Testimony of
the NATIONAL MENTAL HEALTH ASSOCIATION RALPH IBSON, VICE PRESIDENT FOR GOVERNMENT
AFFAIRS before
the SUBCOMMITTEE ON HEALTH HOUSE
VETERANS AFFAIRS COMMITTEE on VA PROGRAMS FOR VETERANS WITH MENTAL ILLNESS AND SUBSTANCE
USE DISORDERS JUNE
20, 2001 Mr.
Chairman and Members of the Subcommittee: I had the privilege
of serving on the staff of this Committee for nearly 10 years, and am
honored to appear before you today on behalf of the National Mental
Health Association (NMHA). The National Mental Health Association
NMHA is the
country’s oldest and largest nonprofit organization addressing all
aspects of mental health and mental illness.
In partnership with our network of 340 state and local Mental
Health Association affiliates nationwide, NMHA works to improve
policies, understanding, and services for individuals with mental
illness and substance use disorders.
Several NMHA affiliates have developed and operate programs
serving persons who are homeless and suffer from mental illness and
co-occurring substance use disorders.
Within the last year, NMHA has initiated a working group
partnership with VA, the National Coalition for Homeless Veterans, and
USVets (a Los Angeles-based non-profit that has developed transitional
housing and rehabilitation programs across the country for veterans
who are homeless) to foster the development of new community-based
coalitions and programs to serve homeless veterans. The Significance of VA’s Specialized
Treatment Programs
During my years
working in the House I was often asked why there continues to be a
need for a Government-operated health care system for veterans.
Some questioned why, for example, the obligation owed veterans
couldn’t be as effectively discharged through a voucher system or
some other contractual arrangement.
The response I gave to such questions was similar to a response
VA Secretary Tony Principi recently gave to a C-Span interviewer.
Secretary Principi identified VA’s specialized treatment
programs for veterans with mental illness as one of a core of
specialized programs that are central to what makes VA a unique, vital
national resource. VA: A Unique “Safety Net” for
Veterans with Mental Illnesses
Those explaining the
importance of maintaining the VA health care system also cite its
uniqueness as a “safety net” for veterans.
That safety net mission is particularly important to veterans
with mental illness or substance use disorders because – unlike many
other veterans – these individuals often lack other health care
options. Both the
Medicare program and most private health insurance, for example,
impose arbitrary, discriminatory barriers to mental health care.
Under the Medicare program, individuals face a 50% copayment
for outpatient mental health services and a lifetime cap on coverage
of psychiatric hospitalization. In
a report last year on the Mental Health Parity Law of 1996 (which
prohibited disparate annual and lifetime dollar limits on mental
health care in private group health insurance), the General Accounting
Office reported that while 86% of the employers it surveyed complied
with the limited parity requirement of that law, 87% of those who had
complied evaded the spirit of the law by substituting other
discriminatory mechanisms (such as limits on numbers of outpatient
visits or days of hospital coverage, or greater cost-sharing burdens)
to limit coverage of mental health services.
These barriers help explain the reliance veterans with mental
illness place on VA for care. For
example, more than 50 percent of veterans service-connected for a
psychosis, and more than 60 percent of veterans service-connected for
PTSD, used VA health care services in FY 2000. As you know, Mr.
Chairman, some five years ago VA embarked on what became a remarkable
transformation of its health care system.
The clear danger that a zeal to achieve cost-savings would
threaten the viability of often costly specialized treatment programs
led Congress in 1996 to enact legislation to protect this unique
program capacity. This
Committee can proudly claim authorship of the statutory requirement
that VA maintain its specialized capacity (within distinct programs
dedicated to veterans’ specialized needs) to treat veterans with
mental illness and other specified conditions.
As this Committee has ably documented, competing VA priorities
and fiscal incentives – which were dictated by policy not law –
largely thwarted that statutory protection.
As a result, VA mental health programs, in particular, fell
prey to sweeping contraction and cost-cutting in many networks across
the country. Capacity and Effectiveness of VA
Mental Health Programs
Your inquiry today
regarding the capacity and effectiveness of VA mental health programs
is both timely and important.
Let me offer a few observations.
First, over the last five years the VA health care system has
markedly diminished – by its own measures -- its capability to
provide care to veterans with mental and substance use disorders.
Second, this loss of program capacity has been variable from
network to network – wholly at odds with VA’s obligation to
operate a national health care system and provide equitable
access to care. And
third, with its failure over the last five years to maintain and
reinvest mental health funding to establish needed community-based
mental health programs, VA can no longer claim to provide state of the
art mental health care. The
implications of these observations are profound, in my view. Mr. Chairman, I trust
you would agree that the real issue before this Committee is not
simply whether VA has maintained a specified level of program capacity
– which it has not -- but whether, as a national system, it provides
veterans reasonably accessible, effective, high quality care and
services for mental and substance use disorders. I believe the hearing record you compile will
demonstrate that it does not. State-of-the-Art Mental Health Care
More than 450,000
veterans suffer from a mental illness which the VA has determined to
be service-connected, that is, the illness was incurred or
aggravated in military service. Surely such veterans should be afforded care and services of
the highest quality. Indeed
the Department’s budget submission for FY 2002 states (at p. 2-122)
that VA provides “state-of-the-art” mental health care. Do the facts bear out
that claim? As the Surgeon General documented in the landmark 1999 Report
on Mental Health, state-of-the-art care for severe mental illness is
recovery-oriented care which requires an array of services that
include intensive case management, access to substance abuse
treatment, peer support and psychosocial rehabilitation such as
pharmacologic treatment, housing, employment services, independent
living and social skills training, and psychological support to help
persons recover from a mental illness.
VA mental health professionals have recognized and identified
these as needs “that should be the target of developmental efforts
in the coming years” (Report of the Committee on Care of the
Severely Chronically Mentally Ill Veterans [hereinafter “the
SCMI Committee”], February 2000, p. 64.
As an entity established pursuant to law – the product of the
House Veterans Affairs Committee’s initiative – the SCMI
Committee’s findings and recommendations are particularly
noteworthy.) But,
notwithstanding the courageous advocacy of VA mental health
professionals, the Department is clearly not furnishing this
comprehensive spectrum of services to veterans with severe mental
illness today. While budget
pressures and other constraints may in the past have posed barriers to
VA’s providing the spectrum of services identified by the Surgeon
General, a health care system providing state of the art mental health
services would certainly not have de-institutionalized patients with
mental illnesses, as VA did over the last five years, without
establishing accessible community based services in all networks to
assure continuity of care. It
is clear that in many parts of the country VA failed to meet this
critical obligation. But
while instituting a comprehensive, state-of-the-art mental health
system for veterans remains an imperative, VA has yet to meet the more
modest goal it has set of establishing a sufficient number of
intensive case management programs to serve veterans’ needs.
As the SCMI committee recently noted, entire networks and many
major metropolitan areas have no such VA service available. And while
VA opened hundreds of community-based clinics in the last five years
– in part through rechanneling funds freed up from psychiatric bed
closures -- only half these clinics provide mental health services. I urge the Committee
also to consider the issue of substance abuse.
As many as half of people with serious mental illnesses develop
alcohol or other drug abuse problems at some point.
Substance abuse is a major problem among veterans, and many
suffer from both substance use and other serious mental disorders,
including psychoses and PTSD. A
state-of-the-art mental health care system would not countenance a
situation in which eight of the country’s 25 largest metropolitan
areas lack programs to treat drug addiction, for example, or in which
the numbers of patients afforded substance use treatment has declined
in the face of substantial increases in the numbers receiving care for
other health conditions. A state-of-the-art
mental health care system would also not subject its patients to
policies or practices of “failing first” on lower-cost medications
before permitting its physicians to prescribe a drug of choice.
It is our understanding, however, that such a policy
--applicable to so-called “novel” or atypical antipsychotic
medications -- has, in fact, been adopted and in use in two of VA’s
networks. Atypical
antipsychotic medications are newer medications found to be
efficacious in the treatment of schizophrenia.
The network policies on the use of these medications provide,
in effect, that veterans are eligible for the more costly of those
medications only if they have “failed” on a course of therapy with
one of the less costly agents. It
is our further understanding that VA clinical managers had proposed
the adoption of such a policy for use systemwide. The establishment of
such a “fail-first” policy would seem to assume that the various
newer antipsychotic medications can be used interchangeably in any
patient with equal results. These network policies, however, ignore the reality that
individual patients differ in their response to different medications
and in their sensitivity to the particular side effects of the drugs.
And they ignore the fact that “failing” a course of therapy
can result in a psychiatric crisis that may lead to hospitalization.
To our knowledge, there is no apparent scientific basis for
denying veterans eligibility for particular medications.
The rationale for these policies (other than cost-savings) is
particularly mystifying in light of the fact that the National
Institute of Mental Health has a study underway to compare the
effectiveness of a wide range of antipsychotic medications in persons
with schizophrenia (titled Comparative Effectiveness of Antipsychotic
Medications in Patients with Schizophrenia often referred to as the
“CATIE Schizophrenia Trial). If
the National Institute of Mental Health is still studying the
differences among these medications, it is difficult to understand the
scientific basis that would warrant an individual VA network or VA
itself to deny a veteran “eligibility” for a particular
antipsychotic medication that his or her physician, in the exercise of
clinical judgment, deems most appropriate for that individual. Remedial Steps
Can the problems NMHA
and others have identified be remedied?
This Committee is to be applauded for making important,
valuable recommendations to increase funding for VA mental health
care, as well as for convening this hearing.
NMHA would urge the Committee to go further.
Increasing VA funding, for example, will not necessarily assure
that additional new funds are allocated to mental health care, as
proposed. The seemingly
almost unfettered latitude that VA network directors have enjoyed –
to maintain specialized programs or to close them, to provide
substance abuse services or not, to deny veterans access to certain
medications, etc. -- raises a concern that spending decisions will
continue to be made in accordance with vastly divergent priorities
from network to network. And it underscores that
– regardless of veterans’ needs -- mental health and
substance abuse will not necessarily be a high priority in each
region. Mr. Chairman, the
enormous disparities from region to region in access to care for
mental health and substance use disorders for the large numbers of
veterans with these conditions must be remedied. That remedy, in my view, should find expression in
legislation. There are several
avenues that might be considered.
A first, though not exclusive, step might be to amend the
capacity law itself to include clarifying that the requirement to
maintain specialized program capacity is not simply a systemwide
mandate, but one applicable to each network.
NMHA would urge the Committee to go further, however.
Consideration might also be given to the concept proposed in
the Heather French Homeless Veterans Assistance Act, H.R. 936, (which
NMHA supports) which would alter the resource allocation model for
funding specialized programs serving veterans with mental illness and
substance use disorders. Anomalously,
fiscal incentives have often proven more powerful than statutory
directives in effecting desired changes within the VA health care
system. Still another
approach – perhaps an intermediate step to the more far-reaching
VERA proposal -- would be to direct those VA networks which have most
egregiously reduced their support for these specialized mental health
and/or substance abuse programs (as measured by patients served and
dollars expended, as adjusted for inflation) to develop and carry out
a management plan for bringing these programs to the required levels
by a specified date. In
any case, NMHA would recommend that any such remedial legislation
provide for an independent oversight mechanism, such as auditing by
the VA’s Inspector General, through which the Committee could be
assured that the legislation produced the intended result. NMHA urges the
Committee, however, not to set its sights solely on the issue of
“capacity” – challenging as that has been – but to work to
bring VA programs for veterans with mental illness and substance use
disorders to the level that experts inside the VA and elsewhere
acknowledge to be state-of-the-art. Thank you for the
opportunity to present NMHA’s views on this very important subject. Ralph Ibson Vice President for Government Affairs National
Mental Health Association
Ralph Ibson is a graduate of Tufts University (B.A. 1967) and
the University of Pennsylvania Law School (J.D. 1973).
He is a veteran of service in the U.S. Army (1968 – 1971). Ralph began a career of government service in 1973 working as an attorney for the Veterans Administration (VA) on its Board of Veterans Appeals. In 1976 he joined the VA’s Office of General Counsel, moving in 1980 to the position of Deputy Assistant General Counsel. In that capacity, he served as counsel to the Commission on the Future Structure of the VA
Health Care System.
In 1990, Ralph joined the staff of the House Veterans Affairs
Committee, taking a position as Staff Director of the Subcommittee on
Hospitals and Health Care (later the Subcommittee on Health).
Ralph retired from the Committee in June 2000 and accepted the
position of Vice President for Government Affairs with the National
Mental Health Association.
The National Mental Health Association (NMHA) has not received
any grant or contract from the Department of Veterans Affairs. NMHA
has received contracts or grants (which may be deemed to have some
relevance to the subject matter of this testimony) during the current
or previous two fiscal years from: The Substance Abuse
and Mental Health Services Administration contract for $24,000 to
undertake a project on consumer involvement in public managed
behavioral healthcare; The Center for Mental
Health Services of the Substance Abuse and Mental Health Services
Administration contract for $300,000 to operate a resource center
providing technical assistance and training to facilitate self-help
approaches, recovery concepts, and empowerment for mental health
consumers. The Department of Justice, National Institute of Corrections: a grant for $150,000 to develop a manual for prison staff about effective mental health services needed in prisons, and a grant for $24,120 to address the needs of adults with mental illness in community corrections programs. Back to Witness List |