Any effort to reform the U.S. healthcare system must make behavioral healthcare a priority, treat the “whole person” not just disease symptoms, and eliminate the stigma and system fragmentation that stand in the way of patients seeking treatment and preventative services, according to a consensus statement issued by the Substance Abuse and Mental Health Services Administration (SAMHSA).
“As lawmakers seek to revamp America’s health care system, the prevention and treatment of mental and substance-use disorders must play a foundational role in reforms and be given equal weight to medical care provisions,” according to the document, “Ensuring U.S. Health Reform Includes Prevention and Treatment of Mental and Substance Use Disorders — A Framework for Discussion” (PDF).
“There is no health without addressing mental and substance-use disorders and it is time to give Americans the comprehensive care and support they need and deserve,” the report stated.
The consensus statement was released in late May by SAMHSA just as healthcare-reform discussions were heating up in earnest on Capitol Hill. It includes a list of nine “Core Consensus Principles for Reform” based on input from “hundreds of stakeholder and consumer groups and dozens of nationally and internationally recognized experts in the fields of mental health and addictions,” according to the agency. The American Society of Addiction Medicine, National Alliance on Mental Illness, the National Council of Community Behavioral Healthcare, and Community Anti-Drug Coalitions of America were among the groups that provided input into the report.
“Despite the broad range of organizations and areas of focus we surveyed, there were clear themes running through the responses we received,” the report noted. “With consistency and solidarity, mental health and substance-abuse professionals, consumers, and family members from every part of the country, every cultural and socioeconomic group, and every diagnosis and condition spoke with a single voice: Our nation is crying out for a health system that makes prevention and treatment for mental and substance use disorders a priority rather than an afterthought, that considers the whole person rather than physical symptoms alone, and that seeks to eliminate the stigma and fragmented systems that interfere with Americans’ ability to access necessary preventive and treatment services fundamental to achieving recovery and enabling them to lead healthy and productive lives.”
The Core Principles elucidated by SAMHSA included:
1. Articulate a national health and wellness plan for all Americans that “provides for comprehensive, community-wide prevention, screening, health, and wellness services from infancy through old age.”
“The plan should provide for public education, prevention, early intervention, treatment, and recovery services, and must be a holistic, standardized system that emphasizes promoting wellness and resilience, preventing risky and unhealthy behaviors before they occur to avoid the onset of illness or drug use, and addressing symptoms when they first emerge rather than waiting until they become acute or chronic,” according to the consensus statement.
2. Legislate universal coverage of health insurance with full parity. “Simply talking about parity in private insurance coverage for mental and substance use disorders is not enough,” according to the document. “Equal treatment for people with serious mental illness and substance use disorders must mean access to effective services and high-quality care.”
3. Achieve improved health and long-term fiscal sustainability. “There is a substantial body of evidence to demonstrate that providing adequate levels of mental and substance use disorders prevention and treatment services as well as integrating these services with primary health care can improve outcomes; cut and/or control the growth of overall health care costs; lessen the rate, duration, and intensity of disability of many illnesses; improve productivity; and control the size and growth of other social costs,” the document stated.
4. Eradicate fragmentation by requiring coordination and integration of care for physical, mental, and substance-use conditions.
5. Provide for a full range of prevention, early intervention, treatment and recovery services that embodies a whole-health approach. “Addressing physical health including mental and substance use disorders through effective prevention efforts that promote healthy environments, norms, and behaviors rather than waiting for the development of full-blown acute or chronic diseases is the most cost-effective approach,” the SAMHSA paper said.
6. Implement national standards for clinical and quality outcomes tied to reimbursement and accountability. The consensus statement said that establishing “specific and measurable” outcomes criteria is an “essential element” of healthcare reform, adding, “Reimbursement guidelines and benefits should be tied to need and severity regardless of payer.”
“These guidelines must link quality improvement with reimbursement and both encourage and reward the use of evidence-based practices without restricting coverage for those consumers who may not achieve desired outcomes with the least-costly alternative,” according to the consensus statement.
7. Adopt and fully utilize health information technology, including electronic health records that allow providers to share information and improve data collection aimed at improving access to and quality of care.
8. Invest in the prevention, treatment and recovery-support workforce. “Lack of adequate health care for mental and substance use conditions is a constant cycle exacerbated by a system that has failed to grow with the needs of a quickly expanding society and has not equipped its workforce with the right tools and experience to provide sorely needed care,” the consensus group stated. “It must become a National priority to increase the mental and substance use disorders workforce and provide appropriate compensation and professional support for these key members of the U.S. health system.”
9. Ensure a safety net for people with the most serious and disabling mental and substance-use disorders. “We can ill afford to dismantle the current safety net of block grants to states and other resources that in many states and communities are the only blockade between even higher rates of risky behaviors, illness, disability, death, health care costs, and lost productivity,” the report said. “Assuming expanded access to private and public insurance (Medicaid) for people with mental and substance use disorders will require a reexamination of the role of the public system at the local, state, and federal levels. Absent clear evidence that newly substituted health reform programs, systems, and processes are fully implemented and effective, it is imperative that our nation’s current safety net that finances health services, including school and community-based prevention programs and treatment programs for mental and substance use disorders, not be dismantled prematurely.”
Alexa Eggleston, director of public policy for the National Council of Community Behavioral Healthcare, said that the consensus statement would be useful in providing background and educating the public and lawmakers about key concerns regarding addiction, mental health, and healthcare reform.
“From that perspective it's helpful,” she said, although Eggleston also stressed the need for the behavioral healthcare field to draft legislative language for healthcare reform and for SAMHSA to “assert its role” in advocating for inclusion of addiction and mental health benefits in emerging legislation.
Consensus Reflected in Other Field Documents, Priorities
Recommendations forwarded to Congress by the Coalition for Whole Health, which is being coordinated by the Legal Action Center, include legislative language that advocates would like to see incorporated into the House and Senate healthcare reform bills (PDF). The coalition recommendations echo many of the priorities cited in the SAMHSA consensus document, including recognition of addiction and mental illnesses as preventable and treatable health conditions, a call for parity coverage, and maintenance of so-called “safety-net” programs like the addiction and mental-health block grants to states.
The SAMHSA consensus statements regarding information technology and workforce development also are among the top current priorities for addiction and mental health advocates working on national healthcare reform, added Eggleston, along with efforts to get Congress to recognize addiction as a chronic illness.
Congress has been debating proposals that would extend healthcare to all Americans — perhaps by creating a government-run “public option” health insurance plan that would compete with private health insurance. This week, Department of Health and Human Services Secretary Kathleen Sebelius appeared before the House Energy and Commerce Committee to press lawmakers to take decisive action on healthcare reform, while also signaling that the Obama administration remains flexible about how reform is accomplished and how it is funded.
“At this point the questions are so much bigger than individual illnesses,” noted Eggleston, who said that Congress appears more likely to punt more detailed discussions to a commission after the broad outlines of the reform plan are in place. “Delving into what a benefits package looks like doesn't seem likely to happen legislatively,” she said.
However, coverage for addiction and mental illness treatment is included as part of the “essential” benefit outlined in both the House bill and the Senate Health, Education, Labor and Pensions (HELP) Committee bill, noted David Rosenbloom, Ph.D., president and CEO of the National Center on Addiction and Substance Abuse at Columbia University.
“Coverage for addiction treatment is a key part of the solution to affordable health care reform,” said Rosenbloom. “Research has shown that when individuals get good addiction treatment, their families' regular medical expenses decline almost immediately, producing large net savings to the entire health system. So far, the Congressional committees seem to recognize this important fact by including addiction treatment in their draft bills.”