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Carefully crafting consensus on mental health legislation

November 19, 2015

To date, the U.S. House has only crafted a mental health bill (HR 2646: The Helping Families in Mental Health Crisis Act of 2015) that is neither consensus-based nor bipartisan. A major chasm in positions between Democrats and Republicans reflects a similar gulf within the mental health field itself.

Because of this large disparity in points of view, it seems best to propose alternatives to the core features of the current bill that have the potential to foster the needed consensus. If this consensus can be developed, then legislation can be passed which will meet the requirements of our field and be respected by all of us.

To help move the agenda, several proposals are offered here around the issues in the current bill that have been most divisive.

Reconfiguring SAMHSA. A foundational difference exists between those who wish to retain SAMHSA in its current form and those who wish to change its programs in some fundamental way. Because SAMHSA’s programs are a critical part of our national mental health infrastructure, these changes should not be made lightly, and they probably should not be made by elected officials who have only limited knowledge and expertise. As an alternative, the legislation could create a commission. This commission could be staffed to represent all points of view in the field, and it could be charged with reviewing SAMHSA formally. It could assess current programs, staff, and financial resources against what will be needed going forward, and then make specific proposals for improvement.

Creating an Assistant Secretary for Mental Health. A division exists among those who want an assistant secretary who oversees SAMHSA, those who want an assistant secretary who is the SAMHSA administrator, and those who do not want an assistant secretary. If the issue being addressed is the need to coordinate field activities and programs for children and adults with serious mental disorders, as has been stated repeatedly, then, perhaps, another approach should be considered. A White House Office of Mental Health Policy and Program Coordination could be created to address this need. This office could be modeled on the Office of National Drug Control Policy, which has operated successfully in the Executive Office of the President for many years.

Requiring Assisted Outpatient Treatment. A chasm exists between those who want to require mandatory outpatient treatment and those who do not. Since the underlying goal is the receipt of high-quality mental health care, several alternatives can be recommended that preserve human rights and dignity. These would include advance directives which could be implemented through one’s health insurance, including Medicaid and Medicare; medical power of attorney which could be vested in a trusted family member or friend; or peer-led dialogues when a crisis arises and the other two tools are not available.

Limiting Legal Representation. A difference in points of view exists between those who wish to restrict further the right to legal representation of persons with mental illness and those who wish to continue the current federal Protection and Advocacy Program operated by SAMHSA. The alternative to be recommended here seems very straightforward: Persons with mental illness should have the same rights to legal representation as do those from all other disability groups.

Most other issues that have surfaced on the Hill in recent days, i.e., Use of Substance Abuse Prevention and Treatment Block Grant funds to pay for mental health services; modifications to the Institution for Mental Disease (IMD) restrictions; expanding the mental health workforce; and provision of support for electronic health record (EHR) development should be taken up by the proposed Commission identified above. Each relates to how care is delivered and financed.

The time already is very late to move quickly beyond today’s wrangling to produce meaningful mental health legislation that can address the many problems confronting us now. We all recognize that our national mental health care system requires improvement, and we all want the best care for all Americans who suffer from mental illness.

I call on the Republican majority and the Democratic minority in the House to consider the alternatives identified above. The House Mental Health Caucus would be an ideal setting in which these alternatives could be discussed.

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