Eileen Elias, M.Ed. and Diane M. Jacobstein, Ph.D.
Apportioning scarce resources is an essential activity of economics. Economics takes on a disturbingly human face when the scarce resources are facilities and services and the recipients are individual children and adults with co-occurring developmental and emotional disorders. The stakes are high since the risks include homelessness, institutionalization, or criminalization. In this current economic recession, it is more necessary than ever to stop the historic "ping-pong" approach that is typically used among mental health and developmental disability agencies and other state authorities to determine eligibility and funding. It is no longer acceptable to dispute or ignore the necessity for coordinated and integrated services, where each state's service systems and authorities mutually plan and work together to address the complex needs of these individuals.
States' current fiscal challenges are resulting in budget decisions based on the near-term bottom line rather than on enlightened health policy. Each time a family is forced to give up custody to obtain services for their child, the costs are shifted to either the social services or the criminal justice system. When the behavioral health issues of the adult with developmental disabilities are not addressed and become unmanageable, the costs are shifted to homeless shelters, the judicial system, or other state institutions. This is short-sighted, because when society does not deal comprehensively with individuals' complex needs that cut across agencies, the state or local government often becomes the caregiver of last resort anyway. This only increases the likelihood that the most restrictive and expensive placements will be used. Additionally, some states that applied for and were awarded Medicaid discretionary funds are now declining them out of concern that the federal allocation or the state's match would not be available in future budgets. It is unfortunate that a more comprehensive policy review did not assess the "downstream" costs of preventable institutionalization, homelessness, and criminalization.
During this economic crisis, there are solutions that can benefit the child and adult with co-occurring disorders. Two actions are needed:
1.Maximize the effectiveness of available resources through creative partnerships. This is achieved by two means. The first is to eliminate administrative duplications (e.g., redundant screening and assessment processes) and divide service tasks realistically. The second is to foster free communication among the mental health and developmental disability state authorities, and all other relevant agencies (such as education, child welfare, and juvenile justice) as well as service providers. All need to be willing to plan on how to "pool" or "braid" respective resources, both economic and professional, and to identify ways to provide jointly supported services that prevent escalation of behavioral health issues yet maintain one entity's lead responsibility.
2.States should reassess the potential benefit of Medicaid discretionary grants for individuals with complex needs by reviewing the cost-benefit of this federal funding. They can examine how these funds could enhance the ability to support children and adults in community-based services, preventing clinically unnecessary institutionalization, homelessness, or criminalization.
The benefits of these actions are potentially far-reaching. In a time of growing homelessness, it is especially important to keep adults or youth with co-occurring disorders in needed community-based services rather than on the streets. Developmental disabilities, education, mental health, and other state authorities can benefit from the more streamlined provision of services. The challenge is recognizing that partnership planning is needed in order to "do more with current funds." Several states have recognized this need and have undertaken statewide planning for either child or adult services.
Eileen Elias, M.Ed.
Senior Policy Advisor for Disability and Mental Health
JBS International, Inc.
Prior Commissioner for Mental Health, Massachusetts
Former Deputy Director, DHHS Office on Disability
Diane M. Jacobstein, Ph.D.
Clinical Psychologist/Sr. Policy Associate
Research Associate Professor, Pediatrics
Georgetown TA Center for Children's Mental Health
The "U.S. Public Policy Update" is an ongoing column in The NADD Bulletin. We welcome your comments and submissions for this column. To learn more or to contribute to this column you may contact Joan Beasley, Editor of the U.S. Public Policy Update at firstname.lastname@example.org.