Discussions on the Governor’s proposed budget for 2016 and 2017 are in full force, and its cuts to mental health stand in direct contrast to the recently delivered recommendations of the Sandy Hook Advisory Commission. Can Connecticut make progress in mental health without the resources to help its most needy populations?
Friday, March 6 was a particularly busy day in the state capital. For most of the day, the Appropriations Committee worked its way through the final day of budget hearings held in response to Gov. Dannel Malloy’s proposed state budget for fiscal years 2016 and 2017. The theme for the day was health, and the budgets of the Department of Public Health, the Department of Developmental Services, the Department of Veterans’ Affairs and the Department of Mental Health and Addiction Services were the topics of discussion.
In short, they were being slashed.
Removed from the proceedings on the floor above, the Sandy Hook Advisory Committee, formed in the wake of the shooting at Sandy Hook Elementary School, was holding its final meeting in a conference room on the first floor of the Legislative Office Building. Over the course of two years of testimony and discussion, the group of community leaders had crafted a 256-page report outlining recommendations in the areas of school safety, gun control and mental health.
Malloy joined the committee for this final meeting to accept their final report, and as he delivered closing remarks in the committee meeting, he offered his gratitude for the group’s work.
But in the press conference that followed, the sentiments were less optimistic. Journalists hounded Malloy with questions about the cuts in DMHAS funding, and it became evident that the committee members’ recommendations were just that — recommendations.
“No budget is easy, and some budgets are more difficult,” Malloy said. “Let me assure you, the cuts are less than they might have otherwise been.”
Almost immediately after Malloy spoke and the press conference concluded, the Appropriations Committee opened its doors to a public hearing. Testimony ranged from hospital administrators to patients at risk of losing treatment. Many of the cuts they argued against, including maintaining decreased grant funding and changes in Medicaid rates, were in stark contrast to the recommendations accepted by Malloy only a few hours earlier.
“It was an agonizing day,” said Carl Schiessl, director of regulatory advocacy for the Connecticut Hospital Association. “It’s an example of the two faces of Connecticut when it comes to addressing the needs of mental health in our state.”
CUTS, TWO YEARS IN THE MAKING
Going into the process of developing the budget, the state faced daunting deficits. As of April 1, the comptroller’s office had forecasted a deficit of $172.8 million for the 2015 fiscal year, and a joint report by the Office of Policy Management and the Office of Fiscal Analysis in January predicted a $1.14 billion deficit for fiscal year 2016 if cuts were not made.
To address that dire possibility, the governor’s office had proposed a series of comprehensive cuts, including those to the DMHAS budget.
But one of the main cuts was not even part of the proposed budget — rather, it was a relic of the last one. In the budget for fiscal years 2014 and 2015, $25.5 million was cut from DMHAS’s state grant funding for mental health and substance abuse services, reducing the agency’s previous sum of $41.3 million in grant funding by 62 percent.
But the $25 million cut was never realized due to a fortuitous combination of outside and internal funding. In fact, DMHAS was able to offset the cost by a full $20 million, pulling $10 million from the Tobacco Health and Trust Fund and scraping together $10 million within the department, said DMHAS Public Relations Manager Mary Kate Mason.
This year, though, the department does not know if it will have those same sources of revenue, and thus, the recipients may finally feel the full blow of the cuts, Mason said.
The cuts to outpatient services, which will comprise the bulk of the losses, are some of the most damaging, said Heather Gates, president and CEO of Community Health Resources. Outpatient services include walk-in appointments, medication evaluations and regularly scheduled check ups. They are the mental health equivalent to primary care.
They are also available to the largest number of people, Gates said.
“It is the most obvious place to access health care and usually helps keep people out of higher, more expensive levels of care,” she added.
The cuts will be compounded by others in the newly proposed budget, including a change to Medicaid eligibility. The income threshold to qualify for HUSKY A, Medicaid for parents with minor children, will decrease from 201 percent to 138 percent, permitting fewer people to enroll in the program.
Currently, over 20 percent of Connecticut residents use Medicaid, and that number is even higher among mentally ill patients. As Medicaid eligibility decreases, mental health agencies in Connecticut will instead be turning to the state government for help in subsidizing the cost of treating these patients.
But if the proposed budget is passed, they may have no place to turn.
MAINTAINING SERVICES, WITHOUT THE MONEY TO DO IT
Paul Hammer SOM ’85 was diagnosed with bipolar disorder in 1997. With a family history of mental illness, he has been in and out of treatment, receiving a combination of talk therapy and medication.
But in 2014, his provider told him he could no longer receive individual therapy.
He could only meet with his therapist once a month, and weekly group therapy would have to suffice for his weekly needs, his provider told him. But all the groups were held during the day, when Hammer was working, so he ultimately had to find a new provider.
Hammer suspected that these changes were because of financial reasons, a common Achilles heel of many mental health centers, he said.
Roberta Cook, president and CEO of BHcare, has seen the same budgetary constraints at work at her center, where funding has remained constant for the past seven years, despite the increasing cost of living.
As a result, some patients who used to receive individual therapy for one hour every week or alternating weeks are now only able to receive group therapy. These groups, each comprising eight patients, only meet once a month. For other patients, appointments that used to be one hour have been pared down to half an hour, Cook said.
“We’ve been trying to manage with [the cuts], and we’re cutting back, but you can’t give patients the same level of care,” Cook said.
Unlike Hammer, many of these patients do not have an alternate provider to which they can switch.
If a local mental health authority, which receives state grants from the DMHAS to serve low-income patients, such as BHcare loses its funding, its displaced patients may have nowhere else to go.
“We are looked at as the provider of last resort for many low-income, seriously mentally ill folks,” said Barbara DiMauro, president and CEO of Bridges, another LMHA.
For Bridges, the budget cuts could signify the end of its adult outpatient clinic, DiMauro said.
Bridges has already experienced a preview of the impending budget cuts and is in the process of eliminating two more clinical positions in anticipation of further budget cuts, DiMauro said. Each clinician at Bridges has a caseload of 65 patients, on average. Cutting two clinicians would likely leave 130 patients without a doctor.
“We always struggle with waiting lists and not having the staff to meet demand,” DiMauro said. “If the need keeps increasing and funding keeps decreasing, how will we be able to keep up?”
The Wheeler Clinic in Plainville, Conn., serves more than 19,000 people each year, 500 of whom are uninsured. If the budget cuts are passed, the clinic will have to stop serving all 500 of those patients, said President and CEO of the clinic Susan Walkama in her testimony to the Appropriations Committee.
Though not an LMHA, the clinic still receives funding from the DMHAS and a significant portion of its patients are covered by Medicaid.
One of the major problems facing the Wheeler Clinic and others like it is inadequate Medicaid reimbursement, the effects of which will only be exacerbated when cuts to DMHAS’s grant funding are implemented. Medicaid typically only covers 50 percent of the cost of services, Cook said.
Take, for example, the Clifford Beers Clinic, 95 percent of whose patients are on Medicaid. The clinic loses $100 for every unit of service — one doctor’s visit, for instance — provided to patients on Medicaid, said Alice Forrester, executive director of the clinic.
The balance is supposed to be offset by state grants — the very same ones that have been cut.
Part of the reason that clinics find themselves only partially reimbursed comes from Medicaid’s definition of “billable expenses.” Clients on Medicaid typically have greater needs than the average client, Cook said, and they require additional services to support them, including housing advocacy, employment assistance and referrals to related services such as addiction treatment. These expenses, considered non-medical but often crucial to the patient’s treatment, are left to the clinic to shoulder.
The administrative costs of maintaining a Department of Public Health license — and even the administrative costs of Medicaid — are also sizable. Twenty-five cents of every dollar of funding are spent on administrative processes, said Michael Hoge, professor of psychiatry and director of the Yale Behavioral Health program.
Many private providers accept Medicaid patients, but, if reimbursement rates do not improve, Polun fears this may come to an end.
The decrease in funding may especially be a problem for patients in rural Connecticut, said Sheldon Toubman, an attorney at the New Haven Legal Assistance Association who primarily works with clients on Medicaid. As an urban center, New Haven has a wide variety of providers, but in places like southeast Connecticut, there may only be one specialist who accepts Medicaid, he noted.
Psychiatry is one specialty in which it is more difficult to find providers who accept Medicaid, according to a 2014 study carried out at Weill Cornell Medical College. In 2010, fewer than 45 percent of the psychiatry providers that were examined accepted Medicaid, in comparison to 70 percent of all other specialists.
If a provider stops accepting Medicaid, patients have two options: They can pay the full cost of their treatment, which can be upwards of $100 per hour, or they can find a new provider, Hoge said.
But for those who are living on the bare minimum, like many of Toubman’s clients, the latter is impossible.
POOR AND MENTALLY ILL: A TRYING COMBINATION
For many who are low income, the question is not where they seek care, but whether or not they do at all. For them, insurance can not only provide an affordable way to access mental health care, but also the impetus to seek out care at all.
For Hammer, an attempt to take his own life was the turning point.
In 2004, Hammer attempted suicide when he jumped from the top of East Rock Park. He survived the fall, which ended a period of five months in which he had not been receiving treatment. Unemployed since 2002, Hammer had no way to pay for treatment. He received COBRA, a temporary insurance for the unemployed, for the mandated 18-month period, but once his coverage ended in December 2003, he was left uninsured.
“If I had been in my right mind, I could have looked for free care here and there,” Hammer said. “But I was not in a space to have resources to do that.”
Because it reflected mental illness, Hammer’s suicide attempt qualified him for disability and Medicare, while his lack of income qualified him for Medicaid to pay for his recovery. Now, after years of being treated in a variety of mental health settings, he has found the right medication and treatment plan to manage his mental health.
Inability to advocate for oneself plagues many low income people suffering from mental illness, Hammer noted.
In DiMauro’s experience, there is a correlation between mental illness and low income. Patients with multiple hospitalizations are more likely to be unable to hold down a job or may even have a low level felony as a result of their untreated mental illness, DiMauro added.
“I think having a serious mental illness clearly predisposes one to, if they’re not already low-income, become low-income,” DiMauro said.
The relationship may even be reciprocal. At Bridges, DiMauro has seen an increase in self-referrals over the past five years, ever since the economic downturn began. She thinks financial stressors could trigger a depressive episode in people who are predisposed to depression but may not have displayed symptoms of serious mental illness in the past.
CULTURAL ATTITUDES TOWARD HEALTH
Claire Bien had suffered from depression since her mid-teens, and by college, she had decided to see a psychiatrist. A decade later, when she first began experiencing symptoms of hearing voices, she had had enough experiences with mental health services to know there was a problem.
In retrospect, Bien credits her successful recovery to having a supportive family, private insurance and knowing that early treatment is essential for mental illness — three advantages that a low-income individual might not have, Bien admits.
When she went for doctors’ appointments, for instance, she was able to accurately communicate her symptoms, which she said she thinks allowed the doctors to make correct diagnoses. But these language and social skills are ones that many people who grow up in poverty do not have, said Bien, who now works with low-income clients through The Connection, Inc.
“[Providers] make diagnoses based on what a person is telling them at that time,” Bien said. “People live with those diagnoses for years, if not decades.”
If low-income patients face significant barriers, patients who are both low-income and come from marginalized communities often find it even more difficult to get treatment. All of the patients who come to the HAVEN Free Clinic, a student-run partnership between Yale and the Fair Haven Community Health Center, are uninsured, said Marina Di Bartolo MED ’15. But for the two thirds of the clients who are undocumented immigrants, there is the added stressor of being displaced from one’s home country, she said.
Compounding these struggles are cultural differences, Di Bartolo said, explaining that none of the clinic’s patients have come in with the chief complaint of mental illness.
“In our culture, we’re trained to think about mental health,” she said. “We point out, ‘I’m sad. I need help.’ Many patients can be sad, but won’t acknowledge that as a reason to seek medical help.”
Even when doctors refer them to behavioral health programs, patients at HAVEN often refuse treatment because they see it as unnecessary, Di Bartolo said.
Bien has seen similar cultural stigmas among populations that she works with, especially among people of color or religious patients, for whom, she said, mental illness signifies a lack of faith. Especially in the inner city, people living in poverty often do not trust physicians, the very people who are able to diagnose them with a mental illness, Bien said.
Even in her own experience, Bien’s Chinese parents were horrified when she began seeing a psychiatrist, who they equated to a “witch doctor,” she added.
Hoge noted that, although one in five adults has a diagnosable mental health condition, only 39 percent of those adults receive any care.
“Unless it’s a seriously debilitating mental illness, people continue to suffer quietly and tough it out,” Hoge said.
FLAWS IN THE SYSTEM
The budget proposal is not, however, an attempt to cut off the state’s most needy residents from the health care they deserve, but rather an attempt to adapt to the Affordable Care Act. The ACA sets up health exchanges to serve as affordable alternatives for patients who do not qualify for Medicaid but cannot afford private insurance. Those whose incomes fall between 139 and 400 percent of the federal poverty line — $33,708 to $97,000 for a family of four — qualify for the health exchanges, which in Connecticut is known as Access Health CT.
But there has not been as much migration to the exchanges as expected. At Community Health Resources, for instance, the percentage of uninsured clients has only decreased from 12 percent to 7 percent.
“There was a flawed assumption that everyone would be insured, so there would be no need for grant dollars,” said Cook, who has seen no change in the 10 percent uninsured rate among clients at BHcare.
Many of Toubman’s clients are among those who would be affected if the proposed budget is passed. These clients cannot afford the marketplace’s insurance premiums, so if Medicaid eligibility is changed, insurance may become a luxury they must forego, Toubman said. Even those who are able to scrape together enough to buy insurance may choose not to use it to avoid copays. For low-income clients, even a $1 copay is an impossible luxury, after paying for food and utilities, Toubman added.
“Very often people can barely afford insurance to begin with,” Gates said. “They can’t use benefits until they’ve paid deductibles, but they can’t afford to pay deductibles. It’s a vicious cycle.”
Based on Toubman’s experience, half of those who fall short of the new Medicaid eligibility requirements will likely forego private insurance and instead opt for the penalties, he said.
According to Gates, this would leave many of them in difficult situations. Some may end up homeless or committing crimes that leave them in the even more overburdened prison system.
The shooting at Sandy Hook Elementary School occurred on Dec. 14, 2012. On Jan. 24, 2013, a little over a month after those 20 first graders had been killed, the Sandy Hook Advisory Committee convened for its first meeting.
“The recommendations you will craft over the coming weeks and months will no doubt take us towards the goal [of] better mental health, better safety in our schools and a system that is set up to stop the glorification of violence,” Malloy said at that meeting.
Colorado Gov. Bill Ritter was in attendance as well to share his experience leading his state years after the 1999 shooting at Columbine High School. Among his suggestions was a reflection on the role of mental health in the Columbine report. In retrospect, mental health should have been more of a focus, Ritter said, and he encouraged the SHAC to consider that in their recommendations.
Ritter also echoed Malloy’s comments about the power that rested with the commission, noting their that their recommendations could actually make a difference.
But as the commission adjourned from its last meeting over two years later, there is still the sense, for some members, that its mission has been somewhat unfulfilled.
“It’s disappointing to understand that we handed the governor this pretty extensive report … but there doesn’t seem to be any impetus to make any of the changes suggested,” said Forrester, one of the members of the commission.
There are still weeks of discussions to go before the budget comes to a vote. Legislators have been proposing bills that fit the commission’s recommendations, Forrester noted with optimism, but the budget remains in limbo.
“Increases in mental health funding are often tied to tragic events,” Hoge said. “But the commitment to mental health is very short lived.”