Mental Health Policy Overview
Mental Health Policy Overview
- Christine M. RineChristine M. RineEdinboro University of Pennsylvania
Mental health practice is inextricably linked to how this concept has been understood in a historical context from which policies and systems of care develop. How mental health is perceived has shaped policy, as much as policy has influenced how mental health has been defined and subsequently treated. Early frameworks evolved, furthering the multidisciplinary nature of policies and services highlighting social and environmental contributions. Holistic approaches that appreciate social determinants are a comparatively new way to understand and advance mental health policy that underlies access to insurance, programs, and services based on qualifications and eligibility. A chronological and historical overview highlights interconnectedness and provides context to the development of mental health policies, initiatives, and systems of care. Content specific to roles of the social work profession should be included.
- Mental and Behavioral Health
- Policy and Advocacy
The concept of mental health has existed since the earliest civilizations. Anthropological discoveries indicate that treatment for mental illness dates back to the Neolithic Period or about 5000 bce (Porter, 2002). Our understanding of mental health has evolved reflective of prevailing scientific, religious, political, and philosophical thought of the time. It was not until the late 1700s that formal policies and systems of care began to emerge. These structures became inextricably linked to how the concept of mental health is distinguished within a historical context. Prior to this era, abnormal behaviors were largely thought to derive from mystical means as punishment for a lack of moral character. As a result, those who displayed such were commonly shunned by family, subjected to harmful physical procedures, forcibly restrained, and kept in isolation (Foerschner, 2010; Klein, 2018). These long held beliefs did not disappear en masse but rather persist and are evident throughout the history of mental health policy and systems of care. Our understanding of mental illness has grown significantly; however, policies are mutable and continually offset by adverse and unforeseen developments that diminish enduring progress.
How mental health is perceived has shaped policy as much as policy has driven how mental health has been defined and subsequently treated. Mental health has been described in both very limiting and comprehensive terms. This is most often in regard to the breadth and depth of impairment regulating access to treatment, dependent on funding source (Goldman & Grob, 2006). This makes understanding the sufficiency of policies difficult and complex. On the surface, many mental health initiatives appear comprehensive and targeted as intended; yet, in practice they are found to be insufficient with unanticipated repercussions. For example, the Pennsylvania Hospital founded in 1751 as the nation’s earliest medical facility, was the first to care for the sick, poor, and those who had curable psychological conditions. Although this private non-profit institution spearheaded the treatment of mental illness in the United States, those who were deemed incurable were left to subsist in jails or poorhouses, or on the streets. Strategies to address mental health continue to contend with transmutable meanings, criteria, and sufficiency.
Perceptions of mental health are also influenced by the terms used to describe psychological conditions, the individuals who experience them, and the systems in which treatment occurs. Madness, disease of the mind, and derangement were among the earliest formal terms used to describe mental illness, which was treated in madhouses. In the 1800s lunatic, insane, and hysterical began to characterize those with mental illness who were treated in lunatic and later insane asylums. This progression was accompanied by the rise of colloquialisms such as fool, crazy, coo-coo, and nuts. As an outgrowth of the mental hygiene movement, more sophisticated terminology developed throughout the 1900s with the acknowledgment of discrete psychological conditions. In this era, terms such as mental illness, mental health, and behavioral health emerged which was treated in mental hospitals. At the same time, slang became more diagnosis specific with terms such as psycho and schizo. From this, one can appreciate how even those who sought to better understand and treat mental illness used terms that created stigma, stereotypes, and shame that has persisted into the 21st century (Porter, 2002; Rine, 2018; Rush, 1812).
Mental health policies are also heavily inspired by their predecessors; change advances gradually in relation to established viewpoints. Driven by colonialization, Elizabethan Poor Laws served as a model to contend with mental illness in the United States (Grob, 1994). William Tuke in England and Phillippe Pinel in France were early influencers who promoted humane, moral, and spiritual treatment of the mentally ill. These pioneers provided care in asylums aimed at rehabilitation through environmental intervention with the intent of returning patients to their families. Institutionalization was intended to aid in recovery by separating “the insane” for their own benefit while also keeping society removed from the recovery process (Foerschner, 2010; Klein, 2018; Porter, 2002; Rothman, 1971). These efforts formed the basis for the early development of mental health care in the United States, spurring the mental hygiene movement in the 1800s. This also marked the beginning of policy fluctuation between the two extremes of confinement and independence with varying levels and degrees of government involvement.
A chronological and historical overview highlights interconnectedness and provides context to the development of mental health policies, initiatives, and systems of care. Attention to the relationships between mental health legislation, political and societal trends, and scientific advances that inform treatment and policy are at the crux of this understanding. The role of the social work profession in progressing mental health policy and treatment occurs throughout its evolution.
The Mental Hygiene Movement
The country’s two-hundred-year legacy of institutionalization began in the early 1800s with the widespread creation of insane asylums later known as mental hospitals (Porter, 2002; Rothman, 1971). Support for early asylums grew out of local government poor laws and were often private or philanthropic in nature. As the number of mental hospitals increased, so did their formal structure. A dramatic upsurge in asylums soon emerged due to the culmination of numerous factors reflecting prevailing thought about the etiology of mental illness and changing societal conditions in a rapidly growing nation. In turn, these dynamics prompted the development of policies, treatment, and the rise of the mental hygiene movement (Foerschner, 2010; Grob, 1994; Klein, 2018; Porter, 2002). This movement was led by physicians, particularly William Sweetzer; psychiatrists including Adolf Meyer, J. B. Gray, and Isaac Ray; psychologists, notably G. Stanley Hall; and advocates like Dorothea Dix. However, former insane asylum patient Clifford Beers is often credited with being the most influential leader within the mental hygiene movement (Porter, 2002; Rothman, 1971). This movement endorsed moral treatment and humane care for the mentally ill, countering the appalling conditions suffered in the early 1800s. Understanding early developments brings insight to the manner and means by which policies and systems of care progressed.
Influential in this period and pioneer of the mental hygiene movement, physician Benjamin Rush published Medical Inquiries and Observations upon the Diseases of the Mind (Rush, 1812). This work asserted insanity can be treated and cured; however, harsh physical procedures were commonly among therapeutic methods (Franklin, 1954). Notably, he was the first to categorize mental illnesses paired with specific treatments and introduced the concept of addiction as a medical disease (Fox et al., 1996). Although the Pennsylvania Hospital intended to provide a compassionate approach to care for the mentally ill, Rush found the institution’s conditions deplorable and led efforts to modify their treatment protocol in his role as a staff physician. Rush is credited with publishing the first psychiatry textbook and is often considered the father of American psychiatry (Deutsch, 1936; Fox et al., 1996). His work was instrumental in developing early theories about the causes of mental illness, means of treatment, and advancing the asylum era.
The mid-1800s saw continued rapid growth of asylums, particularly in rural areas, that gained momentum from an increased focus on the beneficial properties of bucolic life in response to urbanization and overcrowding in city centers (Porter, 2002). At various points throughout history, “the insane” and those with developmental disabilities, termed “the mentally retarded,” were often grouped together and addressed the same in policies and services. The creation of insane asylums allowed the mentally ill to receive treatment and reside in specialized facilities. The increasing number of individuals in need of treatment and the large-scale development of asylums initiated a transfer of responsibility for the care of the mentally ill. Whereas local municipalities first led efforts to at least house the mentally ill and those with developmental disabilities, counties began to take on this increasingly onerous role. This later became the charge of states. Massachusetts, New York, and Pennsylvania led the nation in the movement to establish state asylums; most states followed suit. For example, an 1842 state law launched the New York State Lunatic Asylum at Utica as an acute care facility that accepted transfer patients from county poorhouses if they were considered curable. Unfortunately, many patients were released back to poorhouses when deemed incurable (Stuhler, 2013). The state’s Willard Asylum Act of 1865 furthered separate and specialized care by requiring all patients with a diagnosis of insanity be removed from poorhouses across New York. Those deemed curable were placed in the Utica State Asylum and those considered incurable were placed in the new Willard Asylum for the Chronic Insane (Stuhler, 2013). New York was also a forerunner with the passage of the State Care Act of 1890, making all severely mentally ill (SMI) wards of the state; nearly all states did the same (Grob, 1994). Using these early examples as an illustration highlights the challenges, considerations, gaps, and unintended outcomes encountered when the country first began to formulate policies and design facilities to treat the mentally ill.
While states were making efforts to care for the mentally ill, the mid-1800s marked the nation’s first attempt to seek federal accountability. Dorothea Dix began her career as a teacher; she gave up this profession for a less demanding role as a governess due to poor health, which may have included depression. As a governess, she traveled widely and formed relationships with social reformers and forward thinkers such as members of the lunacy reform movement in Great Britain who sought direct government involvement in social welfare. Dix began her rise as an early activist by advocating for federal funding in the hopes of improving poor conditions in state hospitals. Her landmark initiative was the Bill for the Benefit of the Indigent Insane, which found support in Congress but was vetoed by President Franklin Pierce in 1854. Similar to mental health reformers that came before, Dix also advocated for asylums to provide moral and humane treatment. However, she proposed that the federal government contribute to the care of the mentally ill through extensive land grants to benefit “the insane” (Foerschner, 2010; Klein, 2018). Although Dix was not successful in her groundbreaking attempt to create a national public psychiatric asylum system in the United States, she was successful in establishing 32 state funded hospitals in 18 states (Deutsch, 1936; Grob, 1994; Tiffany, 1892).
The mental hygiene movement continued to advance throughout the late 1800s, producing a significant increase in the number of institutions for the mentally ill. This was accompanied by changes in the fundamental nature of asylums and treatments. Where they began as small institutions primarily focused on therapeutic short-term care for the curable, they grew into large facilities providing custodial care for the chronically mentally ill (Grob, 2008; Klein, 2018). This formed our current understanding of the concept of institutionalization that sustained the asylum era ideology that remained predominant until the 1950s (Deutsch, 1936; Porter, 2002). The growth in the number of long-term mentally ill in asylums was also accompanied by emerging scientific, moral, political, and philosophical thought that inspired new developments in the 1900s.
The Turn of the 20th Century
The turn of the 20th century ushered in new thought about human development and the nature of mental illness, with advances in psychiatry favoring behavior modification and interpersonal insight (Foerschner, 2010). Most notable in this era was Sigmund Freud and Carl Jung, who promoted psychoanalysis as a means of talk intervention founded in a deficit-based medical model with focus on the pathology of mental illness. The movement towards psychoanalysis grew within institutional settings, while also expanding the treatment of mental illness into office-based care, which continued throughout the 1900s (Klein, 2018). The higher socioeconomic status of those receiving psychoanalysis and the settings in which they were received differed in terms of the stigma attached. Whereas office-based psychoanalysis was frequently perceived as a privilege, psychoanalysis in hospitals, for those of lower socioeconomic status, was often viewed as a financial drain. Likewise, diagnoses of those treated in office settings were more likely to be mild in nature, regardless of presentation, compared to those in institutions. The surge of office-based treatment was also propelled by anti-Semitism, as Freud was not able to practice in German state facilities and therefore turned to private practice as an alternative (see Thomas Szasz in “Further Reading”). These inequities contributed to a two-tiered system of mental health care.
Although institutional mental health treatment continued to progress in tandem with scientific advancements of the time, the conditions within state hospitals for “the insane” remained horrific. In 1908, Clifford Beers published The Mind That Found Itself, detailing the abusive treatment he received in both private and state hospitals. As a professional Yale-educated, white male, Beers brought legitimacy to claims of severe physical and emotional mistreatment. Consequently, he was afforded the opportunity to inform efforts to improve institutional conditions from a firsthand perspective. He was also instrumental in establishing numerous organizations whose efforts were significant to reforms of the early 1900s and are still relevant in the 21st century known as Mental Health America (MHA).
While the numbers of those institutionalized in public state mental hospitals continued to rise, the turn of the 20th century brought insight and advocacy that shaped polices and treatments for mental illnesses. Reform efforts of this era established state, national, and international recognition of mental health as a social problem, rather than a personal deficiency and drew attention to enduring perceptual and practical disparities between mental and physical health. Furthering this paradigm shift was acknowledgment of the pervasive and debilitating mental health symptoms experienced by soldiers returning from both World War I and World War II. This raised substantial concern for the country’s military stability and national security (Grob, 2008; Klein, 2018). Public awareness of the treatment and conditions experienced by those in state mental hospitals gained national attention in May 1946 with Life Magazine’s publication of “Bedlam 1946: Most US Mental Hospitals are a Shame and a Disgrace” (Maisel, 1946). This broadly circulated article served as an exposé accompanied by jarring photographs of patients that were widely likened to images of concentration camps in Nazi Germany (Sutherland, 1969). Two months after this publication, mental health policies and systems of care were addressed on a national level for the first time in July 1946 with the passing of the National Mental Health Act (NMHA).
The Advent of National Mental Health Policy
The NMHA marked the country’s first federal legislation on mental illness. This law supported research and established the National Institute of Mental Health (NIMH) in 1949. The NIMH was charged with developing effective treatments and training programs to meet the growing need for mental health professionals (Brand, 1965). The NMHA and the NIMH brought far-reaching innovation to the way mental health policy and systems of care were perceived and how their aims were administered. Whereas states had previously been left to initiate policies alone, the federal government now had a substantial guiding voice positioning the NIMH at the forefront of influencing funding, treatment, and policy (Grob, 1994, 2008; Klein, 2018). However, the NMHA was limited in its scope and ability to adequately aid states in meeting the needs of their constituents. It was not the intention of this legislation to establish a comprehensive nationwide effort to ameliorate this social problem, but rather to encourage states to develop and implement less costly community-based care (Brand, 1965). This federal perspective on mental health mirrors that of public health wherein the onus for care remains on individual states.
Deinstitutionalization Policies Beginning in the 1950s
Building on growing legislation and changing conceptualization of mental health, the late 1950s ushered in an era of deinstitutionalization. The development of antipsychotic medications increased the potential of this movement, giving rise to advances in both treatment and policy. Drug therapy supported the ascent of community-based care that aimed to increase quality of life through family involvement and reduce the need for inpatient hospitalization (Sutherland, 1969). The federal government continued their attention to mental illness and passed the National Mental Health Study Act of 1955 (NMHSA) to evaluate treatment and prevention methods for mental illness. The NMHSA also created the Joint Commission on Mental Illness and Health (JCMIH) to review findings and make recommendations for combating mental illness nation-wide (Grob, 2008; Klein, 2018). This was largely in response to ever-increasing costs of institutionalization and public criticism of prevalent treatments. Social perceptions and further condemnation of institutionalization was influenced by Erving Goffman’s (1961) publication of Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates. Goffman conducted participant observation fieldwork at St. Elizabeth’s Hospital in Washington, D.C., where he gained employment to carry out his year-long study of the inmate world. This work became a widely referenced classic with considerable bearing on legal cases and mental health policies. Goffman’s treatise, based on the total institution model, views asylums as discrete settings that serve as the sole source of socialization, thus promoting a shared sense of self in the inmate role. This indoctrination process, as a function of institutionalizing the mentally ill, heightened criticism of mental hospitals and negative patient outcomes.
The recommendations of the JCMIH set the stage for the national movement towards community mental health throughout the 1960s. The Kennedy administration brought a great deal of restructuring to mental health care. This was spurred by President Kennedy’s personal awareness due to the developmental disabilities of his sister Rosemary, findings of the Action for Mental Health Report, and the President’s Panel on Mental Retardation established in 1961. Reform efforts began with the Maternal and Child Health and Mental Retardation Planning Amendment to the Social Security Act of 1935 (SSA), which financed services for those with developmental disabilities and mental illness. This was accompanied by the Community Mental Health Act of 1963 (CMHA), which granted federal funding for the development of community-based programs (Klein, 2018; Mechanic & Grob, 2011). This is recognized as the first federal legislation to subsidize programs for mental health treatment and for those identified as “mentally retarded.” The actions of the Kennedy administration were viewed as progressive, postulated on research asserting effective treatment is best delivered outside of institutional settings, with families, and in communities. Yet NIMH data went unheeded that cautioned community care was not a viable option for the large number of patients in public state mental hospitals who did not have homes nor families to support community efforts (Grob, 2008; Mechanic & Grob, 2011). The ability of community mental health centers (CMHC) to decrease state spending for treatment compared to hospital settings likely outweighed this concern along with the all-inclusive federal vision, which was not realized. CMHCs were intended to bring a continuum of care providing short-term inpatient, outpatient, and emergency services augmented by preventative and educational programming afforded to all, regardless of ability to pay. It was hoped that CMHCs would replace the need for mental hospitals over the next few decades (Grob, 2008; Klein, 2018). However, Congress cut monies set aside within the CMHA for staffing prior to its passing.
It was soon found that CMHC funding was inadequate to support their original far-reaching intentions that not only included mental health treatment, but also macro interventions as stipulated in the CMHA. As a result, many who sought treatment in these settings returned to state institutions or remained untreated in the community. Another unintended consequence was a separation and lack of coordination between state-run facilities and federally administered CMHCs. Since CMHCs were uninhibited by state regulation of their operations, they primarily served populations and used treatment methods that matched the orientation, training, and expertise of their staff, which differed greatly across the country. To this end, many centers provided interventions to middle socioeconomic status clients, with mild mental health disorders, through a variety of individual talk therapies (Grob, 1994, 2008; Mechanic & Grob, 2011). Some centers looked to other mandates of the CMHA, turning their focus to other social problems necessitated by the communities they served such as family problems, delinquency, and addiction. This resulted in unequal access to treatment and further maintained a two-tier system of mental health care.
Broadly, CMHCs did not meet their initial aims and community-based services have not replaced the need for inpatient institutions decades later. However, their effectiveness varied dependent upon the severity of client disorders, therapeutic strategies employed, and the sufficiency of staffing to deliver treatment, which were all disparate across centers. Nonetheless, the research that drove the development of CMHCs, noting limitations, bares that if delivered comprehensively, community treatment can be an efficacious alternative for some who are institutionalized.
The Impact of Medicaid and Medicare
Amendments to the SSA of 1935 included minimal mental health care provisions until the enactment of Titles 18 and 19 in 1965. Title 18 brought Health Insurance for the Aged and Disabled, which is commonly known as Medicare. This legislation established health insurance for individuals 65 or older and those with a disability. This benefit included hospital coverage, or Part A, and Supplementary Medical Insurance coverage known as Part B, which helps pay for various outpatient services. Medicaid, or Title 19 of the SSA, is an entitlement program jointly funded by state and federal governments to provide medical assistance for low-income individuals and families. While Medicaid is broadly managed by the federal government, individual states set their own eligibility criteria, remuneration rates, and the nature, quantity, length, and range of services allowed (Frank & Glied, 2006).
These amendments drastically increased the role of the federal government in health and mental health care but did so with unintended consequences. Titles 18 and 19 resulted in a profound change as to where the elderly received care. Prior to these amendments, it was common for elderly suffering from dementia and other medical conditions, to receive custodial care alongside those with mental illnesses in public state hospitals. In these institutions, states historically assumed the entire cost of care. However, Title 19 positioned Medicaid as a source of state financial support for the elderly by moving this population into settings paid for by federal Medicaid dollars. Therefore, elderly patients in state mental hospitals, regardless of their mental health status, were transferred to nursing homes en masse because Medicaid paid for a much larger portion of care in those settings, which lessened state burden (Grob, 2008). In essence, Title 19 changed the location of where the elderly were more likely to receive long-term custodial care even if poorly aligned with their needs (Aviram, 2002; Frank & Glied, 2006; Grob, 1994, 2008; Mechanic & Grob, 2011). Compared to initiatives actually intended to reduce state expenditures for institutionalization, Medicaid and Medicare funding structures had more of an impact on reducing the number of those in psychiatric hospitals and related state costs than CMHCs or psychotropic medications. These outcomes indicate a great deal of cost shifting and suggests that more transinstitutionalization occurred than genuine deinstitutionalization (Grob, 2008).
Deinstitutionalization Policies in the 1970s
The push for deinstitutionalization that began in the 1950s strived to reduce the high cost of hospitalization, further humane treatment, and ensure a better quality of life for the mentally ill. Unfortunately, the policies and programs that were developed were largely unsuccessful due to a myriad of factors such as inadequate funding, poorly thought-out policy stipulations, unintended consequences, and a lack of state and federal coordination. This left CMHCs unable to manage the magnitude of those in need of services and the severity of mental health symptoms. Concern for the ever-rising cost of inpatient care, mental health consumer lobbies, and public outcry brought increasing pressure for another attempt at deinstitutionalization (Grob, 2005).
In the 1970s, state and federal regulations began mandating various forms of consumer or patient participation in decision-making roles across medical and psychiatric services that was rooted in President Johnson’s antipoverty program to include “maximum feasible participation of the poor.” Mental health groups gained national attention with the Willowbrook exposé in 1971 led by a young investigative journalist, Geraldo Rivera (Goode et al., 2013). The Willowbrook State School, an institution in New York City for the “mentally ill and retarded” (as it was identified then), was exposed for its deplorable treatment of patients and residents. Other similar revelations of horrendous conditions in institutions across the country prompted a movement toward “deinstitutionalization” in the “least restrictive environment” as a legal framework for patient-centered programs. These frameworks were based on class action lawsuits, specifically “Pennhurst” against a state hospital in Pennsylvania, and “Wyatt v. Stickney,” against a state hospital in Alabama. The impact of these lawsuits would reverberate throughout the country and contribute to the passage of the federal Civil Rights of Institutionalized Persons Act of 1980 (Rothman & Rothman, 1984).
Changes in the mental health service arena in the 1970s were also brought about by the growth of the consumers’ movement, self-help groups, and a more prominent role of families. The overarching aim of patients’ rights initiatives was to have a greater voice in service delivery systems. Founded in 1979, the National Alliance on Mental Illness (NAMI) was among the most influential of these grassroots organizations. NAMI has been very successful in leveraging research funding, shaping the national mental health research agenda, and increasing public awareness and positive perceptions of mental illness. The empowering efforts of patients’ rights groups effectively reframed language where psychiatric patients became referred to as consumers, victims, and survivors within service systems. Although the consumer movement was not directly spurred by policy, the mental health landscape was amenable to hearing the perspectives of those personally impacted by mental illness with increased attention on deinstitutionalization (Aviram, 2002; Frank & Glied, 2006).
In 1977, a new endeavor to develop a cohesive system of care for mental health emerged in the Community Support System (CSS). Once more, this signaled an increased onus and commitment of the federal government to address mental illness with the passing of the Mental Health Systems Act of 1980 (MHSA). The CSS took on many aims as it strived to oversee and coordinate all local, state, and federal mental health services offered in community settings across the country (Klein, 2018; Mechanic et al., 2013). Funding for the CSS was embedded within the MHSA, which was repealed by President Reagan’s Omnibus Budget Reconciliation Act (OBRA) of 1981 just nine months later. OBRA decimated federal progress in mental health gained over the previous 20 years, reduced the role of the NIMH, and lost oversight of limited technical assistance dollars that remained for community services. This legislation was so wholly antithetical from the MHSA that the term “community mental health center” was omitted altogether. As a result, nation-wide coordinated community treatment and supportive mental health services were hindered once again.
Responsibility reverted back to individual states to manage and fund a larger portion of mental health services, which slowed the community treatment movement. Minimal federal assistance allotted through the CMHA remained to assist states. However, this funding lacked appropriate administration. Specifically, it was intended that patients released from psychiatric hospitals were to receive subsidies following them into the community to provide supports such as housing and treatment. The majority of individuals affected by this mismanagement were the SMI who have historically been the target of efforts to reduce costs of care with little success. This contributed to a substantial increase in poverty, homelessness, addiction, and the widespread criminalization of the mentally ill, thus validating and intensifying stigma (Grob, 2008; Klein, 2018).
The Reagan and George H. W. Bush administrations brought continued New Federalism in policy, which reduced federal spending and returned responsibility of social welfare to states. Overall, these developments resulted in further solidification of a two-tiered system for treatment. CMHCs became central to the care of the deinstitutionalized and homeless, while those who could afford private mental health treatment sought such (Mechanic et al., 2013).
The Impact of the Health Security Act, Managed Care, and Parity
The Health Security Act (HSA) of 1993 proposed a system of universal health care. This legislation would have included mental health care, eliminating a siloed two-tier system of private and public by combining both. The HSA hoped to challenge growing inequity in the country’s health care system by stimulating means to control the market for services (Quadagno, 2014). This was to be accomplished through a Health Maintenance Organization (HMO) model. The HSA failed for many reasons; overall, the HSA was complex, lengthy, and often viewed as extreme by opposing capitalist ideals. The defeat of this legislation in the Senate led to a three-tiered system of private for profit, private nonprofit, and public, which included Medicaid and Medicare (Grob, 2008; Quadagno, 2014).
The attempt of the Clinton administration to institute universal health care had an implicit effect on managed care, HMOs, and in turn, mental health. Managed care practices used by HMOs controlled costs and quality of care while expanding the three-tiered system. This gave health insurance companies and care providers the ability to advance managed care principles that actually increased government oversight, which was a fear of universal health care. Managed care in community mental health had some positive influences. In many instances, it increased informal community supports, continuity of care, access to services, and flexible and integrated funding, and hastened the emergence of evidence-based practices (EBP). Managed care became part of Medicaid, the largest payer of mental health services, and grew to proliferate the administration of contracted mental health provisions in insurance. This brought the potential for opening access to a more extensive array of services. Yet, managed care can also be limiting, poorly aligned with need, and divergent across states (Aviram, 2002; Grob, 2008).
The ability of managed care to cut costs and provide a wider range of services for some, contributed to the passage of the Mental Health Parity Act (MHPA) of 1996. This legislation required that annual and lifetime insurance plan limits for mental health benefits be the same as those for medical care. Parity initiatives of this nature had previously been implemented in some states, but the MHPA marked the first federal legislation of this nature. At the same time, this legislation had its shortcomings critiqued for providing the same level of care regardless of the severity of mental illness (Goldman & Grob, 2006). Yet again, the SMI remained less likely to receive treatment commiserate with their needs. In 2008, President George W. Bush signed the Mental Health Parity and Addiction Equity Act (MHPAEA) into law. This largely replaced the MHPA and soon after broadened to require parity from insurance plans not previously included. This was achieved through the passage of the Patient Protection and Affordable Care Act of 2010 (ACA), a transformational legislative accomplishment under President Obama.
The Patient Protection and Affordable Care Act From 2010 to 2020
The ACA is the most noteworthy advancement in the county’s system of health care since the introduction of Medicare and Medicaid in 1965. This legislation aimed to guarantee access to health care, including mental health care, through affordable insurance coverage. It was projected that the act would bring insurance coverage to 94% of the population, drastically reducing the number of uninsured. The ACA increased access to treatment for those with behavioral health needs inclusive of individuals with mental health and/or substance use concerns. This was accomplished while also maintaining quality and regulating costs (Rine, 2018). Yet, while the ACA was successful in improving access on a federal level, individual states differed significantly. This legislation lowered income thresholds for federally controlled Medicaid provisions administered by states. Each state was able to decide whether to expand state-regulated Medicaid to include those who met lower federal income levels. Subsequently, states that did not expand their Medicaid guidelines hindered access to a range of medical and behavioral health services, particularly for low-income populations (SAMHSA, 2015). Changes to the political environment brought efforts to dismantle this groundbreaking legislation by Republicans, which continued under President Trump; as a result, its intentions were not fully realized.
The MHPAEA and the ACA launched a new era of how behavioral health services are envisioned and provided. The MHPAEA enhanced access to mental health and substance use services by mandating that health insurance coverage bounds are the same for behavioral and medical care. The ACA increased access to behavioral health services by radically increasing the number of insured individuals. Together, these acts enhanced and shaped holistic perceptions of mental health through increased access and reduced limitations to a variety of services.
2016 and Beyond
From the outset, the Trump administration prominently expressed intentions to repeal and replace the ACA among its campaign promises. Although these proposed changes did not occur, they would have significantly reduced access to behavioral health services. Yet, President Trump approved the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for the Patients and Communities Act in 2018 to address the opioid crisis, but later decreased funding to administer provisions of this legislation. An executive order created the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) Task Force on veteran suicide prevention in 2019; yet, SAMHSA funding was decreased, thus reducing their role in this effort (Kaiser Family Foundation, 2020).
In March 2020, the Coronavirus Aid, Relief, and Economic Security Act (CARE) was passed with numerous health provisions in response to the COVID-19 pandemic. In relation to behavioral health, this legislation expanded SAMHSA funding, coverage for remote services, mental health services provided by the Department of Veterans Affairs, and support for Certified Community Behavioral Health Clinics (Kaiser Family Foundation, 2020). It is likely that the adverse social, economic, and mental health effects of COVID-19 on individuals, families, and communities will result in continued attention and funding for services under the Biden administration.
Roles of Social Work in Mental Health
As the social work profession advanced, it both influenced and was affected by mental health policy, treatment, and systems of care. Differing perspectives of the function of social workers emerged within the profession as well as among those of other disciplines in mental health settings. The turn of the 20th century gave rise to new assumptions about individual worth, human development, and the etiology of mental illness. These changes brought an era that was particularly relevant to social work. Previously, it was a fledgling profession with limited involvement in mental health treatment. Caring for those released from mental institutions in the community had been the focus of practice (Aviram, 2002). Although Flexner’s Report to the Congress of Charities and Correction in 1915 claimed social work did not meet the criteria to be considered a profession, psychiatric social work flourished throughout the early 1900s. The rise of this practice area grew in response to an increased need for mental health care staffing and the national movement towards community treatment. Advancements of the time validated social work by establishing discipline-specific higher education, professional organizations, and a role in mental health. Concurrently, the growth of social work as a profession created divides between medical, psychiatric, and community-based practice (Aviram, 2002; Mechanic et al., 2013).
In the 1960s, increased involvement of the federal government in support of the community mental health movement contributed to the growing role of social work. The shortcomings of CMHCs provided social workers with an opportunity to expand their functions into mental health treatment where they soon became integral. Social workers were also formally recognized among mental health professionals in nation-wide CMHC planning, further legitimizing their role in treatment. Yet, the rise of social workers in community settings fraught with disorganization brought contention between disciplines due to unclear professional roles (Aviram, 2002). Similarly, the short-lived attempt to build a CSS in the late 1970s had a consequential impact on the role of social work in mental health, furthering division among those practicing in institutions and those in community outpatient settings. Schisms within the profession mirrored that of the system itself, which primarily consisted of state institutions and private, public, and nonprofit community programs. Meanwhile, the proliferation of social workers providing therapeutic direct practice created a larger divide between micro and macro work (Aviram, 2002; Mechanic et al., 2013).
A lack of agreement about the role of social work in mental health, both within the profession and among others, remains in the early 21st century. Lack of consensus is directly related to changes within mental health policy, treatment, and systems of care. Recurrent shifts towards deinstitutionalization, increased use of therapeutic medications, ascent of managed care, and expansion of governments’ social responsibility have all played a significant role in this ongoing debate. Social work is not considered the primary profession in the mental health care system, especially in relation to therapeutic treatment. Yet, social workers are the largest group of mental health service providers, outnumbering psychiatrists, psychologists, and psychiatric nurses combined (SAMHSA, 2015). Roles outside of treatment are inarguably well-suited to the profession such as case management, family support, community needs assessment, advocacy, utilization review, administration, and those that counter medicalization tendencies of other disciplines. Regardless of these professional strengths, social workers continue to primarily seek therapy and counseling positions within mental health that are shared with other professionals. Pursuing such may cause the profession to lose footing in areas that are indisputably aligned with discipline-specific skills devoid of competition. In this context, it is questioned whether “social workers seem to fight the wars of the past rather than respond to the present needs and prepare for the future” (Aviram, 2002, p. 630).
Historically, developments are demarcated by periods of reform, both progressive and reactionary, that bear upon mental health treatment, administration, funding, access, and setting. Shifting ideologies wrought reconsideration of the same conundrums over time such as distribution of state and federal responsibility, institutional versus community treatment, and overarching perceptions of mental health care as a human right or a privilege. At some junctures, progress appears evident, purposeful, and effective; while in others, it seems halted or regressed, wanton, and unsuccessful. Sometimes advancement and backward ebb occurred together with unintended outcomes as an immediate consequence of shortsightedness.
Although the future is uncertain, recent trends inform potential directions yet to come. National mental health organizations have outlined policy and research strategies beyond the early 21st century that delineate a prospective vision moving forward. MHA identified priorities that center on proactive approaches by pursuing peer services, school-based prevention, early intervention, access, primary care integration, suicide prevention, crisis intervention, and workplace mental health (MHA, 2020). The NIMH outlines research goals through 2025 that focus on behavioral neuroscience, mental illness across the lifespan, prevention, and public health outcomes of EBP (NIMH, 2020). The future aims of both MHA and the NIMH reflect a trend in holistic approaches that appreciate social determinants of health, which has expanded and is likely to grow. This can be seen in the upsurge of Health Homes, which is an optional Medicaid plan benefit to support states in care coordination for the whole person that includes mental health. Likewise, similar programs and initiatives serve to devolve siloed mental health and substance use services to better address the needs of individuals with dual diagnoses under the umbrella of behavioral health.
Revitalized attention to universal health care, particularly as result of the COVID-19 pandemic, has caused an increase in public sentiment in support of government responsibility to provide health care coverage. The Pew Research Center reports that more Americans were in support of a single national program in 2020 than in 2019 (Pew Research Center, 2020). COVID-19 has done much to illustrate deficiencies within our current health care system with 78 million uninsured or underinsured individuals during a global health crisis that requires swift diagnosis and isolation to reduce contagion (Galvani et al., 2020). Since health insurance is most often dependent on employment status, and the pandemic caused many to become unemployed or underemployed, loss and gaps in access to health care became common, yet more widespread, among low-income and people of color. COVID-19 continues to have an all-encompassing impact on the nation’s health care with a particularly negative influence on racial and economic mental health disparities. Systemic shortcomings highlight areas for improvement, lessons learned, and directions for sustaining and furthering approaches adopted in crisis that forced quick mental health policy responses propelled by necessity. Allowances for telehealth was hastily established, foregoing provider regulations for Health Insurance Portability and Accountability Act compliant technologies, SAMHSA made exceptions for take-home methadone doses, psychotropic drug monitoring rules were loosened, and Medicaid, Medicare, and private insurances allowed for more flexible reimbursement for mental health services. From a provider perspective, work from home and telehealth became an accepted and expected mode of intervention accompanied by similar means for administration and oversight (Goldman et al., 2020). As these challenges continue, there is a heightened demand for future preparedness based on new knowledge gleaned. Policy change is traditionally a slow and arduous process, but it was found that policies can indeed be altered and instituted in a timely manner.
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