Last week, Rep. Tim Murphy (R-Pennsylvania) led the “markup” — the rewriting — of the mental health reform bill he introduced in June, which would gut the Substance Abuse and Mental Health Services Administration (SAMHSA) as well as the confidentiality regulations governing substance use disorder (SUD) treatment (see ADAW, June 15). During the markup by the House Energy & Commerce Oversight and Investigations Subcommittee, which Representative Murphy chairs, an amendment allowing use of the Substance Abuse Prevention and Treatment (SAPT) block grant for treatment of mental illness was added; the much smaller Community Mental Health Services block grant would also be able to be used for SUDs. Advocates for SUD treatment were present throughout the markup and sent a letter to Energy & Commerce Committee chairs objecting to the block grant switch.

As introduced, the bill, called the “Helping Families in Mental Health Crisis Act” (H.R. 2646), would gut SAMHSA, abolish 42 CFR Part 2, provide incentives to states that allow assisted outpatient treatment (AOT; committing patients to outpatient treatment, which usually means medication), and make it easier for people — in particular, parents — to access private health information about the mental health treatment of their adult children. These are all highly controversial proposals among Democrats, however, and the markup aimed to resolve some of the differences so the bill could get out of the subcommittee and committee and to the floor for a vote.

The bill would increase the availability of mental health treatment. This one point — and nothing else really — is what has the entire mental health field supporting it, even the AOT provisions. Families of people with mental illness also support it, and want the privacy rules in the Health Insurance Portability and Accountability Act (HIPAA) changed so that they can have access to mental health records.

The bill had its inception after the Newtown, Connecticut, mass elementary school shootings in December of 2012, and has always had as its main justification the need to address violence by people with mental illness, putting advocates for people with mental illness in the difficult position of repudiating any link between mental illness and violence while at the same time desperately wanting and needing the increased access to treatment. However, more and more mass shootings are taking place, and instead of looking at gun control, conservatives are using the issue to advance mental health reform. This time, the mental health field is taking the pragmatic approach of supporting the bill for what it would do — expand mental health treatment.

However, as markups go, this was a particularly messy one.

Block grant letter

The reaction to the proposal to shift money out of the SAPT block grant was swift: it was a November 3 letter from SUD treatment advocates to Rep. Fred Upton (R-Michigan) and Rep. Frank Pallone (D-New Jersey), ranking members of the Energy and Commerce Committee, urging them to strike the amendment calling for “flexible use” of SAMHSA block grant funds.

“It is our hope that the Committee will make this change in order to maintain a strong commitment to programming specific to substance use disorders,” states the letter, a copy of which was obtained by ADAW. Citing the opioid crisis, the letter said that “it is time to invest more in programs that help the millions of Americans with the primary disease of addiction and to maintain programs that have a unique focus on the challenges associated with alcohol and other drugs,” and noted that SUD treatment and prevention services have long been “severely underfunded.” In particular, the country spent $24 billion on SUD services, or 1 percent of the $2.3 trillion spent on all health services, from 1986–2009, compared to $147 billion on mental health services, or 6.3 percent of the total, said the letter, adding that this makes the role of the SAPT block grant critical. Over the past 10 years, the SAPT block grant has lost 25 percent of its purchasing power and needs an increase of $452 million just to stay even with inflation.

An amendment that would have allowed 20 percent of funding to be redirected from SAMHSA’s Center for Substance Abuse Treatment and Center for Substance Abuse Prevention to be used for mental health was removed, which the organizations who signed on to the November 3 letter appreciated. “We urge the Committee to, once again, take action to remove a provision that would change current statute governing a program’s unique focus on addiction,” the letter stated.

Below is the list of organizations that signed on to the November 3 letter:

  • Community Anti-Drug Coalitions of America
  • International Certification and Reciprocity Consortium
  • Faces & Voices of Recovery
  • Harm Reduction Coalition
  • Legal Action Center
  • NAADAC — The Association for Addiction Professionals
  • National Addiction Studies Accreditation Commission
  • National Association of Addiction Treatment Providers
  • National Association for Children of Alcoholics
  • National Association of State Alcohol and Drug Abuse Directors
  • National Association of Drug Court Professionals
  • National TASC
  • Partnership for Drug-Free Kids
  • Treatment Communities of America
  • Young People in Recovery

The gun issue

Mark Covall, president and CEO of the National Association of Psychiatric Health Systems, explained why it is important to change HIPAA. “Our members continue to tell us that one of the big barriers to engaging the family and helping the individual is HIPAA,” he told ADAW. “The way HIPAA is structured, there is a real barrier to treatment and it’s resulted in individuals not getting the treatment they need.”

Conceding that it is gun violence, and not the need for more treatment for patients, that has made mental health reform “front and center” now, Covall paraphrased the words of Sen. Chris Murphy (D-Connecticut), who has a similar bill in the Senate: “He said, ‘I am not going to apologize for the way that mental health issues have got to the forefront, which is these mass murders — I’m not going to apologize because we do know that the mental health system is broken.’”

Recognizing that only a small percentage of people with mental illness are violent, Covall said, it’s been important to avoid the stigma associated with this link. “If this is used negatively, we’re against it,” he said. “But what we’re trying to do is improve the system, get people access to treatment. Would we rather that this was based on real need? Obviously. But if this can drive positive change, we are for it.”

The National Association of State Mental Health Program Directors (NASMHPD) also is concerned about stigma. “NASMHPD is supportive of efforts to strengthen the mental health system,” said Executive Director Brian M. Hepburn, M.D. “However, we are not supportive of stigmatizing persons with mental illness by saying these efforts will reduce violence.”

Gutting SAMHSA, 42 CFR Part 2

However, NASMHPD supports the language in the bill that “elevates the SAMHSA Administrator to Assistant Secretary status, in order to augment SAMHSA’s statutory authority to coordinate the 112 programs targeting the needs of individuals with serious mental illness administered by various federal agencies,” he said.

Meanwhile, there was little talk of 42 CFR Part 2, the confidentiality protections applying to SUD patient records, with talk of even the much weaker HIPAA being weakened even more. The mental health field doesn’t support 42 CFR Part 2, wants part of the SAPT block grant and is going along with AOT — which it formerly opposed — in order to get the increased treatment availability. The people still supporting 42 CFR Part 2 are now fighting even more basic battles — for the very treatment itself.

Sea change in mental health

The Murphy bill has made for some strange bedfellows, with many new supporters since the Newtown massacre. The Treatment Advocacy Center (TAC), which opposes SAMHSA and supports AOT, has always supported Representative Murphy. But the TAC, which patient advocates had viewed as not respecting the civil rights of people with mental illness, now has plenty of company.

On November 3, mainstream mental health organizations wrote a guest editorial for the conservative newspaper The Washington Times, supporting the bill. The piece, by Covall, along with Saul Levin, M.D., CEO and medical director of the American Psychiatric Association; Paul Gionfriddo, president and CEO of Mental Health America; Mary Giliberti, executive director of the National Alliance on Mental Illness; and Barry S. Anton, Ph.D., president of the American Psychological Association, called for mental health reform as represented by the Murphy bill.

Funding

Meanwhile, there are still questions about how this increased treatment would be paid for.

The Congressional Budget Office estimated that the previous version of the bill would cost $3 billion, but if it included a repeal of the Institutions for Mental Diseases exclusion, it would cost up to $66 billion over 10 years due to increased Medicaid costs.

“America is in dire need of additional mental health and addiction treatment investment,” said Chuck Ingoglia of the National Council for Behavioral Health. “Demand for services is higher than ever, yet our nation’s treatment system has been crippled by decades of funding cuts. As a result, each year, 60 percent of Americans living with mental illness and 90 percent of those with addiction don’t get the care they need.”

The National Council had supported the Murphy bill but was disappointed by the elimination of the expansion of the 2014 Excellence in Mental Health Act from the latest revision to the Murphy bill, as well as the elimination of incentives for behavioral health providers to adopt electronic health records. Said Ingoglia: “We recognize that members of Congress face a difficult funding environment; yet, reform cannot succeed if it does not address the funding shortfall that is jeopardizing the health of the nation.”

To track the progress of the Murphy bill, go to https://www.congress.gov/bill/114th-congress/house-bill/2646.

For the October 23 letter from Democrats discussing their opposition to certain provisions of the Murphy bill, go to http://matsui.house.gov/uploads/Mental%20Health%20Letter%20to%20Upton%20and%20Pallone%2010.23.15.pdf.

Bottom Line…

Murphy bill analysis: In addition to adding treatment for mental illness, does mental health reform have to mean weakening privacy for patients, using SUD treatment funds and relying on a link between mental illness and gun violence?