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Mental Health Policy Making in the United States

It is commonplace to believe that the federal government has greater power than other levels of government on all matters. It's just not so. The Constitution of the United States and more than 200 years of history make it clear that there are areas over which the federal government has little or no authority.

In order to formulate effective mental health advocacy strategies with government, it is critical to know what level of government and what branch of government are responsible for what mental health policies. In many cases there is overlapping responsibility and it will be necessary to decide which of the responsible bodies or officials to approach for change.

Federal Mental Health Policy Making

Mental health policy is an area of governmental responsibility in which the federal government has a limited role. By tradition, the states have primary responsibility.

The responsibility of the federal government for mental health includes research, practice leadership, and funding of services through Medicaid & Medicare and several comparatively small grants program, including the Mental Health Block Grant.

Over the past couple of decades, the federal government has also had a significant impact on issues related to the rights of people with serious mental illnesses. For example, the Fair Housing Act and the Americans with Disabilities Act prohibit discrimination against people with mental illnesses in housing and employment.

The federal government has also weighed in recently on the issue of mental health insurance coverage, has set standards on restraint and seclusion, and has created new requirements for the VA stressing community mental health services for veterans.

Making Federal Mental Health Law

To make mental health law, a bill must be introduced in both the House of Representatives and the Senate by at least one member of each. It is best to have multiple sponsorship including members of leadership.

Depending on the nature of the legislation, it will be sent to one or more committees. In the House this will usually include The Health Sub-Committee of the Energy and Commerce Committee. In the Senate it will usually include The Health, Education, Labor, and Pensions Committee.

Any bill with fiscal implications will also be sent to the Ways and Means Committee of the House and the Finance Committee of the Senate.

The bill generally must be approved by the committees and the leadership to come to the floor for a vote. The bill must also be supported by a majority of members in both the House and the Senate.

If the bills passed in each house are different, a House-Senate conference committee will be convened to reconcile the differences. The House and the Senate generally approve these compromises routinely.

• To become law, the President must sign the bill.

• A 2/3 majority in both the House and the Senate can override a veto.

• It is very important to have a presence in Washington during the last minute passage of bills.

Making The Federal Budget

• The President submits a budget proposal to the Congress in February.

• Congress develops a budget through its committees using a complex process.

• First, Congress is supposed to pass a Budget Resolution, giving the overall shape of the Federal budget, by April 15. Usually it is late.

• When the budget resolution diverges substantially from current budgetary authority, a Budget Reconciliation Act is passed. This Act is stitched together from decisions made by committees about how to bring the spending for which they are responsible in line with the Congressional Budget Resolution.

• The Budget Resolution essentially "allocates" specific amounts of money to broad areas of spending, which are the responsibility of specific committees.

• Each committee must make "appropriations" specifying how its allocation will be spent.

• Often appropriations bills are passed shortly before the fiscal year begins on October 1. When the budget process has not been completed on time, "continuing resolutions" are usually passed. Occasionally the government has shut down temporarily.

• To influence the budget, advocates should work with federal departments prior to February and with the Congress and the federal departments after the President's budget is released.

Federal Administration of Mental Health Policies and Programs

Research and Practice Leadership

• Mental health research is primarily the responsibility of the National Institute of Mental Health (NIMH), which is part of The National Institutes of Health (NIH.)

• Practice leadership is primarily the responsibility of the Center for Mental Health Services (CMHS), which is part of the Substance Abuse and Mental Health Services Administration (SAMSA).

• CMHS tries to stimulate the development of services using state-of-the-art service models by funding demonstration programs and services research.

• For the most part, it does not provide funding for ongoing service programs.

• The primary sources of federal funding for ongoing service programs are Medicaid and Medicare, which cover a major portion of the public sector’s costs of providing mental health care.

• The Centers for Medicare and Medicaid are responsible for Medicare and Medicaid.

• Some funds are made available to the states through the Mental Health Block Grant, which is administered by SAMHSA.

Under federal law, some people with long-term disabilities are eligible for Social Security Disability (SSD) and others are eligible for Supplemental Security Income (SSI). The Social Security Administration administers both of these programs.

The Department of Health and Human Services

NIMH, SAMHSA, The Centers for Medicare and Medicaid, and The Social Security Administration are all parts of The Department of Health and Human Services (HHS) and are ultimately responsible to the Secretary of HHS.

Other Federal Departments

Other departments which have major roles with regard to mental health policies and programs include The Department of Housing and Urban Development (HUD), The Department of Education, and The Department of Labor.

Mental Health Policy Making in NYS

• In the United States, the states have primary responsibility for care for people with mental illnesses and have a very extensive role in determining mental health policy.

• New York State's functions include the operation of state psychiatric centers, provision of unding for local mental health services directly and through Medicaid, mental health planning, regulation of the mental health system, licensing of mental health programs, approval of new program development, and some research.

Making Mental Health Law in NYS

• Making law in NYS goes through a process that includes the introduction of bills, the gathering of sponsors, approval by relevant committees, acceptance by leadership, passage by The Assembly and The Senate and signature by the Governor.

• It is important in NYS for both the Assembly and the Senate to pass the same bill because NYS does not have a routine process to resolve differences between the two houses.

• The key committees for mental health law are usually The Mental Health Committee in the Assembly and the Mental Health and Developmental Disabilities Committee in the Senate. Some mental health bills must go through other committees.

• The Assembly Ways and Means and Senate Finance Committees must approve bills that involve state spending.

• All legislation must get approval from the Speaker of the Assembly and the Majority Leader of the Senate to get to the floor for a vote.

• In the real process of negotiation that leads to the enactment of a law, the key parties are the committee chairs and their staff, legislative leaders and their staff, the Governor and his staff, the Division of the Budget, and the Office of Mental Health.

• The NYS Legislature convenes in early January and adjourns during the summer. Special sessions are usually called in the fall to wrap up some unfinished business.

• It is difficult to pass legislation that is introduced for the first time after the session is convened; therefore, it is best to begin work with legislators in November and December.

• It is very important to have a presence in Albany during the last minute passage of bills.

Making the Mental Health Budget in NYS

• The Office of Mental Health submits its request to the Governor (actually the Division of the Budget) in the fall.

• The Governor submits a budget request to the legislature in mid-January.

• The legislature passes a budget with the approval of the Governor by April 1. (April 1 is the date required by the State Constitution, but until recently NYS has not had a budget on time in 20 years.)

• Prior to agreeing to a budget, the Governor and the Legislature generally have protracted, acrimonious negotiations that end in sullen compromises.

• Advocacy about the budget needs to have three phases.

  • In early summer, advocates should communicate with The Commissioner of Mental Health.

  • In November and December, advocates should communicate with the Governor’s Office and the Division of the Budget.

  • From the release of the Governor's budget request until the passage of the budget, advocates need to work with the Legislature, the Governor, the Division of the Budget, and relevant state agencies, such as The Office of Mental Health. Work with the Legislature must be focused on the chairs of the committees that cover mental health and with the committees that cover finance as well as with the leaders of the Assembly and the Senate.

Administration of Mental Health Policy and Programs in NYS

• Administration of mental health policy and programs in NYS is primarily the responsibility of The Office of Mental Health, which is headed by a commissioner.

• A member of the Governor's staff attends to day-to-day and policy developments in OMH.

State Psychiatric Centers

• The Office of Mental Health operates state psychiatric centers throughout NYS. They are a major source of inpatient and outpatient treatment and of community housing and community support programs.

• There are psychiatric centers for children and for adults and for people with mental illness who have committed serious crimes (forensic centers).

• Directors of state psychiatric centers have a high degree of independence within allocations of staff and funds made by OMH centrally.

• Each state psychiatric center is overseen by a Board of Visitors appointed by the Governor.

• Most also have family and consumer advisory committees, consisting of patients and their families.

Funding Local Programs

• New York State provides funding for mental health programs that are not operated by The Office of Mental Health through a variety of “funding streams." These include Medicaid, local assistance, community support systems (CSS), housing, reinvestment, etc.

• Medicaid funds go directly to licensed service providers, which bill for the services they provide.

• Most other funds go to local governments, which contract for services with local providers or provide services themselves. Some funds are subject to contracts between OMH and a local provider.

• Local governments or local agencies must match some of the funds from the state. For example, federal, state, and local governments share Medicaid costs. And "local assistance" funds require a local match, which in most parts of the state is 50%. Most funding of this kind has been replaced by Medicaid funding.

Mental Health Planning

• State law requires OMH to develop a five-year plan for mental health and update it annually.

• These plans are supposed to link to local mental health services plans, which are prepared by local departments of mental health annually.

• Local and state planning processes both use planning advisory committees, which consist of people with various interests in mental health including providers, families, and recipients.

• At the state level, the two primary planning advisory organizations are The Mental Health Services Council, which has members appointed by the Governor with the approval of the Senate and The Mental Health Planning and Advisory Committee, whose members are appointed by The Commissioner of Mental Health.

• These planning advisory committees create opportunities for advocates to have input into mental health planning either by becoming members of advisory committees or by simply attending their meetings, which are required to be open to the public.

Regulation

• OMH promulgates regulations covering such matters as licensing standards, requirements for new program development, and procedures for involuntary commitment among many others.

• Regulations are drafted by teams of OMH staff but are the direct responsibility of the Bureau of Policy and Regulation within the OMH Counsel's office.

• All regulations are issued for information and comment before they are issued by the Commissioner, except those that are issued on an emergency basis. Advocates may send written comments to OMH.

• Regulations are also subject to review by the Mental Health Services Council before they are issued.

Certification (Licensing)

• New York State requires many, but not all, mental health programs to be licensed.

• All inpatient and outpatient treatment programs and some housing programs must be licensed.

• To get a license, a program must first get approval to be established (see below).

• To continue to be licensed, a program must pass inspections, which take place periodically. The frequency of inspections depends on findings of OMH certification specialists. If a program is in virtually total compliance with licensing regulations, it can get a license for as long as three years. If a program is not fully in compliance, its license would be for a shorter period of time.

• Certification is not a public process, but it is possible to get copies of certification reports under the Freedom of Information Law (FOIL).

• State licensing was not created to assure that programs are of the best quality but only to assure that a program meets minimum standards.

Approval of New Program Development

• Licensed programs and programs which depend on public funding must get permission to establish a new program or to significantly expand or close an existing program.

• Generally new program development is subject to public review both at local and state levels.

• In NYC, local reviews take place through the Federation. (see NYC below)

• In Westchester, WDCMH conducts local reviews.

• The Mental Health Services Council does public review at the state level.

• The local commissioner decides whether or not to recommend the establishment of a new program to the state commissioner, who decides whether or not the program can be established and expanded.

Role of the Field Office

Field offices carry out some functions of OMH. This includes making recommendations regarding new program development, local planning, and funding for local services. The NYC Field Office of OMH is located at:

330 Fifth Ave.
9th Floor
New York, NY 10001
212-330-1650

The office that covers Westchester and 15 other counties is:

The Hudson River Field Office
4 Jefferson Plaza
3rd Floor
Poughkeepsie, NY 12601
845-454-8265

Research

The Office of Mental Health also operates two research institutes.

Other State Departments Which Affect People with Mental Illnesses

The population for which OMH is responsible has substantial overlap with the populations for which The Office of Mental Retardation and Developmental Disabilities (OMR/DD) and The Office of Alcoholism and Substance Abuse (OASAS) are responsible. Services for people with what are now called "co-occurring" disorders are very much affected by tensions, conflicts, and the failure of integration among these three departments.

These three departments are all subject to review by The Commission on the Quality of Care and Advocacy for Persons with Disabilities, which has wide authority to inspect mental health, mental retardation, and chemical dependency programs and to issue reports about the quality of care and about the organization of the systems of services.

• The Department of Health has overall responsibility for Medicaid and is involved with the development of mental health rates and funding regulations.

• The Department of Education

  • Is responsible for vocational rehabilitation and oversees a number of programs which serve people with mental illnesses who want to go to work,

  • Oversees school related services to children and adolescents with serious emotional disturbances,

  • Licenses or certifies mental health professionals.

• Department of Insurance has responsibility for health insurance, including mental health insurance.

• The Office of Children and Family Services is responsible for the child welfare and juvenile justice systems, through which many youngsters with serious emotional disturbances are served.

• The Office of Temporary and Disability Assistance and The Department of Housing are also important.

Mental Health Policy Making in NYC

NYC's mental health functions include planning, contracting with local providers, providing city tax levy funds to match state and federal funds, and service provision by the Health and Hospitals Corporation.

Making Mental Health Laws and Budgets in NYC

• Local governments play virtually no role in making mental health laws in the United States.

• The role of the City Council regarding mental health is limited to the making of the city budget.

• The City budget process has two components-- (1) a preliminary budget, which provides a projection of spending and revenues for four years and (2) an annual budget.

• The Mayor submits the preliminary budget in mid-January. The Mayor submits an annual budget proposal at the end of April.

• Negotiations take place until the budgets are adopted, no later than June 21.

• The Council's Mental Health Subcommittee of the Health Committee can have significant impact on the budget for mental health.

City Funding for Mental Health Services

• New York City uses funds that it derives from city taxes ("NYC tax levy funds") to provide the matching funds required by NYS to receive "local assistance" from the state.

• NYC also uses its tax levy funds to pay its share of Medicaid.

• NYC tax levy funds are also used to provide some funding for The Health and Hospitals Corporation (HHC).

• In addition, NYC sometimes uses its tax levy funds to cover the costs of special programs, which it believes to be important enough to do even without federal or state financial participation. Funds for special programs may be put in the budget by the Mayor or by The City Council.

Administration of Mental Health Policies and Programs in NYC

The administration of mental health policies and programs in NYC is primarily the responsibility of The Department of Health and Mental Hygiene, which is headed by a Commissioner. Reporting to the Commissioner is an Executive Deputy Commissioner/Director of Community Services, who has responsibility for mental health, mental retardation, and alcoholism services.

The functions of the department are primarily mental health planning and contracting.

For information call 212-219-5400.

The Community Services Board

• All county governments in New York State (including the City of New York) are required to have a Community Services Board to advise the Director of Community Mental Health Services.

• The Community Services Board oversees the three disabilities areas that constitute “mental hygiene”—mental health, mental retardation and developmental disabilities, and alcohol and substance abuse.

• In NYC, the Mayor appoints members of the Community Services Board.

• It meets regularly with the Executive Deputy Commissioner of the Department of Health and Mental Hygiene, who is the Director of Community Services for NYC.

The Local Planning Process in NYC

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