The American Public Health Association,
Recognizing that the US health care system is undergoing rapid and fundamental change in structure and financing;1-3 and
Further recognizing that proposed changes in the Medicaid program involve the proposals of block grants to states, which are intended to increase the efficiency and flexibility of state government in the provision of health care services, but which also threaten the entitlement to a prescribed range of services that currently exists for vulnerable populations, including individuals with disabilities;4-6 and
Noting that states have depended upon the Medicaid program to provide a wide range of community-based services for persons with severe and disabling mental illness, and that many states have recently sought waivers from the Health Care Financing Administration expressing the state's intentions to contain Medicaid mental health costs;7 and
Further noting that many of these waivers involve the use of managed care strategies, which have created new and expanded roles for the private sector and reduced the traditional role of the state in the care of persons with severe and disabling mental illnesses;8,9 and
Realizing that managed care cost-containment strategies may further fragment systems by separating critically important support services that are provided or funded by state sources (e.g., housing, vocational rehabilitation) from treatment services that are funded through Medicaid; and
Concluding that both the proposed changes in the federal Medicaid program and the ongoing state efforts to shift the financial risk and care-management responsibilities to private entities involve fundamental changes in the locus of accountability for this highly vulnerable population;10,11 therefore
Urges government at all levels to maintain an entitlement to effective health and welfare services for the most vulnerable populations, including adults with severe and disabling mental illness and children with severe emotional disorders;
Underscores the importance of collaboration among government, service providers, public health professionals, service recipients, and their families in the development and implementation of effective accountability systems that monitor the access to, quality of, and outcomes of services, including assessment of the process of care to assure that it conforms to best-procedure standards;
Asserts that in order for these accountability systems to be effective, issues of service system fragmentation must be addressed directly through state and local policy relating to the funding, structure, and operation of service programs;
Maintains that when considering persons with severe, disabling mental illness these accountability systems must monitor not only the health and mental health status of individuals who use services, but also the potential adverse consequences for persons with mental illness such as rates of homelessness, incarceration in jails or prisons, and death;
Urges the Congress and the Administration to assure that revisions of the Medicaid program contain explicit requirements for acceptable accountability systems in all state Medicaid programs. These systems must assure the confidentiality of individual medical and mental health records and should include population-based outcome indicators as well as those related to individuals who seek and receive care; and
Encourages other relevant national organizations (such as the National Alliance for the Mentally Ill, the National Mental Health Association) to develop model accountability systems that can be adopted by states and localities for monitoring managed care systems.
- Iglehart JK. American health care system: introduction. New Engl J Med. 1992;326:962-967.
- Iglehart JK. American health care system: private insurance. New Engl J Med. 1992;326:1715-1720.
- Iglehart JK. American health care system: managed care. New Engl J Med. 1992;327:742-747.
- Rowland D, Rosenbaum S, Simon L, et al. Medicaid and Managed Care: Lessons from the Literature. Washington, DC: Kaiser Commission on the Future of Medicaid; 1995.
- Koyanagi C, Schlosberg C, Schulzinger R, et al. Shallow Promise: A Critique of Medicaid Block Grant Proposals and Their Approaches to Meeting the Needs of People with Mental Illness. Washington, DC: Bazelon Center for Mental Health Law; 1996.
- National Advisory Mental Health Council. Health Care Reform for Americans with Severe Mental Illness. Rockville, MD: National Advisory Mental Health Council; 1993
- Helf C. Medicaid Managed Care and Mental Health: An Overview of Section 1115 Programs. Washington, DC: Intergovernmental Health Policy Project; 1994.
- Trabin T, Freeman MA. Managed Behavioral Healthcare: History, Models, Strategic Challenges and Future Course. Tiburon, CA: CentraLink Publishers; 1995.
- Mechanic D, Schlesinger M, McAlpine D. Management of mental health and substance abuse services: state of the art and early results. Milbank Q. 1995;73:19-55.
- Durham ML. Healthcare's greatest challenge: providing services for people with severe mental illness in managed care. Behav Health Sci Law. 1994;12:331-349.McFarland BH. Health maintenance organizations and persons with severe mental illness. Community Mentl Health J. 1994;30:221-242.
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