Fostering FederalState Innovation in Mental Health

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Fostering Federal-State Innovation in Mental
Health
NAMI Conference 2005 Stuart M Butler
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The Climate for Action

• Medicaid is under pressure.
• Health in competition with education etc.
• Mental health must compete with acute care,
  long-term care
• Little public or congressional enthusiasm
• Partisanship and gridlock in Washington
• States are the drivers of policy

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Improving Mental Health

• Focus on effective outcomes
• Place greater control in hands of patients and
  families
• Allow greater use of non-traditional service
  delivery and support
• Foster state innovation with beneficiary
  protections

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Keys for Improvement

• Tax and insurance reforms for health insurance
• Tax benefits for insurance through non-employer
  groups
• Insurance reforms to spread risk and encourage
  insurance specialization
• Foster enhanced federalism

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Aims of Enhanced Federalism

• Test major federal-state initiatives in willing
  states
• Break the political logjam in Washington
• Enable Members of Congress to accept approaches
  they would block for their state
• Test rival strategies

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Core Elements

• Congress sets goals for coverage and protections
• Congress enacts a la carte policy toolbox
• Proposals that states can try not mandates
• States and federal government agree on policy
  covenants
• Congress pays for performance. New funds or
  savings for
• Technical assistance
• Federal component of approaches to be tested
• Monitoring and data collection
• Bonuses to successful states

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Some Issues to Consider

• The mental health dimension
• Community-based approaches
• Family-based care
• Preventive and management drugs
• Cash and counseling
• Integrating long-term care
• Outreach to the homeless

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Some Issues to Consider

• Process for selecting the state initiatives
• Base closing commission approach
• Composition of commission critical
• Procedure for selecting initiatives
• States propose initiatives with state and toolbox
  components
• Commissions reviews and negotiates within budget
• Slate sent to Congress for up-or-down vote

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Some Issues to Consider

• Designing the toolbox
• Turns demonstrations from appeasement items to
  core of approach
• Importance of ideological symmetry and logrolling

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Some Issues to Consider

• Rewarding Success
• Trust but verify third-party evaluation
• A formula for federal contribution to proposals?
• Maybe a bidding process