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Advice For The Next Governor of New York StateAn Opinion by Michael B. Friedman, LMSW
The next Governor of New York will have to confront a vast array of mental health issues. Here are a few observations I hope will be helpful. Mental health is important to all New Yorkers and should be one of the next Governor’s priorities. 50% of us will have a mental disorder in our lifetimes, and 20% will have a disorder in any given year. Most mental illnesses are not severe, but they result in substantial pain for both people with mental illness and for their families. They also take a toll on the economy. Mental illness is the leading cause of disability in the United States and the fastest growing cause of disability in the workforce. Untreated mental illness reduces productivity and costs American business over $100 billion per year. Mental illness also drives up the cost of health care. Psychogenetic symptoms result in unnecessary testing and treatment. And, when combined with mental illness, physical illness becomes more complicated—and costly. For example, people with cardiac conditions and depression cost almost twice as much to treat for their heart problems. A Governor committed to a high quality of life for New Yorkers and to a thriving economy should make mental health a priority. He should focus, of course, on how the public sector can promote mental health, but also should focus on helping the private sector to understand that promoting mental health is good for business. The next Governor should commit to continued progress towards the development of a comprehensive community-based mental health system for adults with long-term psychiatric disabilities with particular attention to problems of transinstitutionalization. A half century ago NYS passed the first community mental health act in the United States setting the stage for the nation’s shift from institution-based mental health policy to community-based policy. The first step in the transition was “deinstitutionalization.” It helped many people avoid unneeded long-term institutionalization, but it also resulted in the abandonment of tens of thousands of people in communities unprepared to serve them. (Fortunately, families filled the void for many of them.) A quarter century ago, NYS instituted the Community Support Program, which—over time—has addressed shortcomings of deinstitutionalization with expanded outpatient treatment, housing, rehabilitation, family and peer support, and more. For those of us who have been around since the late 1970’s, the progress is apparent—but so is continuing need. The next Governor should continue the momentum with expanded housing and more services and supports oriented to recovery, particularly for those most likely to be underserved, such as people with co-occurring mental and addictive disorders. Continued progress will entail confronting the future of the state hospital system and the nature of “reinvestment” if more hospitals are closed. This will be among the thorniest of political issues the next Governor will have to face. In addition, the new Governor should anticipate that the large presence of people with serious mental illnesses in adult homes, nursing homes, jails, and prisons will re-emerge as a major crisis as they did in the Carey, Cuomo, and Pataki administrations. It would be wise for the new Governor to confront transinstitutionalization before it confronts him. Among other things, this will entail a commitment to increase and remodel housing for people with serious mental illness. The Governor should commit to continued progress towards the development of a community-based mental health system for children and adolescents. Over the past quarter century, incremental progress (with a big leap this year) has been made in addressing the mental health needs of children and adolescents. This has included the development of more specialized child mental health services, the development of non-traditional services, new efforts to treat families with respect and as partners in care, strides towards integration with other child-serving systems, use of a home and community-based waiver program to reduce institutionalization, and—this year—a vast increase in screening, assessment, and treatment through Clinics Plus. If Timothy’s Law passes the Senate as promised and Governor Pataki signs it into law (no word as I write this), services will also be increasingly available to those covered by employer-based health plans. But all of these gains leave much still to be accomplished. The next Governor should commit not only to continued expansion and improvement of mental health services for kids in the public sector but should also press for increased access through workplace benefits and programs. The march of demography calls for increased attention to the mental health needs of minorities and older adults. Our society is undergoing major demographic shifts. Over the next quarter century minority populations will grow from 30% of the population to 43%. The population of older adults will grow from 13% of the population to 20%. Neither NYS nor the nation is prepared to meet the mental health challenges of these demographic shifts. In NYS some progress has been made. The Geriatric Mental Health Act has led to the creation of a planning council and a services demonstrations grants program. There may soon be centers of excellence in minority mental health. But so much more is needed: a workforce that speaks the language of its clientele and is knowledgeable about geriatrics, cultural differences, etc.; public education to overcome stigma; development of more mobile services providing outreach to populations unable or reluctant to seek out mental health services; integration of services, and more. The next Governor should lead NYS into the future by laying the groundwork now for meeting the needs that will increasingly emerge as the march of demography moves ineluctably forward. Quality of mental health services is uneven in NYS. The Governor should commit to continued support of research and the use of best practices. Improving the quality of mental health services through the translation of research into practice has become one of the central tenets of mental health policy in NYS and in the nation. Doing so requires a research agenda that has eventual application to the real world and a commitment to support the use of best practices. New York State has been a leader in research and in the effort to improve practice. The new Governor should support these efforts. Using Medicaid to fund mental health care has reduced NYS’s costs. The next Governor needs to understand the role of Medicaid in supporting the state’s public mental health system. Without doubt, Medicaid spending will be a major target for the next administration. But Medicaid spending in NYS is extremely complex, reflecting decisions to cover more people and services than other states as well as the high costs of health care in general. The next Governor probably knows this already, but it would be surprising if he knows much about the use of Medicaid as the major underpinning of New York’s mental health system and of its use to generate federal funds to supplant state and local funds. The new Governor needs to understand that cuts to Medicaid for mental health are likely to ultimately drive up the state’s costs. He should support the remarkably clever state bureaucrats who have figured out year after year how to use Medicaid to preserve and improve NYS’s mental health system. The new Governor should also understand that efforts to reduce Medicaid costs by closing general hospitals can inadvertently have a devastating effect on NY’s mental health system—which relies heavily on general hospitals to provide essential inpatient and outpatient services. In general, the next Governor needs to recognize that, while mental health constitutes an extremely small part of the overall Medicaid budget, Medicaid is absolutely crucial to the of the public mental health system. Are new approaches to the way Medicaid is used to fund mental health possible? Probably, but both the Cuomo and the Pataki administrations developed brilliant ideas about how to restructure Medicaid funding for mental health, and both failed. The next Governor needs to understand why before taking off in similar directions. Since becoming a mental health advocate, I have lived through two gubernatorial changes—Cuomo and Pataki. Both were rough for mental health because neither new Governor initially understood how delicately balanced the mental health system is. It relies on a mix of state, community, and general hospital providers. It relies on leadership by state and local governments. And it relies on a very complex mix of funding sources—federal, state, local, philanthropic, private insurance, and self-pay. The new Governor needs to keep all this in mind if the next transition is to be smoother than the previous two. (Michael B. Friedman is the Director of the Center for Policy and Advocacy of The Mental Health Associations of NYC and Westchester. The opinions expressed in this column are his own and do not necessarily reflect the positions of the MHAs. Mr. Friedman can be reached at center@mhaofnyc.org.) Return to the top of the page.
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