace with general inflation levels. 4 There is concern that these cost containment policies and budget cuts could be exacerbating gaps in communitybased services, decreasing the number of mental health care providers willing to treat Medicaid patients, and negatively affecting the ability of low-income patients with serious mental illnesses to obtain needed services. This paper describes the gaps in community-based services for low-income peoplewithseriousmentalillnessesintwelveu.s.communities,asreportedby mental health professionals, general medical care providers, and policymakers. Our interviews indicate a broad consensus across sites and respondents that there hasbeenanoticeableerosioninservices,withuninsuredpeoplebeingthemostaffected. Despite some signs that public officials are becoming more aware of the widening gaps in some states and communities, it is uncertain whether the resources needed to address these gaps will be forthcoming. Study Data And Methods Data for this analysis come from site visits that are part of the Community Tracking Study (CTS), a longitudinal study conducted by the Center for Studying Health System Change (HSC) every two to two and one-half years. Round Five of the CTS was conducted between January and June 2005 and included interviews with more than 1,000 health care leaders from a wide range of organizations across twelve nationally representative markets: Boston, Cleveland, Greenville (South Carolina), Indianapolis, Lansing, Little Rock, Miami, northern New Jersey, Orange County (California), Phoenix, Seattle, and Syracuse. The 2005 site visits included questions about community-based services for people with serious mental illnesses. Interviews were conducted with local mental health departments, community-based mental health providers, advocates for the mentally ill, community health centers, local hospitals and hospital emergency departments, and state and local officials. Questions focused on major gaps in mental health services, the adequacy of local mental health care provider capacity, and recent state and local initiatives aimed at expanding community-based services. 5 An average of fifteen interviews were conducted in each community. 6 HEALTH AFFAIRS ~ Volume 25, Number 3 695

3 Quality & Access Study Findings More gaps in services. There was broad agreement from respondents in all twelve communities including mental health professionals, general medical care providers, and state and local officials that large gaps in services exist for lowincome people with serious mental illnesses and that in most cases, these gaps are growing wider as a result of budget pressures at both the local and state levels. Residential services were consistently mentioned as being in short supply, including housing, group quarters, transitional shelters, and other support services. The federal Section 8 voucher program is the major public and subsidized housing program available to low-income people with serious mental illnesses; however, there are often barriers related to cost, availability of units, and resistance to supportive housing programs in many neighborhoods and communities. 7 Some respondentsreportedthatthelackofhousingresultedinpatients beingkeptininstitutions longer than necessary (such as in northern New Jersey). On the other hand, closure of state facilities in some of the CTS communities resulted in patients being discharged to the community without adequate residential services. Lack of psychiatric inpatient beds for acute care was another major gap in services cited by a broad range of both mental health and non mental health professionals in the CTS communities. Although state and county psychiatric hospital capacity has been declining for several decades, capacity at private psychiatric hospitals and psychiatric units of general hospitals declined sharply during the mid- and late 1990s. 8 Much of this decline could reflect the increasing emphasis on outpatient and residential care versus inpatient care, although some community respondents believe that this shift has occurred too quickly and that increases in outpatient capacity have not kept pace with the decreases in inpatient capacity. In a few instances, the lack of inpatient beds has become so severe that patients have to go outside of the community to receive inpatient care. In Boston, a community with a large number of hospitals, respondents reported that some patients are being admitted to facilities as far away as Springfield (ninety miles) because of lack of bed availability. Similarly, in Syracuse, the recent closure of a children s psychiatric facility has forced children and adolescents to seek services outside the community. Shortages of key outpatient care staff, especially psychiatrists, were reported to be worsening in most of the CTS communities, resulting in longer waiting times (reportedly as long as six months in Syracuse). As with other physicians, psychiatrists are much more likely to limit Medicaid and uninsured patients in their practices than to limit privately insured or Medicare patients. 9 Some respondents reported that even psychiatrists who nominally accept Medicaid patients are seeing fewer of these patients, or shifting to private practice where they have greater control over the types of patients they see. In addition, increases in demand might contribute to the perception of a worsening shortage of psychiatrists. Between 2000 and 2003, the number of Medicaid recipients and uninsured people in- 696 May/June 2006

4 Community-Based Care creased about 18 percent nationally, while the number of psychiatrists increased only about 3 percent. 10 Impact of service gaps on the community. Virtually all community respondents, including both mental health and non mental health providers, had a strong sense that large (and increasing) numbers of low-income people with serious mental illnesses are unable to get care or are receiving inadequate care, although few communities have precise estimates of the level of unmet need. However, the extent of unmet need for mental health services in the community is manifest through the high prevalence of mental health problems among homeless and incarcerated populations and spillover effects on other health care providers, especially hospital emergency departments (EDs). Homelessness. In all twelve communities, respondents blamed cutbacks in psychiatric inpatient capacity without corresponding increases in the community mental health infrastructure and supportive housing for the high and increasing rates of mental illness among homeless people (reportedly as high as 65 percent in Cleveland and 90 percent in Boston). Respondents in Cleveland reported that many people in homeless shelters either are on waiting lists for supportive housing or have become too discouraged to apply for supportive housing because of the long waits. Incarceration. Many mental health professionals, and some non mental health respondents, across the CTS sites reported that correctional facilities have become the de facto institution for the mentally ill. Respondents in Seattle, for example, estimated that 70 percent of inmates in the local jail are mentally ill, and respondents in Miami reported that the largest institution for people with serious mental illnesses in Florida is the Dade County (Miami) jail. Although there are no hard data readily available to verify these claims, these perceptions are directly related to the perception of shortages of inpatient care in respondents communities. According to some, because demand for inpatient psychiatric beds exceeds supply, people with serious mental illnesses who need constant supervision frequently endupinjail,oftenconvictedofnonviolentcrimes.evenafterinmatesarestabilized and released, they have difficulty enrolling in Medicaid and obtaining ongoingtreatment,whichoftenleadsmanytoendupbackinjail. Emergency departments. ED directors report that use of the ED has been increasing among people with mental illnesses living in the community, which is consistent with national data on ED use. Between 2000 and 2003, ED visits in which the primary diagnosis was a mental disorder increased by about 20 percent nationally four times the rate of increase for ED visits in general during this period. 11 In communities such as Boston and Orange County, ED directors reported that patients are often in the ED for many hours or even days waiting for a scarce inpatient slot, thus contributing to overcrowded conditions. Police officers have been trained in some communities, such as Miami, to divert patients away from the criminal justice system and into the mental health system, although they often end HEALTH AFFAIRS ~ Volume 25, Number 3 697

5 Quality & Access up bringing patients to the ED because of lack of outpatient mental health capacity. Medicaid and state budget pressures. Although many of the service gaps and access problems described here are not new, many respondents believe that they have worsened in recent years as a result of state budget pressures. State mental health agency spending in all states was increasing throughout the 1990s and early 2000s; however, the rate of increase between 2002 and 2003 (4.9 percent) was considerably less than in previous years, and lower than that of private health care spending (8.4 percent). 12 To the extent that these trends continued in 2004 and 2005, financial pressures are arising either through explicit reductions in state funding for mental health services (three of the states with CTS sites had reductions in 2003) or because funding increases have failed to keep pace with the cost of providing services. Low Medicaid reimbursement. Low reimbursement from Medicaid was the most frequently cited reason for gaps in outpatient capacity for mental health services, especially the shortages of psychiatrists. On average, Medicaid payment rates for a forty-five- to fifty-minute outpatient psychiatric visit were 64 percent of Medicare reimbursement nationally in 2003 (Exhibit 1). 13 Medicaid fees were well below Medicare fees in all states where the CTS sites are located, except Arizona and Arkansas. 14 Even when states do not explicitly reduce Medicaid reimbursement or provide only modest increases, services could be negatively affected to the extent that reimbursement levels do not keep pace with the cost of providing services. For ex- EXHIBIT 1 Medicaid Fees For Outpatient Psychotherapy Visits In Twelve U.S. Communities, 2003 Community Tracking Study site Orange County, CA Miami, FL Indianapolis, IN Boston, MA Lansing, MI Northern New Jersey Syracuse, NY Cleveland, OH Greenville, SC Seattle, WA Phoenix, AZ Little Rock, AR Medicaid fee for individual psychotherapy, minutes $ a Medicaid fee as percent of Medicare fee a SOURCE: Urban Institute/Center for Health System Change (HSC) State Survey of Medicaid Fees, NOTES: Based on Current Procedure Terminology (CPT) code a Not available. 698 May/June 2006

6 Community-Based Care ample, one major provider of mental health services in Seattle cited the lack of rate increases in Washington State during the past seven years as one factor that contributed to a large increase in caseloads for case managers, staff layoffs, and a decrease in the amount of services that patients were receiving. Declining reimbursement relative to cost was also cited as one of the primary reasons for inpatient capacity constraints in many communities. Moreover, as competition among hospitals for more profitable services (such as cardiology, oncology, and orthopedic services) intensifies, less profitable services such as psychiatric wards might be eliminated. Respondents in Greenville, for example, reported that private hospitals in South Carolina have eliminated about 200 psychiatric beds in recent years, while expanding more lucrative services. Other Medicaid policy issues. States have implemented numerous Medicaid cost containment measures during the past three or four years, including cuts in eligibility, greater administrative barriers to enrollment, increased cost sharing, and more restrictions on drug usage. With a few exceptions, reports of serious erosions in mental health care as a result of these measures were not widespread. Boston stood out as the CTS site that had been most affected by cuts in Medicaid eligibility. In 2003, Massachusetts cut 36,000 adults from MassHealth Basic, a large proportion of whom were long-term unemployed people with serious mental health problems. The program was eventually reinstated, but with more stringent eligibility standards and an enrollment cap of 18,000. Another major concern is the effect of the increased use of prior authorization and preferred drug lists to manage drug costs in states Medicaid programs. 15 The majority of states with prior authorization requirements or preferred drug lists exempt at least some psychiatric medications from these restrictions; however, Florida has recently removed its exemption. 16 Some respondents in Miami are concerned that this will harm patients compliance with drug regimens, leading to negative outcomes for patients and, ultimately, higher treatment costs. Federal rule changes can also have major consequences for mental health services, especially to the extent that states are allowed to use Medicaid funds to cross-subsidize non-medicaid services. In 2005, Washington lost $82 million in federal Medicaid funding for mental health services (about one-fifth of the state s community mental health budget) because of a federal rule change, which the state had used to cross-subsidize care for the uninsured. 17 Had the state legislature not moved to replace most of the lost federal funds with state funds, mental health professionals in Seattle reported that services for uninsured people would have been all but eliminated. Funding for non-medicaid services. In general, respondents appeared to be more concerned about the non-medicaid part of state mental health budgets than about Medicaid. State mental health agencies revenue from state general funds increased only 5.7 percent between 2001 and 2003 (compared with a 15 percent increase from all sources), and six of the twelve states with CTS sites experienced HEALTH AFFAIRS ~ Volume 25, Number 3 699

7 Quality & Access Some states are increasing funding for community-based services, with or without prompting from the Olmstead decision. net reductions in revenue from state general funds for mental health care between 2001 and 2003, after accounting for general inflation. 18 According to respondents in Seattle, Greenville, and Orange County, state budget pressures contributed to the closure of state psychiatric facilities, which further strained the capacity of acute inpatient and outpatient facilities. Mental health care providers in some communities reported having to narrow the definition of serious mental illness for the purposes of determining who is eligible to receive their services. State cuts in the budget for alcohol and substance abuse services in Massachusettsledtoanalmost50percentreductionin detox bedsinboston,resulting in long waiting lists and many people not getting services. Care for the uninsured. The recent trends in state funding for mental health servicesarepartofalonger-termtrendofstatesshiftingasmuchofthecostsoftheir mental health services as possible to Medicaid, to enhance the federal match. Community respondents overwhelmingly agreed that reduced funding or slower growth in non-medicaid funding is severely eroding services for uninsured people with serious mental illnesses. In Cleveland, some mental health professionals predict that the public mental health system will be a total Medicaid system in two to five years, and uninsured people will not be able to get services in the public system. A recent budget developed by the King County Department of Mental Health (Seattle) funds services for about 800 uninsured people, representing only 5 percent of the total number who will be served through the public system (compared with an average of 30 percent in the rest of the state). Consequently, the uninsured will need to turn to nonspecialty providers, such as hospital EDs and community health centers, for mental health services. State responses to service gaps. There is growing recognition in a few states with CTS communities of the need to bolster public mental health funding. OnepossiblereasonforthisistheU.S.SupremeCourt s1999olmstead v. L.C. decision, which required states to develop action plans to provide medically appropriate community-integrated care to institutionalized people with disabilities, including mental health related disabilities. 19 However,therewaslittleevidencethroughour interviews with mental health care providers that the decision was having a noticeable impact on the capacity of community-based services for the mentally ill. Some states with CTS communities are increasing funding for communitybased services, with or without prompting from the Olmstead decision. In Arkansas, a severe shortage of state institutional capacity and years of underfunding of community-based services prompted a governor s task force to earmark $5 million to boost community-based capacity. And, as discussed earlier, the Washington State legislature moved to replace with state funds most of the $82 million in lost 700 May/June 2006

8 Community-Based Care federal Medicaid funds resulting from federal rule changes. New Jersey has made sizable investments in mental health care in the past five years, including an infusion of $20 million into the community mental health system, $15 million in grants for housing, and expansion of its assertive community treatment program. The state s acting governor at that time made mental health one of his top priorities, allocating increased funding for mental health despite a $4 billion state budget deficit. At the time of the site visits, proposals for further expanding service delivery in New Jersey included loan forgiveness for mental health professionals (to increase the supply of providers) and a $200 million housing trust fund that would create 10,000 permanent housing units over ten years for people with mental illnesses and developmental disabilities. In California, a successful 2004 ballot initiative in California, Proposition 63, created a dedicated source of revenue for mental health support services. Since funds from Proposition 63 cannot be used to supplant existing resources, respondents in Orange County are optimistic that funding will be used for new services relating to housing, supportive services, rehabilitation, and community care. 20 InNewYork,Kendra slaw(passedin1999andreauthorizedforfiveyearsin mid-2005) authorizes court-ordered Assisted Outpatient Treatment (AOT) for people with serious mental illnesses who, because of their behavior and treatment history, require supervised services to live safely in a community setting. Kendra s Law also funds medications and services to bridge the treatment gap and prevent relapse among those released from prison with serious mental illnesses (and before they qualify for Medicaid). A 2005 evaluation of the law by the New York State Office of Mental Health found increased adherence to treatment; reduced hospitalization, homelessness, arrest, and incarceration; and sustained improvements in overall functioning. 21 The governor s fiscal year budget provides more than $32 million for services related to Kendra s Law. In Phoenix, litigation has led to a notable expansion of community-based services for the mentally ill. 22 Arnold v. Sarn, an ongoing lawsuit in Maricopa County that began more than twenty years ago, has expanded mental health services and encouraged community-based care. Periodic audits of services by a courtappointed monitor have required that the county, as well as the state, expand services over time. Also because of pressure from the courts, the regional behavioral health authority that serves the Phoenix area recently changed its interpretation of eligibility for services, after which the number of people with serious mental illnesses who were eligible for services in Maricopa County reportedly jumped from 12,000 to 18,000. Community responses to service gaps. Community responses to the growing access problems of the seriously mentally ill have been narrow in scope, representing incremental change rather than broad-based solutions. These responses include limited capacity expansions, increased coordination of services and collaboration of providers, and new programs or approaches aimed at better han- HEALTH AFFAIRS ~ Volume 25, Number 3 701

9 Quality & Access dling the overflow of people with serious mental illnesses into prison systems, hospital EDs, and homeless shelters. Limited capacity expansions by individual providers and local mental health departments have been a common response to growing demand for mental health services in the past few years, although community respondents almost universally reported that these expansions do not come close to meeting the large amount of need in their communities. In Syracuse and Greenville, mental health care providers are initiating school-based clinics to reach children with mental health needs. Other communities are expanding residential and vocational services, such as a major provider in Seattle, which added fifty beds to existing residential facilities and completed construction on a new fifteen-unit facility that serves homeless women with children. A few communities, including Syracuse and Cleveland, are trying to increase service coordination and collaboration betweenprovidersbothtoimprovequalityandasawaytostretchlimitedfunding. Attention to mental illness in the criminal justice system is growing in at least a few CTS sites. 23 A recent Miami Dade County grand jury investigation into the warehousing of people with serious mental illnesses in the Miami Dade County jail was highly publicized and led to the creation of a jail diversion program. In Indianapolis, the shootings of two police officers by people who were unable to obtain mental health services brought substantial media attention to mental health access problems in that community. In response, county organizations are now working together on an awareness campaign aimed at increasing mental health funding and developing more community-based services. To deal with the frequent use of EDs by patients with serious mental illnesses, hospitals in a few communities have created separate facilities or sectioned off partsoftheiredsforpatientswithpsychiatricproblems.ingreenville,amental health center collaborated with a hospital system to open a twenty-five-bed ED annex for psychiatric emergencies in late 2003, funded in part with state money. ThiscontributedtoasizablereductioninthenumberofpeoplewaitinginEDsfor admission to a state acute care facility, according to state reports. Yet in some communities, severe capacity constraints at the psychiatric EDs actually forced people with serious mental illnesses to seek care at other hospitals. For example, in Indianapolis, the opening of an eight-bed psychiatric ED at one hospital reportedly resulted in a 34 percent increase in mental health related ED visits at a nearby hospital. Most of the CTS sites have initiated programs designed to increase service integration and reduce the fragmentation of community-based services. Assertive community treatment programs, which typically use multidisciplinary teams to promote care coordination and integration and services, are being promoted by state and local mental health departments, advocates, and mental health providers in most of the CTS sites and were recently expanded in three sites (Indianapolis, Miami, and northern New Jersey). Other communities have implemented pro- 702 May/June 2006

10 Community-Based Care Problems that are untreated on an outpatient basis could eventually increase the need for more intensive inpatient treatment. grams that assist homeless people with mental illnesses in making the transition to affordable housing; these include the Action Coalition to Ensure Stability (ACES) program in Indianapolis and Boston s Pine Street Inn (a homeless shelter). Lansing and Little Rock are partnering with Housing and Urban Development (HUD) supported housing programs to provide mental health services for people moving into permanent housing. Despite generally positive reports about the success and potential of these programs, respondents unanimously agreed that there is still a tremendous gap between demand and capacity for housing services. Discussion And Policy Implications More than forty years after the deinstitutionalization of people with serious mental illnesses began in earnest, communities are still struggling to provide the community-based services necessary for a population that is still heavily dependent on a wide array of acute care, residential, and support services. By contrast, deinstitutionalization of people with mental retardation or developmental disabilities appears to have been more successful for a variety of reasons, including greater flexibility in how Medicaid funds can be used, effective advocacy groups connected to middle-class constituencies, and less stigma among the public. 24 Many of the gaps in services described in this paper have been noted before. However, recent state budget pressures have intensified the problems associated with low Medicaid reimbursement for outpatient and inpatient providers, the lack of reliable funding for residential services, and the drop in resources available for uninsured people with serious mental illnesses. It s also likely that gaps in one service area, such as outpatient and residential services, are exacerbating the gaps in other areas, such as the shortage of inpatient psychiatric beds, since problems that are untreated or inadequately treated on an outpatient basis could eventually increase the need for more intensive inpatient treatment. Many community respondents fear that if current trends continue, most uninsured people with serious mental illnesses will be cut off entirely from the public mental health system. This will make them even more dependent on community health centers, hospital EDs, and other providers that are not adequately equipped and staffed to provide the necessary array of services or, worse yet, will leave them untreated altogether. There are signs that awareness of these problems is increasing among public officials, as exhibited by the President s New Freedom Commission on Transforming Mental Health Care in America; however, the commission s Federal Action Agenda includes very little discussion of the erosion of services for the uninsured. 25 There is considerable interest among community providers and some HEALTH AFFAIRS ~ Volume 25, Number 3 703

11 Quality & Access states in addressing the fragmented nature of much current care delivery and financing and in moving toward greater integration and coordination along the entire continuum of services. It remains to be seen whether or not this increased attention also results in greater resources to address some of the most serious gaps in mental health services. This research was supported by the Robert Wood Johnson Foundation. The authors thank Paul Ginsburg, Laurie Felland, and Robert Hurley for providing helpful comments on an earlier draft. NOTES 1. T.L. Mark et al., U.S. Spending for Mental Health and Substance Abuse Treatment, , Health Affairs 24 (2005): w133 w142 (published online 29 March 2005; /hlthaff.w5.133); and R.G. Frank, H.H. Goldman, and M. Hogan, Medicaid and Mental Health: Be Careful What You Ask For, Health Affairs 22, no. 1 (2003): Frank et al., Medicaid and Mental Health. 3. V. Smith et al., The Continuing Medicaid Budget Challenge: State Medicaid Spending Growth and Cost Containment in FiscalYears2004and2005 (Washington:: Kaiser Commission on Medicaid and the Uninsured, October 2004). 4. National Association of State Mental Health Program Directors Research Institute, State Mental Health Budget Shortages: FY 03 and 04, State Profile Highlights (Alexandria, Va.: NASMHPD Research Institute, May 2003). 5. The findings reported in this paper are based on respondents perceptions and experiences with the public mental health system in their communities, and therefore might differ from estimates of unmet need and system capacity based on quantitative data. However, no quantitative data for 2005 were systematically collected for the twelve communities we studied, to our knowledge, and therefore an independent assessment of unmet need and system capacity cannot be conducted. Our main findings are based on a strong consensus from a broad cross-section of respondent types (both mental health and non mental health respondents) as well as communities. 6. The twelve communities are representative of large and medium-size U.S. metropolitan areas and therefore include a broad cross-section of the types of problems that communities are experiencing with respect to mental health services as well as the types of state and community initiatives developed to address them. However, it is important to note that the specific initiatives described in this paper reflect those in the twelve communities only and are not necessarily representative of all initiatives undertaken by states and communities to address gaps in their mental health systems. 7. President s New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America, Final Report (Rockville, Md.: U.S. Department of Health and Human Services, 2003). 8. R. Manderscheid et al., Highlights of Organized Mental Health Services in 2000 and Major National and State Trends, in Mental Health, United States, 2002, ed. R.J. Manderscheid and M. Henderson (Rockville, Md.: Substance Abuse and Mental Health Services Administration, 2002). 9. Unpublished findings from the Community Tracking Study Physician Survey. 10. Estimates of the number of Medicaid enrollees based on E.R. Ellis, V.K. Smith, and D.M. Rousseau, Medicaid Enrollment in Fifty States (Washington: Kaiser Commission, September 2005). Estimates of the number of uninsured people are based on P. Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2005 Current Population Survey, Issue Brief no. 287 (Washington: Employee Benefit Research Institute, November 2005). Estimates of the number of psychiatrists are based on American Medical Association, Physician Characteristics and Distribution in the U.S. (Chicago: AMA, 2005). 11. L.F. McCaig and C.W. Burt, National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary, Advance Data from Vital and Health Statistics no. 358 (Hyattsville, Md.: National Center for Health Statistics, 2005); and L.F. McCaig and N. Ly, National Hospital Ambulatory Medical Care Survey: 2000 ED Summary, Advance Data from Vital and Health Statistics no. 326 (Hyattsville, Md.: NCHS, 2002). 12. Computed from NASMHPD Research Institute, FY 03 Funding Sources and Expenditures of SMHAs: Reports, Table 30a: FY 2001 to FY 2003 State Mental Health Agency Controlled Mental Health Expenditures, 2005, (accessed 17 February 2006). 704 May/June 2006

12 Community-Based Care 13. Based on unpublished data from the 2003 Urban Institute/HSC State Survey of Medicaid Reimbursement Rates. Overall estimates of Medicaid reimbursement rates by states can be found in S. Zuckerman et al., Changes in Medicaid Physician Fees, : Implications for Physician Participation, Health Affairs 23 (2004): w374 w384 (published online 23 June 2004; /hlthaff.w4.374). 14. Fee-for-service (FFS) levels might not be entirely accurate in reflecting compensation levels since much of the mental health care in Medicaid is provided through managed care or carved out to behavioral health providers. However, FFS rates and capitation levels in managed care generally are correlated because states have tended to set capitation rates based on FFS levels. See J. Holahan and S. Suzuki, Medicaid Managed Care Payment Methods and Capitation Rates in 2001, Health Affairs 22, no. 1 (2003): J.S.CrowleyandD.Ashner,State Medicaid Outpatient Prescription Drug Policies: Findings from a National Survey, 2005 Update (Washington: Kaiser Commission, October 2005). 16. C.Koyanagi,S.Forquer,andE.Alfano, MedicaidPoliciestoContainPsychiatricDrugCosts, Health Affairs 24, no. 2 (2005): The loss of federal funding is the result of (1) ending Washington State s exemption to the Institutions for Mental Disease (IMD) exclusion, which prohibits Medicaid funds for state psychiatric institutions; and (2) a more strict interpretation of the 1997 federal law preventing states from using Medicaid funds for non-medicaid patients. 18. NASMHPD Research Institute, FY 03 Funding Sources and Expenditures of SMHAs: Reports, Table 35: FY 2001 to FY 2003 SMHA-Controlled Mental Health Revenues, 2005, RE03/tables/03t35.pdf (accessed 17 February 2006). 19. Olmstead v. L.C., 527 U.S. 581 (1999). 20. For more information, see R.M. Scheffler and N. Adams, Millionaires and Mental Health: Proposition 63 in California, Health Affairs 24 (2005): w212 w224 (published online 3 May 2005; /hlthaff.w5.212). 21. New York State Office of Mental Health, Kendra s Law: Final Report on the Status of Assisted Outpatient Treatment, March 2005, (accessed 23 March 2006). 22. Boston also faces an ongoing lawsuit that is forcing the state to address development of community-based services for its developmentally disabled and mentally retarded population. 23. Additionally, a national effort known as the Consensus Project is working to help federal, state, and local policymakers and criminal justice and mental health systems improve the response to people with mental illnesses who are involved with the criminal justice system. For more information, see project.org. 24. B.C. Vladeck, Where the Action Really Is: Medicaid and the Disabled, Health Affairs 22, no. 1 (2003): SAMHSA, Tranforming Mental Health Care in America The Federal Action Agenda: First Steps, 2005, (accessed 10 December 2005). HEALTH AFFAIRS ~ Volume 25, Number 3 705