As the next state budget takes shape, Gov. Maggie Hassan and legislative leaders have been debating how to fund New Hampshire's mental health system. The state spends more than $100 million each year providing these services, and one word sums up the sentiment in the mental health community right now: uncertainty.
Case in point, a construction site at New Hampshire Hospital.
On any given day, a couple dozen people in a mental health crisis are stuck in emergency rooms across the state. To remedy that, a new 10-bed unit in Concord will be completed by the end of June. Bob MacLeod, CEO of New Hampshire Hospital, says the unit will cut the time it takes those patients to get from the emergency room to an in-patient bed, and then back home.
"That’s what this unit is designed for, is to get them in and get them out as quickly as we possibly can," says MacLeod.
To meet that goal, the new unit needs doctors, nurses and other staff, and when the state will fund their salaries is a point of contention among legislative budget negotiators.
With the right staff, how long would it take to fill this unit with patients?
"Today," says MacLeod. "Instantaneously, we could fill these beds."
Funding the settlement is a top priority
When this hospital was an asylum in the mid-1900s, it was the backbone of the state’s mental health system. But from the 1960s to the 1980s, federal laws shifted the care and funding for mental illness away from big institutions. This led to the creation of ten community mental health centers across the state aimed at treating people close to home, rather than in big institutions.
"There had to be a commitment for funding at that point," says Peter Evers, CEO of Riverbend Community Mental Health Center in Concord. "And that was the building of the community mental health centers."
Since the 1980s, the feds and state have been decreasing the amount of money they commit to centers like Riverbend, which provide the bulk of therapy, social work and other services for people with severe mental illness in New Hampshire.
"It’s a natural tension between a government and a service provider," says Evers. "We’re always going to think that we’re underfunded. And I believe that we have been because we’ve had so many busts in the economy in the past few years that we’ve had a reduction in services. And that brings us to the point we’re at now."
The point we’re at now is this: State services for mental illness were considered so bare bones that New Hampshire was sued in 2012 by the Department of Justice and the New Hampshire Disability Rights Center. In 2013, the state settled that case by promising to commit an extra $30 million over four years to certain services for people with mental illness.
Change on every front
Consider one of those services, something called Assertive Community Treatment, or ACT Teams – a group of clinicians who monitor a patient 24-7 in the community. The goal is to keep those people out of the ER and off the waiting list for in-patient beds. Peter Evers calls ACT Teams "hospitals without walls."
But Evers says even though under the settlement the state was supposed to start paying more money to mental health centers this year for ACT Teams, that’s not happening yet at Riverbend.
"In truth, we’ve had a reduction in funding from our general funds for ACT," says Evers. "So we’ve been asked to meet staffing requirements while we’re being cut. Now that may be a temporary situation."
ACT funding is also on the decline – at least temporarily – at Seacoast Mental Health Center, where Jay Couture is the executive director. Couture says even if the legislature bumps up ACT funding, there's still change on the horizon.
"There’s also a level of uncertainty that gets added because the state is no longer the primary payer for the largest portion of work that the community mental health centers do," says Couture. "They have contracted that out to the two Managed Care entities."
What Couture’s talking about is yet another reason for uncertainty, and it’s a big one: Managed Care. New Hampshire is in the process of handing over the management of Medicaid to private insurance companies, so called Managed Care Organizations.
And not only will the MCOs be writing the checks instead of the state, they’re using a new calculation for how payments are made. All this has the community mental health centers a little jittery, says Couture.
"So we need to provide services as mandated and we need to meet fiscal accountability standards as contractually obligated, but we don’t necessarily have any control over the amount of funds that are provided for us to do that," says Couture.
"The settlement is distracting"
So a quick recap of the state of mental health funding: A big lawsuit settlement requires the state to fund certain services; the Legislature is trying to find a way to fund those services in a way that doesn’t get the state sued again; and who pays for those services -- and how -- is changing as we speak.
Ken Norton with the New Hampshire branch of the National Alliance on Mental Illness says, in some ways, the settlement is distracting. He’s a little nervous budget writers are so focused on avoiding future lawsuits, they could end up funding the settlement while defunding other mental health services.
"A lot of the conversations in both the House and the Senate relative to the budget have been focused on the mental settlement agreement, as they should," says Norton. "But that’s only a component of the larger mental health system. And the settlement agreement does not deal with children at all."
The settlement also doesn’t touch on treatment for substance misuse disorders, which are commonly linked to mental illness.
One thing is clear: despite pleas from Governor Hassan, so far the legislature has declined to reauthorize expanded Medicaid – which was one piece of the Affordable Care Act. Medicaid is the primary payer for mental health care in New Hampshire. That means when the decision to reauthorize or not reauthorize Medicaid comes up in the legislature in 2016, most, if not all of this, could end up on the table again.