By Steven R. Daviss, M.D.

[Winter 2003; Vol. 29, No. 2; Pg 6-7]

Maryland has decided to try something a little different for the next four years-- Republican governor. It is hard to imagine the mental health community faring much worse than it has over the past five years, with a consistently under-funded Public Mental Health System (PMHS). Some community services have been dismantled, as they wrestle in a Darwinian struggle under a new fee-for-service system.

Governor Robert Ehrlich’s record of support for those with mental illnesses is viewed with cautious optimism; it is tempered by the realities of what a $1.8 billion budget deficit can bring. In his prior positions in state and federal public offices, he stood out swimming against the Republican tide, by supporting true parity and non-discrimination for people with mental illnesses. How will he be able to maintain even the current level of under-funded services in this dismal fiscal environment? There are some clues.

The fact that Gubernatorial-candidate Ehrlich met with the Executive Committee – when his opponent would hardly give us the time of day – was quite encouraging. He and his health aide, Craig Williams, spent time listening to our concerns and pledged to continue that dialogue if elected.

We can also look at what he said in September, at the Maryland Mental Health Coalition’s Gubernatorial Forum. Most were impressed by his command of the issues, which appeared to be greater than that of then-Lt. Governor Townsend’s. Now that he will be having to face the promises he made on the campaign trail, I thought it would be interesting to review what he said that day. The MPS has a copy of the videotape if any would like to borrow it.

He opened by making three points:

1. Funding for mental health care will be a priority.
2. A lot of money is going into community rehabilitation services, and the state is probably not getting as much “bang for the buck” as we should.
3. Ending stigma and discrimination in insurance coverage policies is critical.

Marcia Pines, on behalf of NAMI, asked about the under-funding of the PMHS and problems with lack of access. Ehrlich stated that Medicaid is usually raided when the state’s coffers run low, but that mental health should be exempt from cuts – “That’s my pledge.” He acknowledged that the current system planned for 50,000 patients, not the current 90,000. His budget “will reflect that health issues are in my top three priorities.”

Denise Camp, a consumer representing Prologue and the Community Behavioral Health Association of Maryland, highlighted the difficulties in community mental health programs: Clinics shutting down. Staff turnover of more than 30%. No rate adjustments for inflation since 1997. Salaries 15-25% less than comparable state salaries. Ehrlich emphasized the need to pay for good community care, or we all pay for more costly care in ERs and hospitals, which he ticked off as “inappropriate care… lack of care… more expensive care.” He stated that the 30% staff turnover rate is higher than the national average of 17%. He wants to “redirect resources to community-based resources,” citing a fact that 38% of funds are being spent on less than 5% of patients.

Jim McComb from MARFY (Maryland Association of Resources for Families and Youth) asked about services for co-occurring disorders, particularly among children and youth. Ehrlich criticized the Dept. of Juvenile Justice, stating that all DJJ programs must have sufficient mental health components. He also characterized the need for suicide prevention training for staff as “critical”.

Bob Blankfield, representing the Maryland Association of Core Service Agencies, asked about the priority-setting process in the PMHS and the need to balance treatment with prevention strategies. Ehrlich emphasized the need for early intervention in DJJ. He listed his order of priority in thinking through these issues: 1-severe mental illness, 2-dual diagnosis, and 3-high risk of incarceration.

Randy Lutz, who chairs the Coalition’s Task Force on Private Insurance Access, asked about parity and access. He mentioned the dually eligible problem (providers who see patients with both Medicare and Medicaid get 62.5 cents on the Medicare dollar), and he pointed out that the Insurance Commissioner receives a disproportionately high number of complaints about mental health coverage problems. Ehrlich acknowledged that the then-cutting edge parity legislation (which he voted for) from 1994 does not fix access problems. He listed four possible solutions:

1. Establish an Access Task Force [see Pete Hammen’s House Bill 25].
2. When HMOs deny care, send them to the PMHS.
3. Don’t limit access to the “revolution” of new, more effective, medications.
4. Referring to lengthy ER stays waiting for beds, he said “inpatient admissions need to be authorized in the very short term …it’s a Patient Bill of Rights issue.”

Janice Brathwaite, president of On Our Own of Maryland, asked about access to housing and employment opportunities and whether Governor Ehrlich would support a Medicaid buy-in. He thinks the blind and disabled should be able to work without losing their insurance. He mentioned a central, statewide registry for housing for those with disabilities, and temporary housing assistance for those on Section 8 waiting lists.

Sinai’s Suzanne Harrison, representing the Maryland Hospital Association, described the problem of patients backing up in emergency departments and access to crisis services, asking if he’d support and fund the Maryland Crisis Response System [Sandy Rosenberg’s House Bill 483 which passed in 2002]. He said he would, and also that first responders (police, fire, EMT) should have significant training in mental health issues.

Colin McNabb, for the Protection & Advocacy for Individuals with Mental Illness Advisory Council, asked about Maryland’s noncompliance with the Supreme Court’s Olmstead decision that people should be treated in the least restrictive environment. He also asked about closing state hospitals. Ehrlich stated that all states are out of compliance, and that we need to establish timetables to meet these goals. He was non-committal about closing a hospital, but that if it was decided, that the money and jobs saved should be moved to community services.

Dawn Yoakum Calderone, a consumer and advocate, stated that she relinquished custody of her own child so that her child could receive the intensive services that she could not afford herself. She asked if he’d support passing a law to prevent this unfortunate outcome. He said he’d sign an executive order in his first week. In fact, he did sign an order that (1) instructs DSS to manage these cases, and (2) establishes a council to study the problem.

Yvonne Perret, president of the Mental Health Coalition, asked about his support for funding for the PMHS, and also raising the income thresholds for Medicaid eligibility. He said he cannot promise to raise the threshold now; that he needs to find more federal dollars. He also seemed to support past attempts to increase MA payments for those who are dually eligible (MA plus Medicare).

Finally, Linda Raines, of Mental Health Association of Maryland asked about the Blue Cross conversion issue. Ehrlich said he’d wait on Commissioner Larsen’s recommendation first. He added that Medicaid is the insurer of last resort, not Blue Cross.

We certainly do live in interesting times, and this year’s legislative session will set the tone for the next four or more years. Governor Ehrlich’s understanding and support of treatment for people with mental illness is well-known, and we can hope that his powerful endorsement of the cause is followed by fiscal support of crucial services. Hopefully, he and the legislature will be able to work together to improve access, treatment, insurance parity, housing, and employment opportunities for those citizens in need.