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When JFK signed the Community Mental Health Act in 1963, community-based mental health and substance use treatment options began to spring up across the U.S. These new programs allowed people with significant mental illnesses and developmental disabilities to be released from the hospitals and institutions where they’d been housed and return to their own communities for ongoing treatment and care.
Most local communities weren’t prepared for the influx at the time, and to this day many communities struggle to fund the mental health and substance use treatment services that their residents need to get and stay healthy. But community-based treatment options, like those made possible by the Community Mental Health Act of 1963, are still more effective than institutional care for most because they allow clients to maintain their independence, enhance access to local behavioral health services, and reduce both stigma and institutionalization costs for taxpayers and private payers alike.
In the decades that followed the Community Mental Health Act, the services delivered by community mental health agencies, and indeed the expectations we began to place on them, would grow exponentially.
More expectations, more clients
Michigan’s community mental health agencies now deliver more than two-dozen specialty services and supports to clients and communities. These include child therapy, family therapy, crisis stabilization services, occupational therapy, medication assessments, targeted case management, telemedicine, assertive community treatment, and more.
With the 2010 passage of the Affordable Care Act, many more Americans were enrolled in Medicaid. Then, more than two-dozen states across the country chose to expand Medicaid coverage to a broader group of low-income adults.
Michigan did so in 2014, and hundreds of thousands of Michiganders soon enrolled in the state’s Medicaid expansion program, the Healthy Michigan Plan.
Restricted and reduced funding
Initially, community mental health agencies received general fund dollars to cover the cost of the services they provided. General fund dollars were flexible, and allowed community mental health agencies the freedom to invest in the most pressing local needs.
Later, regardless of how many services a client received, community mental health agencies were paid a flat fee for each target client: those who were both enrolled in Medicaid insurance plans and diagnosed with severe mental illness, emotional disturbance, or developmental disability.
Additionally, the payments Community Mental Health agencies received for Healthy Michigan Plan enrollees--a special Medicaid plan for those just above the federal poverty line--were significantly lower than the payments CMH received for traditional Medicaid clients.
Flexible general fund contributions declined by 60 percent and were replaced by federal funding that was so restrictive that many community mental health agencies were forced to discontinue programs that they had once offered to clients and community members who did not meet Medicaid criteria.
“People might benefit from crisis residential services, or case management, or jail-diversion services, but unless you’re on Medicaid, CMH can’t provide those services,” explains Robert Sheehan, executive director of the Community Mental Health Association of Michigan.
Funding-based service restrictions
Today, no matter how efficient the state’s community mental health agencies are with the public dollars entrusted to them--and, on average, they spend just 6.1 percent on administration--the deck seems stacked against them.
“I don’t think the average Washtenaw County resident spends a lot of time thinking about the path of money from the federal government to the state to the county,” says Andy LaBarre, a county commissioner and a key architect of Washtenaw’s Public Safety and Mental Health Preservation Millage, which provides supplemental resources so the county’s community mental health agency can expand services, and offer them to more residents.
“I would bet they would spend even less time thinking about the constraining nature of that money as it moves through those levels.”
In 2016, just two years after WCCMH saw an influx of Medicaid and Healthy Michigan Plan clients, a local study by the Center for Health and Research Transformation, on behalf of the Washtenaw Health Initiative, found that many county residents with mild to moderate mental health needs required support, too, and that these individual faced significant delays when they tried to access services.
It was this understanding that encouraged LaBarre and others to seek a mental health millage that would provide less restrictive funds for WCCMH to serve residents before their untreated symptoms became more severe or they experienced a mental health crisis.
When a county wins grant funding, or passes a millage that provides additional support for community mental health services, that county has control over its destiny in a way that wouldn’t be possible with state and federal resources, says Commissioner LaBarre.
“The money we raised via the millage, or [the money we] get via general fund allocation, that’s available on a basis that you can trust,” says LaBarre. “So it’s the most flexible money, and it’s the most dependable money.”
“The flexibility of the millage dollars allows us to fill gaps beyond what even Medicaid can adequately provide,” says Trish Cortes, executive director of Washtenaw County Community Mental Health.
“We have been able to use these dollars to address upstream issues such as prevention and education, which is greatly needed, and to support our entire community, not just our Medicaid-eligible individuals.”
Pivot and adapt
Today, the Center for Health and Research Transformation is working on another community health needs analysis with a focus on mental health and substance use disorder treatment needs.
The work, which CHRT is again doing on behalf of the Washtenaw Health Initiative, is expected to find that some community health needs have been met with millage resources, while other needs remain or have grown as a result of COVID-19 safety precautions.
Given the flexibility of millage funding, Washtenaw County Community Mental Health should be well positioned to pivot and adapt, focusing millage resources where the greatest gaps remain.