Passage of the Murphy Bill (HR 3717) without expansion of Medicaid in the Southern states will put an impossible burden on state funding for involuntary outpatient commitment, intensive case management and hospitalization of all those not currently judged disabled by the Social Security Administration, particularly those with co-occurring addiction and mental illness problems.This article was written by a mental health advocate in Asheville, NC, who has many years of experience, both as a peer provider in California, and an employee of a Managed Care Organization in North Carolina. Bonnie Schell is now retired.
Bonnie Jo Schell
There is an alternative to passing Rep Tim Murphy's bill. Democrat Ron Barber of AZ has also introduced a bill that would make many reforms of the present public mental health care system. It does not have the most objectionable provisions that Murphy would have us rely on. Rep. Barber has many years of experience working for persons with disabilities in his home state.
The public behavioral healthcare system serves those with the most need and the most limited resources. In NC the average cost per adult with mental illness is $2,405 for Medicaid and $1,302 in state funding. Substance Abuse costs Medicaid $2,102 compared to $48,211 per person per year for those with Intellectual and Developmental Disabilities. A year in prison without treatment costs the government $95,000. Legislators are right to respond not only to the injustice of warehousing people in jails, but also to the costs of this misguided “treatment.”
The Murphy Bill, however, is based on a wrong premise about those who cannot cope with everyday life events. The Murphy Bill portrays the children and loved ones of family members as psychotic, dependent, without insight, unable to care for themselves, and as non-compliant with treatment as patients with diabetes and heart disease are. If this were true, that no one recovered from mental illness or got better, the Medicaid rolls, adding generation after generation, would explode exponentially. The American Psychiatric Association estimates that 50% of Americans will be eligible for a Diagnostic Statistical Manual V label. The Washington based Treatment Advocacy Center estimates that already 40% of those with severe bipolar disorder go untreated and 51% of those with schizophrenia go untreated.
The word "Recovery" is not a part of the Murphy Bill. Even before the second generation anti-psychotic medications were developed, a rule of thumb was that, 25% would need services no longer, 25% would get better, 25% would keep their present symptoms, and 25% would deteriorate. Getting better was attributed to communities that supported people who were different with housing and jobs, usually in small towns. Getting better in the last 15 years has been due to Drop In, Peer and Wellness Centers, Wellness Recovery Action Plans, Care Coordination, training in personal and systems advocacy, development of trust in a nonviolent system of care, hope for the future, and psychiatrists, nurse practitioners and case managers who believe in personal recovery.
The Murphy Bill assumes that the best that can be hoped for by those with emotional and behavioral disorders is maintenance and shaky stability, not long periods of remission which is the experience of many. The thought behind the Murphy Bill, following E. Fuller Torrey and D. J. Jaffe is that those who claim recovery were never sick. They believe that mental illness is a brain disease one is born with and not that it is triggered in part by genetics in families, but also by poverty, domestic violence, emotional and physical trauma and abuse. In NC 11 out of every 100 children have a severe emotional disturbance in a given year yet 70 counties do not have a child psychiatrist. 5.4% of NC adults have a severe and persistent mental illness and 7.8% are dependent on alcohol or drugs. Supporters of the Murphy Bill make the presumption that those who say they are in Recovery were never sick.
The Murphy Bill proposes Assisted Outpatient Treatment as a contingency for states to receive federal block grant funds. Outpatient commitment has already been adopted by 44 states, but in many such as NC, seldom used, due to costs and workforce issues. The drain on the mental health system to force treatment on 8-13% of those with the most serious mental illness symptoms will leave up to 87% without adequate community services due to funding allocation. Under NC Reform only 27% of those with serious symptoms after initial interview were able to have two visits in the next 30 days. Due to a shortage of providers NC is piloting telemedicine in 28 counties without a psychiatrist.
Murphy disparages peer run services provided by trained peer support specialists who have lived experience with mental illness. Not only are these specialists a cheaper labor pool in a field with dwindling workers, but they alone can share how they remember to take their medication, what it is like to return to college or work, how to get along with landlords, how to manage basic needs on $600-700 a month. Peer support specialists, supervised by credentialed mental health professionals, want to give back to others in appreciation for services they have themselves received. NC has over 900 Credential Peer Support Specialists. Many have college degrees but interrupted lives. Murphy carefully uses the word “scientific” proof for medicalized services instead of “Evidenced-Based” practices which have shown peer provided services to be effective-- as they are with cancer and diabetes patients in a coaching and support role. The VA’s use of peer support over past two years found significant improvements in the perceived ability to actively manage their own healthcare.
The outcomes of treatment envisioned by the Murphy Bill are narrow: staying out of jail and the hospital. The Recovery movement in the US, Netherlands, Australia, and Europe envisions an improved quality of life, hope, well- being, keeping housing, having a job or volunteer work, recovering old and developing new skills, and contributing to society. Recovery according to William Anthony of Boston University School of Rehabilitation is having a “satisfying, hopeful, and contributing life even with the limitations caused by the illness.”
The premises behind the Murphy Bill’s proposals are false, and its adoption without Medicaid Expansion would bankrupt the states and disrupt people’s lives.
Bonnie Jo Schell
August 25, 2014