ideastream Focus on Mental Health: An Interview with Eric Fingerhut

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April Baer: After Ohio decommissioned - or "de-institutionalized" - many of the state hospitals that were a main source of care for people with serious mental illness, there was this misunderstanding that community based services would suddenly appear. Why didn't these community-based services develop?

State Senator Eric Fingerhut: Well, simply put, because the state didn't keep up its funding to the community mental health system. The idea was that the state would be saving money on the hospitals and would recycle that funding into the community mental health system. But frankly at the time, as state budgets and other priorities go, the General Assembly did not keep that commitment and they took some of the funds and put them in other places and so the funding of the community system could not keep up with the growing community.

AB: In situations like this where there is a verbal mandate, but no actual legislation to back it up, what could happen or should have been done it a situation like that? What could still be done to prevent it?

EF: Well, what is really needed is a statewide advocacy effort around mental health funding. Frankly, the organizations around the state who work so hard to provide these services, all non-profit groups, all of the human service providers - they have their hands full day to day with serving the people who come through the door. They have not been as organized as they need to be in the advocacy arena. And the result is that unfortunately when the budget is signed in Columbus, the squeaky wheel gets the grease, and they haven't always been the squeaky wheels.

I think they've gotten a little bit better lately, but it isn't getting the level that it needs to be in order to really raise the profile position in the legislature and to meet the commitments. I think there is actually an underlying desire by the General Assembly to do the right thing, but then they get bombarded with all sorts or requests, all of which seem important and determined and things just fall by the wayside.

AB: I imagine especially now with budget battle looming...

EF: Well, I think this year is really a crisis moment. Interestingly, two years ago when we did the last state budget the Director of the State Department of Mental Health, Dr. [Michael] Hogan, testified that the system was fraying and thin and that the budget could not respond to the abuse, and that while he would live with a flat budget for this two year cycle that we're currently in, that in the next cycle it would have to be addressed in a permanent way. Here we are two years later; the odds of seeing a significant increase are diminishing every day. So, you know, I understand we have to deal with the situation that's before us, but 2 years ago he was screaming and saying this is the last time we can take a budget like this, we can't do this again, and still provide responsible safe care.

AB: What's your understanding of which populations across the state are most in need right now?

EF: This is not an easy question to answer because mental health is unique in that there really isn't a private health insurance network that supports it. So, when you think about other health issues, you're able to say a vast majority of the public has private health insurance. They may not be as extensive as you like, the co-pays may be too high, maybe you can't go to the doctor you choose, it's certainly not perfect, but you at least you have access to private health insurance. So the safety net in the community is for those who don't have health insurance. In this case, those who are not getting served for mental illness are not only those who do not have private health insurance at all, but also those who have private health insurance but it doesn't cover mental illness. So, it's almost hard to say who's not getting served because really it's vastly, we're vastly under serving every population.

I do want to say, though, that within that vast population, we have a particular blind spot on children's mental health issues. I think if you talk to any school psychologist, or any of the agencies in town, that we are particularly underserved in having professionals that can identify children's mental health issues and address them when they're young and before they manifest themselves into full blown schizophrenia. So, I think were really underserved in every population, but we're egregiously underserved in the children's population.

AB: Let's talk a bit more about Medicaid. What is the status of Medicaid funding in Ohio?

EF: Well, I think that Medicaid involvement has grown consistently the last few years, but that really has much more to do with welfare reform than it has to do with the funding issues we're dealing with here today. The basic premise of welfare reform is that instead of having people not working and then providing them with healthcare and cash support, that we will instead encourage them to work and then channel the taxpayer dollars into support services helping them get a job, etc. And so we have seen a drop in cash support, but a huge increase in the number of people taking advantage of government supported health insurance, so Medicaid enrollments have gone up. But within the mental health arena there's really been very little change. Medicaid covers a very limited, specifically prescribed set of services that has not been updated in a very long time. Ohio is worse because we have not gotten what's called a waiver from the federal government in a long time. The situation in Ohio is that any Medicaid eligible or Medicaid enrolled family/individual could present themselves to a Medicaid providing mental health agency and receive specifically permitted Medicaid services. The problem is because they want to serve people and get them some help, we've increasingly been providing from that list so that the dollar burden has been growing even while there's more recognition that those aren't necessarily the best use of services or the most efficient way of serving that population.

AB: Someone made the comment to me that more people are enrolled in Medicaid, which is a good thing, but at the same time, Medicaid's menu of billable services has shrunk.

EF: Well, there certainly has been every effort at the state and federal level to try to shrink Medicaid costs, and so it certainly doesn't surprise me that providers are finding that the list of eligible services is shrinking. But what I hear from providers, more than a complaint about the shrinking list of services, is that the services that they are allowed to provide, that are reimbursable from the government under Medicaid, are not necessarily that which are the most indicated services based on their professional judgment. So they experience this frustration where if a adult male comes in and would be best served by being in some kind of group support program including some work support, and some counseling support, that they can't put them in that service and get any kind of reimbursement, but if they did one on one counseling, which would not be the best indicated service for that person, they get reimbursed. So, they're very frustrated by that, they're forced to try to raise private dollars, or other non-Medicaid government dollars, which are shrinking, to provide the indicated services. So Medicaid really needs to adapt. One of the things that Ohio simply must do, and frankly, it's inexcusable that they are not doing this, is to prepare and submit to the federal government a waiver in which we ask the government to allow us to shift dollars from these more expensive permitted services to these less expensive services which are not currently on the list.

AB: Could you explain a little bit about why that is so hard to get or why this is such a stumbling block?

EF: Well, it's actually hard for me to explain why we haven't done it because I feel so strongly that this is something that the state should have done already. Other states have done it. What happens is, when the state starts to graph, I can only tell you what the experience has been. When the State Department of Mental Health sets out to graph the waiver, there has been a disagreement between providers and the state over what the exact terms of the waiver should be and each time that conflict has arisen, almost always the same conflict among the same players and the same disagreements and the same issues, every time the state has just thrown up its hands and said alright, never mind. That's just not good enough. We have to work through these issues, other areas of service have done it. Mental retardation developmental disability communities have worked through these conflicts and built consensus and even hospitals have been able to work their way through waiver issues. Long term care, imagine, nursing homes and in-home care programs are at each other's throats all the time, but we've been able to work through that to get long-term care waivers. We simply have to do this. It's a major failing of our state mental health leadership. Two years ago in the state budget, we mandated that the state actually develop and submit a waiver and once again the Director of Mental Health in conjunction with the Director of Jobs and Human Services came back to the legislature and said we're not going to do this right now and the legislature backed down. I was very, very surprised by that. I would keep pushing. I think we need a waiver.

AB: No matter what level we are talking about, whether it's federal, state or local, this is one of those issues that's very hard for politicians to bring to voters. Why is it such a hot topic?

EF: Well, I have seen some polling that openly suggests this is a harder sell with the public, but I seem to think we can simplify the process. The polls reflect people's current state of knowledge and what campaigns are about, whether it's a levy campaign or a legislative campaign, political candidate campaign, what a campaign is about is educating or changing their level of knowledge about an issue. So, everybody thinks, well it's easy to pass a levy for MRDD because the victims of that particular illness are easier to identify with as victims, and who's going to deny dollars to a sheltered workshop or group home so that a mentally retarded individual can really go through a fulfilling life?

AB: Maybe with other disabilities there's a stronger perception of people being stricken from birth?

EF: There's an emotional attachment to it I hate to say it's like the old Jerry Lewis telethon, it's easier to play on the public's emotions. Mental illness is more difficult because it's your sister, it's your brother, it's your neighbor, it's your friend, it's your co-worker, and the symptoms of mental illness are often uncomfortable, very difficult to deal with. When you're dealing with somebody who's exhibiting symptoms of mental illness, you may not know that it's mental illness. You may just think it's aggressive behavior. You may just think it's abnormal behavior. So it is a harder sell. But I think it's wrong just to accept that because as I've said mental illness affects every family and there's growing awareness of this issue. The coalitions in Columbus, the coalitions in Washington that legislators are pushing are across party lines, they're across racial lines. You simply have to have some experience in your life to where your eyes were open to this and I think more and more people are having that because we live, thankfully, in a society that is more willing to discuss these things openly and more willing to share our experiences.

AB: When we talk about the next budget process, what is mental health competing with?

EF: Well, it's a hard question to answer because there's issues yet to be presented, there's always competition one against the other.

AB: And it changes day by day.

EF: Right. But your biggest spending item, the state is going to have to look at the Medicaid budget. Because so much mental health is in the Medicaid budget, the only place that there's competition is within the Medicaid budget and so you're competing with things like long term care - that's been a problem with the constituency in Columbus - and the basic services to children and families. Because you're in the Medicaid budget, you're facing those kinds of competition. If I could answer your question with just a local thought, even as someone who has historically been an advocate for funding for these kinds of programs and services, I understand that ultimately the only way the state of Ohio is going to be able to provide the services that we want for our citizens is to have a growing economy, rising personal incomes and people pay taxes and we have the money to do it. There's no way in the long run that we can be able to serve the people we want to be able to serve unless we have a growing economy and rising tax revenues. I think that in my encounters with the constituency and all of these things is the question of public focus and state focus on job growth programs. For me, that doesn't mean tax abatements and tax breaks and chasing businesses across the border, though that's part of the state budget. To me it is education, higher education, social issues, so when I think about the complex issues, I'm thinking about those kinds of things: how do we provide for future growth, so that we can fund these programs as opposed to just making do with what we have. If the economy in Northeast Ohio doesn't start growing at a rapid pace again, even the most generous voters will not be able to undertake some of these budget changes. We really have to focus on these jobs and where they're taking us.

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