 Today's talk will be the first talk of the spring quarter, even if it's still a bit chilly outside. This has been a talk that I've been looking forward to and waiting to hear about on the topic of the Affordable Care Act and treatment for patients with mental illnesses. The full title then goes on to say, is the glass half full or half empty? Our speaker today is Professor Mark Hyerman from the law school at the University of Chicago. Professor Hyerman received his JD from the University of Chicago in 1977 and after practicing criminal law Professor Hyerman returned to the law school as a clinical teacher in 1978. His principal focus has involved teaching advocacy to students in the law school's mental clinic by supervising them in litigation but also in legislative advocacy, both on behalf of persons with mental illness. Professor Hyerman is on the boards of the Mental Health America and the Mental Health America of Illinois programs. In 1988, he served as the executive director of the governor's commission to revise the mental health code of Illinois. That was a position in which there were 20 commissioners and Professor Hyerman was in charge of a very difficult to manage group of 20 of the leading legal scholars in the state including the dean of the law school at the time, Norval Morris. Professor Hyerman has been actively involved in clinical legal education and in the movement for it. He's a founder of the Clinical Legal Education Association, served on its board for seven years. He's worked to use the accreditation process to encourage law schools to devote more of their resources to preparing students to practice law adequately and effectively. As I said earlier, you see the topic up behind me. Professor Hyerman will be speaking on the Affordable Care Act and the treatment of mental illness. Please join me in welcoming Professor Mark Hyerman. Good afternoon. So the answer to the question is yes. The talk is going to be a bit of a ping-pong. The good news, the bad news, and then maybe the good news again. And so you'll be up and down. It'll be a little bit bipolar for those of you. So the good news in summary, as you know, one of the elements of the Affordable Care Act is allows states to opt with a lot of money from the federal government to expand Medicaid and that will help lots of millions of people. I'll talk about the details in a minute. A second important element is vast improvement in the number of people with serious mental illnesses who will get traditional insurance through the private market. And then a greater coverage of mental illnesses is going to have a dramatic effect on the huge number of mentally ill people in the criminal justice system about which much has been written in Chicago and across the country recently because we have a sheriff who has been on practically every news media in the world talking about all the mentally ill people in Cook County Jail. So the expansion of Medicaid, here are some of the numbers. So we have about 18 million people nationwide will be newly eligible for coverage under the Medicaid expansion provisions. And a huge number of these people are people with serious mental illnesses or with psychological distress or with substance abuse disorders. So we're talking millions of people across the country who do not have coverage, are not covered, are not on Medicaid. No one will pay for their mental health care and now they will be covered in those states where Medicaid is expanding. In Illinois, which as you probably know is one of the 25 states that elected to expand its Medicaid program, so roughly half the states or exactly half the states expanded, we have about over 600,000 people will be newly eligible and again, quite substantial numbers of people with behavioral health conditions. So that'll have a dramatic effect on people with these conditions in Illinois and those who must provide care for them. So the other thing that people have already begun to see is the so-called woodwork effect or the welcoming effect which is that if we make the whole Medicaid system more welcoming, if with all the publicity there's been over Medicaid expansion, particularly in the states where there has been Medicaid expansion, that lots of folks who are eligible for Medicaid and are not getting it and there are quite a few of these folks. So again in Illinois, three-quarters of a million people are eligible for Medicaid and not enrolled. That's a huge number of people and lots of those folks have serious mental illnesses, psychological distress and already we're beginning to see those folks who are getting registered for traditional Medicaid, that is they were always eligible for Medicaid which is up to 100% of the poverty level. So then of course we have the health insurance marketplace and again we have 19.2 million people nationwide newly eligible for health insurance under the marketplace provisions and again millions of people, more than 6 million people with some kind of behavioral health condition will be eligible for coverage under the insurance marketplace and several hundred thousand, roughly a quarter of a million people in Illinois with behavioral health conditions can get insurance under the marketplace. Now one of the things that has been has been particularly difficult for people with mental health conditions has been the fact that most insurance companies for fairly understandable reasons do not cover pre-existing conditions and serious mental illnesses, the most serious mental illnesses such as schizophrenia and bipolar disorder have a relatively early onset from the late teens to the late twenties. So that means that just as you're beginning to go out and wanting to buy private insurance in the traditional marketplace you won't be able to get it because you already will have been diagnosed with one of these illnesses and show insurance won't cover it. So one of the key elements in the Affordable Care Act for people with serious mental illnesses is that insurance companies will no longer be able to say oh, you already have a condition, we will not cover you. And so that will enable lots of folks with serious mental illnesses to get coverage who were not previously able to get coverage. And all of the policies issued under the exchange are going to require mental health coverage. We'll talk about some of the problems with this in a minute when we get to the bad parts. Okay, so then this is a really big thing in every state. And we have read lots about it in Illinois. It's huge numbers of people. It's a huge expense for taxpayers on the state, federal and local level. And it is the huge number of people with serious mental illnesses who were in the criminal justice system. You can't attribute the fact... I mean, so no reason that all of you should be criminal justice experts. But the United States incarcerates a higher percentage of its population than any other country in the world. With the possible exception in North Korea, we can't get good data from them. If any of you have that data, you'll let me know. But I suspect if you get it, you won't be coming back. It used to be true that the Soviet Union had a higher per capita incarceration, but the Soviet Union is no more. And so they don't do that. And South Africa was a way ahead of us before the end of apartheid. So, of course, there are a variety of reasons why we have so many people locked up in prisons. And it's not all due to people with mental illnesses, but we have a substantial number of people with mental illnesses who are locked up in prisons and jails. And here are some of the numbers. So Cook County is a jail, is the largest mental hospital in Illinois. So again, when Sheriff Dart talks about this, he says, well, 2,000 are the number of people out of 10,000 people who are in the jail on any day. 2,000 are people who are getting prescribed psychotropic medication. So the jail, even though the jail has no particular incentive to hunt down people with mental illnesses, because if they diagnose someone with a mental illness, they're then constitutionally and statutorily obligated to treat them. So most prisons and jails have an incentive to under-diagnose all healthcare conditions for that fairly obvious reason. But Sheriff Dart's pretty open about this. He says, no, the answer is we really have about 3,000 people with mental illnesses in our jail on any given day. And again, we only have 1,200 state psychiatric hospitals in Illinois. And so that one jail is bigger than the entire state mental health system in Illinois. And again, there are many ways in which we often say in Illinois, thank God for Mississippi. Although I've heard in Mississippi they are changing their license plate to thank God for Illinois. But in this regard, we're no different than anyone else. California has the same problem, New York has the same problem. Every part of the country has lots of folks with serious mental illnesses in their prisons and jails. And of course, the problem is this covers a whole range of folks. People with lots of different diagnosis and people with lots of different criminal acts. Of course, you read in the newspaper some horrible tragedies of people with serious untreated mental illnesses who commit quite serious crimes. But what Sheriff Dart and other sheriffs who run jails complain about is that they're stuck with a pretty high number of folks who have committed relatively trivial crimes end up in the jail. And many of these crimes are fairly clearly attributed to untreated mental illness. Untreated mental illness about a third of people who are homeless are, their mental illnesses causally related to their homelessness. There are more people than that who are homeless who have mental illness but the causal direction is the other way. Homelessness is not great for your mental health. And so what happens is these folks may break into an abandoned building to get out of the cold. It has been cold in Chicago lately, I've noticed. And so people try to find some place, of course, if you break into an abandoned building, that's a crime. It's a crime. And you will be arrested. And there are lots of other relatively trivial crimes for which people are arrested, which are caused by untreated mental illnesses. And so one of the problems is, well, we have all kinds of systems in the criminal justice system that are designed to sort people. And one of the very first systems we have is most people who are charged with crimes get out on bail. But judges who make these decisions are reluctant to let people out of pretrial detention because they're fearful that their mental illnesses will prevent them. Their untreated mental illness will prevent them from showing up. And so they don't get out on bail. And so again, these are folks who then we must pay for in our jail mostly with our state tax dollars. And again, when we get to probation, a huge percentage of crimes the judge can sentence you to probation. Certainly that's true for the trivial crimes that are in bullet point number one. But if we don't think you're going to show up and if you have a history of not showing up for probation, then what are we going to do? And part of the problem that every probation officer will tell you is, well, I know what mental health services this person needs, but I can't get him or her those services. Problems get worse. So mentally ill people don't do well in prisons for a whole host of reasons. They're often victims of crime. So here's the basic problem with the criminal justice system and the mental health system. We'll talk philosophy. So the criminal justice system for darn good reasons is based on the idea that people have free will and there are no exceptions to that or there are rare exceptions to that and if we want people to engage in good behavior inside of a prison we will punish them when they don't follow the rules. And so who doesn't follow the rules in a prison? People with untreated mental illnesses. And so one of the things that, for example, this is a horror story that we relatively recently fixed. Illinois, like many other states, decided we were going to have a supermax prison called TAMS. Many other states have such a prison. The federal government has such a prison. And the basic modality of TAMS was sensory deprivation. So the idea was everyone's in a single cell. Light is let in but the window is not really a window and you can't see anything. It's a screen that prevents you from seeing trees, the sun, blue sky, a bird and the door is made so that you can't see inmates or correctional officers walking by and they pipe in white noise so that you can't talk to the guy in the cell next to you. It's all designed to completely isolate you from every other human being 23 hours a day and then for one hour correctional officers will take you by yourself to a small exercise room where by yourself you can walk around and get exercise. And the theory behind these supermax prisons is not crazy. That is the theory. The practice might be crazy. But the theory is not crazy. The theory was that no one would want to go to a prison like this. And so the really bad apples in every other prison would say, we don't want to go there, we've heard how horrible it is and so they would behave themselves. So it wasn't thought that this would be good for anyone. In fact it was thought it would be bad for people but its reputation would be so horrible that the general behavioral level in all other prisons in the state would improve. So again, who ended up in the supermax? Not people who had committed murders. Not people who were involved in gangs. They all know how to follow the rules. The people who end up in... So any of you play the game of hearts? You get to pass the three cards you don't like to the right. So the warden of every prison passed the inmates that made the most trouble failed to follow the rules to Tams. And then they just never got out because they continued to not follow the rules even in this horrible place. Finally we closed it. So that's an exaggerated part of the criminal justice system but the criminal justice system is designed to punish people. And so if you have someone with serious depression in a prison and they get better, then we take them out of the mental health part of the prison and we put them in the regular prison so that we can make them feel badly. That's the goal of being in prison is to make you feel bad. If it makes you feel good, we're failing. So it doesn't work so well. And so that's one of the problems. And so every state has this problem all the way to the Supreme Court just a few years ago in Brown versus Plata. The whole California prison system ordered to release tens of thousands of very dangerous people because after ten years of litigation that California couldn't raise enough taxes to cover the health care and mental health care needs of the prisoners. It's extremely expensive to deliver mental health services in a prison. And it's not particularly politically popular. So not very many people run for governor. You should pay attention to the candidates because we are coming up and see whether any of the people running for governor say I will raise your taxes so that we can provide better health care in our prisons. Okay? I'm confident that no one's running on that platform and neither is anyone in the state legislature. So that's one of the reasons that courts get involved in ordering prisoners to do this. But almost every prison in the country has been the subject of suits over their lack of or their inadequate health care and particularly including mental health care. So how's the ACA going to fix this? Well, one of the main reasons that people with mental illnesses get in the criminal justice system is that 90% of them don't have any insurance. They're not on Medicaid. They're not eligible for traditional Medicaid. But in states which choose to expand Medicaid about 90% of the people who are coming in and out of our criminal justice system will be eligible for Medicaid or private insurance. And so while this isn't going to fix everything we'll talk about why it won't when I get to the bad news shortly. But it will have a substantial positive effect on people with mental illnesses and keeping them out of the criminal justice system. Now, we also have a whole... We have developed... As we have increased the number of mentally ill people in the criminal justice system there's been a lot of pushback. It's so expensive. Judges don't like to have many ill people in their criminal courtrooms. The sheriff doesn't like to have them in his jail because they're expensive and they're hard to handle. The prisons don't like them. And so we've developed a whole bunch of things that are designed to get mentally ill people or keep mentally ill people out of the criminal justice system. This is the thing that now the magic phrase that everyone uses across the country is the sequential intercept model which is just a fancy word for saying we intervene everywhere we can. And preferably we intervene as soon as we can and only intervene later if we weren't able to steer you out of the criminal justice system at an early stage. So the earliest stage of the criminal justice system is when the police come to arrest you. And one of the things that we have done is to improve dramatically the training for people, for police officers to deal with people with serious mental illnesses. We have a long way to go. If any of you read today's New York Times there's a big article about police and mentally ill folks. But here in Chicago we are doing the state-of-the-art training. We're not doing enough of it. And it's designed to train police officers to identify folks who are mentally ill and to have reasonably appropriate responses and know when they need to call in help. But here's the problem. So if you think about these low-level crimes here's a typical scenario that a police officer faces. And police officers are often the first line of interaction for people who are having a serious mental health crisis. That has been true for a long, long time. It is certainly true today all over the country. And rural areas and city areas. Someone is out of control. They call the police. Whatever. Here's the scenario. So someone with a serious untreated mental illness goes into a restaurant, sits, won't leave. A restaurant owner says to him, leave. If you don't leave a restaurant when the restaurant owner tells you to leave you're committing a crime. You may not know that, but you are. It's trespass. The restaurant owner doesn't particularly want to prosecute you. He wants you gone. He wants you out of his restaurant. Perhaps you might not be behaving in the way that he would like to ascribe to his clientele, whatever it is, doesn't much matter. Restaurant owners can do that. So they call the police. The police officer says to the restaurant owner, well, do you want to press charges? The restaurant owner says, well, not really. I just want, please just remove this guy. So that gives the police department, because they have no one who's really interested in making this into a big deal, discretion. They can take this person into the criminal justice system, charge him with trespass. Or they can take him to mental health facilities. If there are mental health facilities. And of course, the problem is that so many of these folks are not going to be eligible for Medicaid under current arrangements, but will be eligible for Medicaid in the 25 states, including Illinois, who have done the Medicaid expansion. Indeed, there's a wonderful piece of research that basically just says what I told you. This group of researchers from Northwestern basically sent graduate students to ride along with the police. They were sworn to anonymity about which city they were doing this in. What I can tell you, it's a large city near a big lake. And could be Cleveland, Milwaukee. And they did. And they watched how police behaved with folks with mental illnesses. And of course, police encountered lots of folks with mental illnesses. And what they basically observed is if the police thought that the person would be accepted into the mental health system, they would be thrilled to take them there. But what the police don't want to have happen is to have the person come back and be back right in their district on the same shift so they have to arrest them the second time. And so we have to have a place to take folks, and if we don't. So that's something that will be improved by the Affordable Care Act Medicaid expansion. Similarly, with people released on bond, the state is in the process. Most of the people who are found unfit to stand trial, which is hundreds of, as I said, we only have 1,200 beds in our state psychiatric hospitals. More than half of them are eaten up by people coming out of the criminal justice system. More than a quarter of them are over 300 are people who are unfit to stand trial. Lots of those people don't need to be in a hospital to be treated to be restored to fitness to stand trial on their criminal charges. But we have no place to put them. And so again, this is another way that will free up beds in our state psychiatric hospitals for people who don't really need to be there. Another really wonderful innovation that is spreading across the country, which has been quite successful, are so-called mental health courts. These are not commitment courts. These are criminal courts modeled after drug courts. And what they do is, early after arrest, they identify people, usually people who are in the jail for reasons I'll say, not people who are out on bond, who have a serious mental illness and they think the mental illness is causative of their criminal justice involvement. And with the agreement of the defendant, folks are put on special mental health probation with a whole team that works on this. And again, this is spreading across the country. We have a dozen counties in Illinois out of the 102 that have started mental health court programs. Right if you're here in Cook County, but in some sense, they're all pilot programs in the sense that if you ask anyone who's involved in participating in these programs or administering this program, they would say, oh, yeah, yeah, yeah, we could handle that as we... There are 10 times as many people who would be appropriate for a mental health court program. But we don't have the capacity to do it. We don't have the treatment resources. And again, that will be helped by having Medicaid expansion pay for all this. Now, there's the bad news. Half of the states have refused to expand Medicaid. Even with Medicaid, we often fail to pay for the things that we know work. We've always done that. And insurance companies similarly fail to pay for mental health interventions that work. We'll talk about the details of that. We have a lack of providers, scarcity of psychiatrists, primary care physicians who treat the vast majority of people with mental illnesses are not treated by psychiatrists for a whole host of reasons. They get relatively little training in psychiatry. I suppose I shouldn't come over to a medical school and make this complaint, but lawyers get zero training in mental health so you can have back at me. And we pay low rates and that, of course, helps to discourage the provision of services and fails to attract sufficient providers of all different kinds, including psychiatrists. Lack of care coordination and system management. We'll talk about these in turn. So as those of you who follow the legal parts of this know, the original Affordable Care Act as written basically said to the states, you either expand your Medicaid program or you must give up your entire Medicaid. Okay? It's a fine choice. You have a free choice, so we're not trying to coerce you in any way. And the Supreme Court said that was too much coercion. And so in upholding the Affordable Care Act in its long and complicated opinion, one of the key elements is that the Supreme Court said that states could choose not to expand Medicaid and what they would lose from that is the federal participation in that expansion, not the federal participation in all of the rest of Medicaid. So 25 states have thus far chosen not to expand Medicaid. So again, we have three-quarters of a million people who have serious mental illnesses are not covered because they're in an opt-out state or a failure to opt-in state. And over a million and a half people with serious psychological distress and over a million and a quarter people or a million and a third people with substance abuse disorder. So those are all people who, if those 25 states had said yes, would be covered under Medicaid, but because thus far they have not said yes, they are not covered under Medicaid. That's a huge number of people. So when you listen to advocates about this, you know, they sometimes over the top, here's one of the articles that dashed hopes, broken promises, more despair. This is an assessment of the Affordable Care Act in mental illnesses. This is the glasses half-empty because of the 25 states that haven't done this. So it's true that if you're in one of those states, they've missed a big opportunity to help the mental health system. Okay. Now, the failure to pay for needed services. Well, this has been true for a long time and the problem with Medicare and Medicaid are the first four letters, medical. So we know, for example, that psychotropic medications are highly effective in treating people with mental illnesses, but with the most serious mental illnesses, we know that that is never going to be enough. And particularly with people with schizophrenia and bipolar, there are lots of other services which the medical model has traditionally not covered. Medicaid and Medicare have not consistently covered and private insurance don't cover. And basically, one of the ways of sort of complaints about why is it that the United States has such a badly ranked health care system compared to countries that supposedly have better, they all provide lots of social services with their health care, France notoriously or famously or wonderfully does lots of social services along with people who get health care from the government. And this is something that's particularly important for people with serious mental illnesses. So if I can give a completely unfair stereotype of what often happens to people who are first diagnosed with schizophrenia, but it's only a mild exaggeration, they have a serious episode, they're first, they have psychosis, hallucinations, delusions, whatever. They appropriately need to be in the hospital because they're in a crisis, they're hospitalized, the doctor appropriately diagnoses them with schizophrenia, and more or less says, your life is over. Go to a community mental health provider where they'll give you medication once a month and group therapy twice a month. That's your life. And it gets better. Almost all of the medications have serious side effects. Your life will be shortened by 15 to 25 years. But you should go, it's great. And so we are shocked, shocked to learn that lots of people who get that message don't show up at community mental health providers and don't say, oh my gosh, what a wonderful community mental health system we have. I love it. And what we have learned, but not quite done, consistently, and certainly not in Illinois, but we haven't really done this anywhere, is to do the kinds of things that we know that keep people engaged. So if we assume that for people with the most serious mental illnesses, it is likely to be true that medication is going to be a necessary part of their treatment, the question is how are you going to keep people engaged so that they will willingly take the medication despite the side effects? And the answer is you must offer a variety of things that practically anyone else, anyone of us, would like. A safe place to live, the opportunity for a job, and some social life. So that's peer support services, social life, supportive housing, supportive employment. And in fact, there's a huge amount of research that show that these services are as effective or more effective than psychotropic medication in keeping people with serious mental illnesses connected to the mental health system, out of mental hospitals, out of homelessness. Now, in many states, the Medicaid program will cover some of these services, but the federal government doesn't always permit that because the federal government in the end decides what states can do and we'll talk more about that in a minute. So with these limitations, we got problems. So just to say, okay, now you have Medicaid, you can go to a mental health provider. If we don't offer the right array of services, we're not going to fix our broken mental health system. That's the way in which I guess I agree with this. We haven't quite done it. So the other thing that's fairly clear is, and there are lots of debates about how much coercion there should be in the mental health system. Should there be any? There are some people who say zero and there are some that say we should have a whole heck of a lot. Most people think that for some people with serious mental illnesses, there will be occasions in which they need to be involuntarily committed to a psychiatric hospital and or have an involuntary court order of medication to help them, okay? Most states have legal... Well, every state has an involuntary commitment statute. Every state's commitment statute is a little different. Most states have some kind of involuntary medication statute. The question is who's going to pay for all that? So our traditional system is the people with the most serious mental illnesses were always in state hospitals and the state hospital employees, including the psychiatrists and the psychologists who may participate in involuntary treatment, are staff and are salaried and this is considered part of their job. But suppose now we have people who, more and more people who will be eligible for Medicaid, presumably more private hospitals will accept them and get paid for them. But none of the third-party payers will pay for the costs associated with involuntary treatment. So just to explain what those medical costs are, we won't talk about the judges since we get to pay for the judges with our tax dollars. But the medical costs are, the psychiatrists or psychologists have to go and testify. We don't commit people without an expert who knows something about the patient and knows something about his or her need for involuntary treatment. And so that time is all uncompensated. Medicaid doesn't pay for it, Blue Cross doesn't pay for it, Medicare doesn't pay for it. And so as it is likely, we'll talk about this more, that as we go more toward a private insurance system that covers mental illnesses and a Medicaid system that covers more people with mental illnesses, we will have even fewer people in state hospitals. And so the question is, what are we going to do with what I think is, one hopes is a relatively small number of people, but still some of the people with the most serious mental illnesses who need involuntary treatment. And somehow the states are going to have to figure that out and let's just say they haven't. So we have an example in Illinois of the failure to figure this out. So Illinois, it might be because the president is from here, the state of Illinois convinced the federal government, the Center for Medicare and Medicaid Services, CMS, to give us a waiver to start the Medicaid expansion in Cook County alone one year early. So now all of a sudden people up to 138% of poverty are covered under Medicaid in Cook County and this was true for all of last year. So Cook County created county care and there's no question that county care had many positive effects. It reduced expenditures inside county hospital so reduced for those of us who pay taxes in Cook County, this is good. We're shifting those taxes to Washington where we can share them with the other 49 states. But what did county care do? They subcontracted all their behavioral health care services to a private managed care entity that had a great deal of experience for managing behavioral health for private insurance companies. But those are typically not people with very serious mental illnesses. And so this entity refused to pay for any of these social supports so most of the, or many of the not-for-profits that are highly regarded in Cook County in Chicago that provide care to people with serious mental illnesses basically said we're not doing it. We're not serving people under county care because they need A, B, C, D and E. And county care won't pay for this and it's incompetent for us to be only offering A when we need A, B, C, D and E. And then some of you may have read there are people in the audience who've been participating in this campaign. The city closed six of its clinics and the remaining six clinics have taken the position that they won't take Medicaid. Either the traditional Medicaid or the expanded Medicaid. There is some logic to that but we'll get to why that logic doesn't go too far. You can have logic and still end up with a bad result and I will, in a minute, I'll explain the logic and explain why that ends up with nonsense or let's just say it ends up with really bad care for people with serious mental illnesses. So lack of providers. So we have a tiny number of psychiatrists in Illinois. I have a map of the state that shows out of the 102 counties in Illinois more than 75 of them are dramatically underserved by psychiatry particularly a shortage of child psychiatrists particularly once you get out of big cities of which Illinois doesn't have that many. We're in one but we don't have that many. So part of the problem is that we have always had low reimbursement rates the Medicaid reimbursement rates have been so low in Illinois that there are very few psychiatrists who will take what I call naked Medicaid. Meaning I'll sit in my office and I'm happy to take anyone who can pay who has Blue Cross, who has Medicare, who has Medicaid, the number of those folks who will take Medicaid is almost zero. So you can get to see a psychiatrist if you go to a community mental health provider and they hire a psychiatrist and pay him or her a salary and bill Medicaid and eat the difference by holding bake sales. That's how we fund our mental health system. We hold bake sales at Thresholds and C4 and Trilogy and the other community mental health providers in this state, in this county and there are hospitals that will pay psychiatrists and bill Medicaid but in fact there are very few freestanding psychiatrists who will take Medicaid because the rates are so low. So we have one other sort of complicating factor which is the so-called IMD exclusion. The IMD exclusion is IMD stands for the Institutes for Mental Diseases and this is an anomaly or a provision in Medicaid law that has existed since Medicaid was invented. So when the Medicaid law was passed, every state had state operated, state funding, all with state tax dollars, psychiatric hospitals. Every state had at least one. States like Illinois had many. We used to have 35,000 state psychiatric hospital beds and now we have 1,200. Basically every state had this system and the federal government launching what was then and certainly is now one of the largest federal programs said we're not going to take on the responsibility of paying for all your state psychiatric hospitals. We want you to maintain that effort and notice that almost no, you can talk about whether this is discrimination, but almost no state, none that I'm aware of, operates non-psychiatric hospitals. I'm pretty sure Illinois has never done so. Some counties do. We have Cook County Hospital. Some cities do. So New York has hospitals. I think San Francisco has a hospital. But as a general matter, the government, state and local government has not operated hospitals other than psychiatric hospitals. So this was not done in my view, and I'm always looking out for discrimination against people with mental illnesses, but I don't think this was done discriminatorily. It was a maintenance of effort thing. But it has had the following effect. So what the federal government said was they created this IMD exclusion and it says if you're running a residential facility where more than half of the residents have a primary diagnosis of mental illness and it's over a certain size, then no one in that facility will be eligible for Medicaid. So basically that excludes every state psychiatric hospital. It also excludes some nursing homes, famously in Illinois, which this has been in the news a lot, and it excludes freestanding psychiatric hospitals. But it allows hospitals like the one we're in, or Northwestern or any other private hospital to have a psychiatric department and be reimbursed under Medicaid. So it basically encourages the state to say in Illinois is not stupid in this regard. I said in this regard. It encourages states to say we will not take anyone with Medicaid into our facilities because we will send them to private hospitals because then typically we have to pay 50 cents on the dollar. The federal government will pay the other 50 cents. It'll be better off for us. And of course under expanded Medicaid, at least for a number of years, the federal government is paying 100 cents on the dollar and then going down to 90 cents on the dollar. So if anything there's more of an incentive for the states to say we don't have enough of this business. Now you could argue this the other way around. I mean if I have a budget and I don't have a lot of money and the federal government says I'm paying for food stamps, that doesn't mean that does that mean that I get to buy more or less clothes? We refuse to subsidize your clothes, we'll subsidize your food. I take it the federal government's goal is to spend less on clothes just because they've chosen not to subsidize it. So in theory, the states were responsible for all mental health services before Medicaid. And in theory you could have seen an increase in the number of state hospital beds because all of a sudden they're relieved with the entire obligation of treating anyone in a private hospital, anyone in the community who's eligible for Medicaid and so now they have lots more money. But in fact the state said well we don't think we should continue to do this for a variety of reasons that are quite complicated and I won't belabor today. So this is another serious problem. So when we're talking about serious mental illnesses again the scenario is you cannot simply say oh I'm a point of service provider I'm a point of service provider you want care for me no if you're talking about people with serious mental illnesses you have to think about care coordination in a very serious manner. So no one thinks that you can discharge someone from a psychiatric hospital with a serious mental illness without making sure that she or he is seriously linked to a community mental health provider. The problem is who's going to pay for all that. So hospitals haven't been paid for that and they have little or no ability to coerce community mental health providers into doing this. So one of the things that's been true in Illinois that private hospitals have justifiably complained about is that the state has funded community mental health providers for decades and decades and decades as they have downsized their state hospital system and what they say to every one of these publicly funded community mental health providers is you must give first dibs to our people meaning people coming from a state hospital and after that you can serve people who are otherwise eligible and so if we have inadequate services inadequate funding which we have always had in the community mental health field by a whole heck of a lot what that means is it's very difficult for folks leaving a private hospital with Medicaid to get prompt and serious linkage to the community. It often just doesn't happen to say you have an appointment three months from now is not going to work for someone with schizophrenia. Just won't. So it gets worse the failure to get appropriate mental health services often exacerbates non-psychiatric conditions there's a huge core morbidity with other chronic treatable but incurable illnesses or generally incurable we can cure some of these things and so there has been no particular financial incentive to hospitals to do anything about this. Their job is to treat people when they come in the door make sure they get the best treatment they can and then discharge them when they're appropriate for discharge. So the problem is that no one's in charge and what happened in the city of Chicago is a perfect example of that we had the city deciding to close six clinics because of inadequate funding from the state we lost several private not-for-profit so if you want to say where was the worst that had happened right here we lost the Woodlawn Mental Health Center and then we lost the Community Mental Health Council a private not-for-profit the Woodlawn was the city clinic and the city position was well we'll offer services but it's not our job to be in charge and the state's position is well we'll fund services but it's not our job to be in charge and so the part of the problem is that someone needs to make sure that there is there are appropriate services provided in every geographic area of the city of the state there are lots of things you can do creatively so Illinois has passed telehealth and telepsychiatry is quite effective in dealing with people that works quite well in rural areas etc but still in the end of the day someone must be responsible for making sure that in every part of the state we connect people and again what happened when the city closed its six clinics did they make sure that every single person got connected to another community mental health provider the answer is no and we have no idea where many of these people are and no one felt it was their job to make sure that that happened and it leads to the extent that the state was doing more of this through its mental health authority they were doing more of this so they funded state hospitals they funded community providers if you came back too quickly they bore the costs of your coming back too quickly but as we have downstied our state hospitals and gotten our mental health authority out of funding community health we now have our Medicaid authority funding community mental health Medicaid just thinks of itself as being Blue Cross they pay for services for appropriate people and so there's no one who says it's my job to make sure that we have a functioning mental health system in Illinois or Chicago or Cook County or basically anywhere in the country so now we'll get to the other ping in the ping pong there are some good news so it took six years for all 50 states to have the original Medicaid program you young folks don't remember this but I remember distinctly that there were lots of states who said this is a completely stupid idea we don't want to be involved with the federal government telling us how to help provide healthcare to poor people that's our job and we'd rather turn down millions and millions and millions or hundreds of millions of dollars than have the federal government involved but notice what happens to you thank you Indiana all your federal tax dollars are coming to Illinois we're happy to have them thank you Wisconsin all your federal tax dollars are coming to Illinois and notice that while there are problems created by all of this new money in different ways shortage of providers we've talked about that if the money gets spent in Illinois suppose it attracts more mental health providers psychiatrists, psychologists, social workers peer support services all of the things that we know work suppose we're spending more money on all those things okay and all of that money at least for a couple of years is coming to the federal government or after that a huge percentage of it this is a huge new flow of money into Illinois everyone who's employed doing this and of course it's not just behavioral health it's all healthcare they got to buy groceries so I've heard they buy cars they buy all the things that everyone else does so all of a sudden we're stealing Indiana's money we're stealing Wisconsin's money it's my prediction that again I don't want to be seen as Pollyannish that a lot of states will realize that they don't really want to give all their money to Illinois there are a variety of reasons that I suspect many people in the audience understand that hospitals have to pay for lots of uncompensated care anyway you can't turn an emergency away from an emergency department it's illegal under federal law and so if you now have the people who are uncompensated being compensated by the federal government that's good for everyone in the state so it relieves a bunch of other things so there are some incentives in the Affordable Care Act to do more care coordination one of them is the optional health homes I think Illinois is going to do this and basically it says if you have one or more chronic conditions it gives incentives to the state to provide coordinated care which really is designed to make sure that people stay connected to the healthcare system people who are cost-curve in healthcare understand that if you have someone with diabetes who also has schizophrenia you better treat their schizophrenia or you won't be able to treat their diabetes they won't come they won't treat their hypertension and so health homes may do this as I suspect many people know in the hospital business there are now our penalties for excessive readmission rates under the Medicare program and there will be people with mental illnesses who will fall into that category if they don't get appropriate care in the community so hospitals across Illinois and other healthcare providers are already creating accountable care organizations that are designed to make sure that hospitals have access to community health services so that they don't get people coming back in and get penalized by the federal government and then there's another piece of good news so the federal government has always permitted waivers under Medicare I'm sorry, under Medicaid and so you can ask the federal government to pay for some of these non-traditional services if you can show them that they're cost-effective and so Illinois has just submitted a huge so-called section 1115 waiver in which they're attempting to get the federal government to allow them to pay for housing for people with serious illnesses and other supports needed to keep people connected to the mental health system I'm done Thank you very much for this antidote to the talk we heard from Dr. Chacar a few weeks ago which completely ignored the topic of mental health and when one member of this audience will remain unnamed asked about it he assured us that everybody who had been thrown out of the closed mental health clinic had been referred to another place it was being taken care of Yeah Right, exactly But anyway, I wanted to touch on something that you just said in passing when talking about the court system you said we get to pay for the judges with our tax dollars that you've kind of laughed at that but that is a fact that we do pay for judges with our tax dollars shouldn't we also be paying for healthcare for everyone with our tax dollars? Yes, the answer is clear I mean I suppose you know my view about the Affordable Care Act is in some sense it was a missed opportunity to have a better system but they have been quoted in the newspaper as saying this is the Affordable Care Act is the best thing that happened for people with mental illnesses in my lifetime and I'm not taking that back despite all of my long list of things that are wrong I mean most of the things that I think one way of summarizing what's wrong with the Affordable Care Act is it doesn't fix everything and it certainly doesn't make sure that every single person has access to decent mental health services that the mental health services they need that's a missed opportunity but will there be lots more services for people with mental illnesses the answer is clearly yes and will many of those services be better than the services available now the answer is clearly yes and we will save lives we will have fewer suicides we will have fewer people with mental illnesses who end up in the jail those are all good things so but we could have done better so I see your presentation focused mostly on the newly eligible for Medicaid if you could just give your opinion on for people who are just over the Medicaid income limit so they're buying into the plans with very generous tax credits and most likely one of the silver plans those silver plans are the ones with the cautionary reductions basically just using the safety net hospitals and even the richer silver plans are not including any teaching hospitals what does the mental health capacity of those hospitals look like is that further exacerbating the problem or is there actually are those good placement services for that population so this place doesn't have an inpatient psychiatric hospital so there are the answer is we really don't know so there are lots of people who have made a big spend a lot of time over the last number of years complaining vociferously about the lack of inpatient psychiatric capacity but it is extremely difficult to know what amount of inpatient psychiatric capacity we need because so much of that turns on what the rest of the mental health system is like so if I have someone with even the most serious mental illness and I discharge them to a really rich array of community mental health services they're not coming back very often and if I don't they're coming back a lot and then I don't have enough beds so there are decent private psychiatric hospitals indeed there is going to be a new expansion of hospitals on the south side not far from here I don't know offhand what the quality of that is but there are plenty of good ones and inpatient psychiatric care generally there are exceptions is a short term important intervention to get people stabilized so we can then connect them to what one hopes are a rich array of services in the community so so one of the things that's happened in Illinois which is particularly good is that the department of health care and family services which is our Medicaid agency has encouraged the creation of several different kinds of accountable care organizations which have different initials which I can't remember because I'm old and some of them have been created by behavioral health entities so thresholds for example which is widely regarded as being either the best or one of the best community mental health providers in the state certainly one of the largest they have partnered with hospitals across the state and other behavioral health entities so that together they can be responsible for a population but you know again the part of the problem is if your question is about geographic distribution that remains a problem we don't have hospitals that are reasonably close to people because not all hospitals have entered into one of these systems and again as I mentioned earlier we've had the closure of the city clinics and other private not-for-profits and so there aren't community providers that are geographically available I mean you don't want to say to someone who has got a very very serious mental illness oh now tomorrow you must go to a neighborhood you've never been in and God knows whether you even know how to get there and without some assistance in doing that and the same thing is going to be true for hospitals you need to make sure that they are linked in and I guess I don't care you know yes I would like every hospital to have inpatient psych I wish this hospital hadn't closed its inpatient psych particularly because it's a teaching hospital and I have smart people here What provisions are being made under ACA for dementia care and I assume that you're covering that under mental health maybe not whether dementia is a mental illness is not a clear question in Illinois by definition it's not but just under our state statute so I don't know that there's any particular arrangements for dementia care so one of the things that is clearly true is that Medicaid has been a funding stream for long-term care and so they are a principal funder of nursing homes unfortunately including many bad nursing homes and many bad nursing homes that care for people with dementia and Illinois notoriously and this really is not an answer to your question notoriously has put people with traditional mental illnesses more than any other state into nursing homes now we're moving away from that because of several lawsuits but I don't know that there's anything in particular in the Affordable Care Act which will affect dementia other than the fact that with the Medicaid expansion there will be more people eligible for long-term care I'm referring to the McLean Center website the most recent speaker in the series Tamara Kineska talked about long-term care issues not my area what are the proposals you want or CCB care coordination entities that's just one of them yes but thank you yes thank you and there's more yes for a wonderful presentation my question I guess relates to another category dementia then the category of developmentally disabled in some other presentations there was a speaker about the large percentage of developmentally disabled in the prisons and I wondered if you could comment on that I actually don't know that much about that there certainly are a large number of people with developmental disabilities in prisons and it's the problems and the solutions are different there for and I'll say what little I do know which is to say the principal difference between developmental disabilities and mental illnesses is we expect someone with even the most serious mental illness to get substantially better with treatment in a relatively short period of time but if you have a substantially low IQ with current technology expect you to get better we can always hope that there will be scientific discoveries that change all that but at the moment we're talking about a steady state and so the fight for developmental disabilities has been what is the what is the most integrated setting we can put people in but we're usually talking about folks who will almost always need to be in some form of residential placement and in Illinois we have continued to maintain large state operated developmental disabilities facilities and relatively recently we have started doing other more integrated residential facilities for people with developmental disabilities some of which are not so good it's not so clear to me what the effect of the Affordable Care Act will be on that I have to just say that I'm not sure if others in the audience are aware of this but in talking about how Cook County itself is expanding Medicaid a year early and how the managed care entity supporting that maybe didn't support mental health services in the best way it seems like that's maybe not the rest of the story and I'm curious what you know about how that will look going forward in the future so there actually is good news it appears that Cook County wants to continue to be an entity that's designated by the state and they have hired a much better entity to manage their behavioral health services it's a line I care so and again not perfect but much better than what happened under county care so Illinois has been in a process by mandated by state legislation of slowly moving more and more people on Medicaid into managed care so for some weird political reasons some years ago the Republicans were pushing this and so the Democrats said fine we will have managed care in the suburbs of Cook County and in the collar counties but not in areas controlled by Democrats you want managed care you can have people in your counties have it so a line I care in Etna where the two entities that were designated by the state and while I can give you a laundry list of complaints about things they didn't do they are way better than what happened in county care during the first year and my impression from talking to lots of folks is they're getting better every day it's a learning curve there is just this lack of understanding including with these two entities about what the kinds of services and what level of outreach you need to get people with serious mental illnesses engaged in these programs and the good news is that they're beginning to figure this out they're beginning to understand that there are people who know how to do this including some of the community mental health providers who have for example what is one of the things that a community mental health provider might do they might have a mobile assessment unit what's a mobile assessment unit they might go to lower Whacker and hunt down people who are homeless in the middle of winter and make sure they're okay and ask them if they need mental health services offer them some food in a decent place to stay and provide people who are paid to ride the subway to hunt for people who are homeless and mentally ill now we don't have enough of those folks and the question is who pays for that and so once you say to an entity you're responsible for this population well then if for them to be making money they have to actually have the population and so the complaint of high care was they couldn't find all their folks and so they figured out that places the community mental health providers know how to do that or some of them do on your last slide you mentioned like a half dozen sort of next steps in a way and one of the things to take home from your talk this is how complex this issue is so if you're trying to educate the broader public or the legislators you're coming up with your top two or three points or sort of priorities how do you frame it so one of the things that we have been saying to the legislature is that they need to have something they've never had a public health approach to mental health which is to say if you're in public health presumably you manage the number of people who have measles in the county and you're responsible for reducing that to the minimum and it seems to me what we don't have is either on the state level the county level, the C level they need to understand that having a payment mechanism isn't going to do that unless they restructure the payment mechanism so that's one thing then the second thing we've been saying to them consistently is that they have to actually think about the rate structure so one of the things that the federal government says to states in Medicaid is you can pay whatever you want and so in some states the Medicaid rate is not so for payment of doctors and other providers is not so substantially different from the Medicare rate but in Illinois it is substantially different and that discourages providers so we have been pushing for them to if you don't believe us do some research what is the level so the only control on this in terms of the federal government is the states are required to have services available and so Illinois was actually sued our Medicaid agency was sued and a federal judge found that we were not under our Medicaid program providing health care to children in Cook County and of course we had a Medicaid program for children in Cook County were required to but the rates were so low that no one was willing to provide services to them and so you can sue the federal government can enforce this or the Medicaid recipients can and to force rates that are reasonably calculated to get sufficient number of providers so those are two messages it is one you know have management arrangement and two figure out a rate structure I got a whole other long list but I think mostly what we're trying to think about is sort of let's see how this works because everything is a moving part at the moment and how it exactly works no one is going to know what you've just been talking about is the continuation of the continued system making it perhaps a little more efficient but there would still be a system for people who are on Medicaid who don't have the money and the private insurance companies which are I don't know what people get in terms of medical care depends on whether it's bronze, blue or whatever else but so I think that I hate somebody mentioned before but wouldn't any single-payer system take care of some of the things that you were talking about and at the same time you wouldn't have a two-tiered system I want to say I was a nurse at Cuccott and Hospitals for 18 years so I know what a two-tiered system is there was always a community to save Cuccott and Hospitals perpetual motion you don't have to convince me I'm a big fan of a single-payer system but this is what we have for now my suspicion is that we're neither going to repeal the Affordable Care Act which is in the Republican's budget just introduced yesterday nor are we going to go to a single-payer system in the foreseeable future but my suspicion is that this is a step down the road to that that after we see how this works I think people will recognize that there are in fact important health gains providing health coverage to millions of new people and that that will all be better off for that I really do think for example that we will save lots of money in the criminal justice system and and the question people will realize that and then the question is well there's still low-hanging fruit there that could be fixed with a single-payer system so that we really make sure that everyone gets all of the health care they need not excessive but all the health care they need so that we don't end up spending more for them there's a wonderful piece that seems to me sort of sums this up was in the New Yorker maybe a decade ago called Million Dollar Murray and there's unfortunately thousands of Million Dollar Murrays and many of whom I've met and this is a story of a guy who had behavioral health problems in Las Vegas and before he finally died fairly young from untreated mental and non-mental health problems the county figured out that they'd spent more than a million dollars on all of his he was arrested for trivial stuff like the stars some of you may have read in the Tribune about this woman who's been arrested 88 times all of them trivial clearly untreated mental illness trivial crimes she gets arrested almost the moment she gets out and no one is sort of saying yes it's expensive to provide the full array of services to engage this woman who is quite difficult ok so just saying come to my office is not going to work I'll give you medication that's not going to work but a sort of community treatment has been found to be quite effective with folks with even the most difficult mental illnesses thresholds tried this with a group of very high end users at the jail and reduced their recidivism by 75% that's a huge savings to taxpayers and it seems to me in the end of the day we will save money with this move and that may give us some momentum to make other moves but there isn't a will in this country to have a single-payer system at this moment I think the question is what's the next year look like what's the next five years look like and I think the answer is they're going to look pretty good and by that I mean we will see more problems but the services for people with serious mental illnesses will get better and other people let's thank Dr. Harman for a great talk