Thanks to Ron Honberg, NAMI National Director of Policy and Legal Affairs, for sharing this analysis on the recently released GAO report on mental health leadership.
[NAMI Release] The Government Accountability Office (GAO), a non-partisan agency that reviews and provides oversight over federal programs, has issued a report emphasizing lack of coordination at the leadership level in the administration of federal programs for children, youth and adults with serious mental illness. The report was conducted at the request of Representatives Tim Murphy, R-Pa., and Diane DeGette, D-Colo., the Chair and Ranking Member of the Subcommittee on Oversight and Investigations of the House Committee on Energy and Commerce. NAMI is grateful to Representatives Murphy and DeGette for their leadership and commitment to improving the lives of people with serious mental illness and their families.
The GAO’s report concludes that there has been poor coordination among the eight agencies and 112 federal programs that provide services to people with mental illness. The report also documents shortcomings in the evaluation of programs serving people with serious mental illness, contributing to the overall lack of information about who these programs serve or what outcomes these services achieve.
Lack of Coordination
The report decries the lack of coordination at the leadership level among different federal agencies. It notes that a Federal Executive Steering Committee for Mental Health, established in 2003 to coordinate services across federal agencies, has not met since 2009. The report further states that the Substance Abuse and Mental Health Services Administration (SAMHSA) is charged with promoting coordination across the federal government on mental illness and concludes that such coordination is not effectively occurring. The report does note that SAMHSA coordinates the Behavioral Health Coordinating Committee (BHCC) within the U.S. Department of Health and Human Services (HHS) and the BHCC has recently formed a subcommittee for serious mental illness to better coordinate efforts on serious mental illness within HHS.
The lack of coordination also applies to individual agencies responsible for administering multiple programs. For example, the National Institutes of Health (NIH) has multiple institutes, including the National Institute of Mental Health (NIMH) that conduct research relevant to serious mental illness. According to the report, the NIH categorizes all of its mental health programs under the category “Scientific Research” yet is unable to state how much funding in total goes into research on serious mental illness. Recognizing this as a problem, NIMH is currently developing a method to categorize all research grants related to serious mental illness across all institutes.
The GAO’s report also reveals that a majority of federal programs targeted for people with serious mental illness have not been evaluated for effectiveness. Only 9 of the 30 programs have completed program evaluations, 7 of them by SAMHSA. Particularly noteworthy is that none of the 8 programs administered by the U.S. Department of Veterans Affairs (VA) have completed program evaluations. This is troubling because without such an evaluation, it is difficult to assess whether the services provided by these programs are effective.
Lack of coordination and lack of accountability in the provision of services to people with serious mental illness are longstanding problems. In 2009, NAMI issued a report assessing the performance of state mental health agencies in providing services to serious mental illness. In that report, we emphasized that many states were unable to provide even basic information about their mental health services. These states did not collect data on specific services provided, who the services were provided to, or what outcomes were achieved through services provided.
In recent years, SAMHSA has worked to improve data reporting by states through its Uniform Reporting System (URS). However, reporting by states is still voluntary, even though all states receive federal funds through the Mental Health Services Block Grant. And, the criteria used by states to report data are not uniform, making it very difficult to compare performance across states or to assess whether public dollars are being spent wisely and appropriately.
Exclusion of Programs administered by CMS
One limitation of the GAO’s report is that it did not examine programs administered by the Centers for Medicare and Medicaid Services (CMS), the agency that administers the Medicare, Medicaid and Children’s Health Insurance Program (CHIP) programs. As noted in the GAO’s report, Medicaid is the most significant source of funding for mental health services. Medicare is also an important source of funding as is CHIP for children and adolescents with serious mental health conditions.
Medicaid in particular is more than simply a source of payment for services. The structure of the Medicaid program as well as the use of Medicaid options and waivers has much to do with shaping mental health services, particularly in the community. Despite this, it is very difficult to find specific information about what mental health services are paid for through Medicaid and what results are achieved through these services because CMS does not collect this data. NAMI urges additional examination of the Medicaid program with respect to coordination and evaluation to benefit people with serious mental illnesses and their families.
At a time in which payment for health care and mental health care services are increasingly being linked to performance, services to people with serious mental illness are at risk of lagging even further behind than they are today. This is in no small part due to poor coordination and data collection on services and outcomes. Severe gaps in availability of quality mental health services and supports have devastating consequences for individuals with serious mental illness, their families, and American society. The evidence of this public health crisis can be seen in the growing ranks of youth and adults with mental illness who are dropping out of school, experiencing homelessness, incarcerated in jails and prisons, or spending hours or days in emergency rooms seeking help that is too often not available. We know that we can do better.
NAMI recommends the following steps for improving federal coordination and accountability on services for people with serious mental illness.
Create a high level position within the federal government responsible for coordinating federal programs serving people with serious mental illness, developing evaluation criteria and outcome measures, and holding relevant federal agencies responsible for achieving relevant outcomes. More effective coordination between programs responsible for research, services, and financing mental health services is particularly important. Coordination must be directed at achieving outcomes.
Identify as a priority for federal funding people with serious mental illness whose lives have been significantly impacted by their illness and the families of such individuals. Federal policies should prioritize both services to prevent adverse outcomes associated with serious mental illness such as homelessness and criminal justice involvement and services designed to facilitate the early identification of psychosis, recovery, education and employment.
Conduct a thorough review of the Medicaid and Medicare programs to determine what resources are spent on serious mental illness and whether these programs are measuring and achieving positive outcomes for those being served.