DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on National Health Promotion and Disease
Prevention Objectives for 2010
September 12, 2000, Proceedings
Agenda Item: Panel: Extending Healthy People State and Local Plans to Embrace Substance Abuse, Mental Health, and the Environment
Ruth Kirschstein/NIH (Moderator)
Elaine O'Keefe, National Association of County and City
Health Officials
Carolyn Givens, Ohio Department of Alcohol and Drug
Addiction Services
Oscar Morgan, Maryland Mental Hygiene Administration
DR. SATCHER: The next topic is Extending Healthy People State and Local Plans to Embrace Substance Abuse, Mental Health, and the Environment. Again, this is an extremely important set of concerns. I think, in some ways, the 2000 initiative fell short in extending to state and local programs parallel to the national efforts in these areas. Only about half of the state Healthy People 2000 plans included objectives for substance abuse, mental health, and environmental health.
To see what might be done to make state plans comprehensive and to address especially the cities and counties within the states, we want to now hear from another distinguished panel of discussants, including state and local health officials. This will be moderated by Ruth Kirschstein, who is, as you know, Principal Deputy Director of the National Institutes of Health. She is running NIH these days and doing it quite well. NIH has a co-lead for Healthy People 2010 focus areas in these three areas of substance abuse, mental health and mental disorders, and environmental health. Ruth?
Ruth Kirschstein/NIH (Moderator)
DR. KIRSCHSTEIN: Thank you, Dr. Satcher. I wasn't being facetious when I picked up on the remark that Ed Brandt said, you've come a long way, because, since tobacco is an abusing substance, I want to add one more thing quickly. That is, we should think exactly about that ad, the Virginia Slims ad, because there are differences between the girls who start to smoke and the boys who start to smoke. This goes back to my years of working on women's health. You can't put the whole thing together. Girls who start to smoke are worried about their weight. You have to tie together the concerns about weight and starting to smoke, or trying to stop smoking. I hope people will remember that in their campaigns.
Now, to get to the program that I am supposed to moderate -- though I did have one more remark, if I might. David suggested I make it, so I will.
That is, when Dr. Lee talked about the ability of the Human Genome Project to now elucidate considerable activities related to health disparities, I think we need to be careful. There is so much on the human genome that is absolutely identical from population to population to population, that we must not generalize, we must not assume that we are going to figure out how to eliminate the health disparities among racial and ethnic groups because of the differences in the genome. We have to concentrate on the other activities, the socioeconomic problems, et cetera. I think it's very important.
DR. LEE: Ruth, I should just put in a comment here. That was not my intention.
DR. KIRSCHSTEIN: No, I know, but I just wanted to make it clear, okay?
DR. LEE: I just think that (inaudible) benefit more from advances in general, it's likely to do this. That's why we have to do exactly what you said, pay attention to these other factors.
DR. KIRSCHSTEIN: Thank you, Phil. I just wanted to put that on the record.
Now, David set the stage for this discussion, so I'm not going to spend a lot of time. Since Ms. O'Keefe was introduced once, I think she doesn't need her background told. She presented beautifully before, and she will be presenting us on the goal related to the environment. The goal is, promote health for all through a healthy environment. Ms. O'Keefe.
Elaine O'Keefe, National Association of County and City Health Officials
MS. O'KEEFE: I can see that NACCHO intends to use me well and hard during my year as NACCHO President. I actually have quite a bit of experience in the arena of environmental health, so I was pleased to have an opportunity to speak on this aspect of Healthy People 2010. I guess I don't have to tell you the profound impact of environmental factors on human health.
We were very delighted to see a much more robust chapter on environmental health in the Healthy People 2010 documents, and also emphasis on some of the pressing contemporary environmental health issues like indoor air quality, for example, and also the need to educate health professionals, in particular, about the connection between human health and the environment, something that I have a particular interest in, having been through the experience of working in a community that has several very highly profiled Superfund sites.
Healthy People 2010, the environmental objectives in Healthy People 2010, I think, will provide a very good framework for local and state action and local and state planning. However, some of the same concerns that were already voiced about applying Healthy People 2010, which is a national plan, at the local level also apply to the environmental arena. I want to highlight a few of those concerns about implementing Healthy People 2010 in the environmental milieu.
There are a couple of examples where it has been done quite effectively. One example is the state of South Carolina. One of the reasons why I believe they have been so effective at doing this is because South Carolina is one, I believe, of only six states where environmental health and control for environmental regulation and public health are joined in one organization at the state level.
One of the issues that is of great concern when it comes to implementing Healthy People 2010 objectives at state and local levels is the reality that there is a schism now between environmental health and environmental issues and public health. That is more the norm in the majority of states in this country than not.
As I mentioned, ASTHO did a survey. I believe they came up with only six states where environmental and public health were joined in one organization at the state level. So that is one of the barriers, I believe, to developing cohesive plans at the state level and at the local level that look at the whole gamut of issues crossing environmental health, environmental regulation, conservation and all of the other professions that interact with public health goals in the environmental arena.
There are also, as I'm sure you are aware, many deficiencies in our science, in our knowledge of the connection between exposure to environmental toxins and health outcome. In many cases, that relationship is tenuous, and it makes it very difficult to identify true health risks that are environmentally related, and then also to measure progress in reducing those risks and outcomes.
That also relates back to the data gap issues. There are lots of gaps in data that exist in environmental health, both at the local and state level.
Another real major concern locally that I can speak to is the current culture of environmental health. If you have ever worked in a local public health agency or in a state public health agency, then you know what I am speaking of. There is very much a regulatory mindset that is very pervasive in environmental health. If we are looking at the environmental arena now in terms of embracing other groups and looking at environmental health issues, such as violence in communities, urban sprawl, looking at disparities in health, looking at environmental injustices that prevail, we need to have environmental health staff that are conversant in all of these areas and share those values and that have more of a generic public health training, a workforce that is trained in the essential public health services. I would submit that that is not the norm today in environmental health in this country, and that is an issue. I think that's one of the barriers we face in achieving the environmental objectives in Healthy People 2010.
There are also major issues with environmental injustice. There is a good amount of data that shows that racial minorities, that lower socioeconomic communities, are much more exposed to environmental toxins in their environments. That's indisputable. Until those injustices and disparities are addressed, it is going to be impossible to achieve the objectives that we've set in the environmental health arena.
There are a few examples of a state and a local model of attempting to apply the Healthy People 2010 document to the local training process. I had mentioned the state of South Carolina, where they have actually come up with a set of state goals and use parallel Healthy People 2010 objectives to align with their goals.
Then there is a county, Ingham County in Michigan, where they started out looking, without an eye toward Healthy People 2010, but just looking globally with the community group at all of the environmental health issues that they were concerned about in their county. Then they went from that to match those up with the Healthy People 2010 objectives and found that, in fact, there are a dozen or so objectives that they had identified that were not included in Healthy People 2010. Nonetheless, there were many crossovers between the Healthy People 2010 objectives and what this community had identified on its own.
I think the way that we can work locally to begin implementing and looking at the environmental objectives in Healthy People 2010 locally are very similar to what I discussed earlier when I was talking globally about implementation. We do have a tool that is specifically geared to environmental health assessments. It's called PACE. It stands for Planning for Assessing Community Excellence in Environmental Health.
This was a very, very important enterprise for NACCHO to take on, because we have found consistently, in general public health planning documents, that environmental health is not well covered. A lot of the environmental health issues that surface when you start talking to communities about their environmental concerns are not represented in those larger, broader public health assessment tools.
So NACCHO for several years labored with lots of input from focus groups and communities around the country to produce a guide that would help communities to identify environmental health concerns and to go beyond that to actually come up with data sets, instructions on how to collect data locally that would help us to measure our progress in meeting environmental health standards that we would set at the local level.
So we have that tool available. We've just rolled it out this year, and we will start to really advocate the use of that tool in the year ahead. We would like very much to do that in alliance with our national partners, and we have quite a few national partners in this room who are part of that process.
We also are excited at some of this collaboration we're seeing at the federal level, for instance, with the children's environmental health initiative. We think that that will work down to the local level in some of the collaborations that we want to advance.
The increase in public concern about environmental health issues is another opportunity to make Healthy People 2010 more of a priority. And of course, some of the scientific advances that have been made, for instance, in dioxin, looking at better science that will link environmental exposures to human health outcome.
Lastly, the fact that information is so much more accessible to the general public and that people can do their own research on environmental issues. This in turn is helping to empower communities to become more involved in identifying and addressing their environmental health issues.
So these are some of the opportunities that we have to begin rooting the Healthy People 2010 objectives in the work that we are doing at the local level. We look forward to working with you on that.
Thank you.
DR. KIRSCHSTEIN: Thank you very much. As we move to the next area of substance abuse, our next speaker is Carolyn Givens, who is the chief policy advisor of Ohio Department of Alcohol and Drug Addiction Services. She joined that department in 1992 and has moved up the ranks to become the chief policy advisor. She has her Bachelor's degree from the Ohio Dominican College, and recently she completed the senior executive's course in state and local government at Harvard University at the Kennedy School of Government. She is going to concentrate on something that all of us need to think about very much, alcohol abuse.
Carolyn Givens, Ohio Department of Alcohol and Drug Addiction Services
MS. GIVENS: Thank you very much. I am very happy to be here today with all of you.
It's important to give just a brief history. The Ohio Department of Alcohol and Drug Addiction Services is 11 years old. It's a cabinet level department, and it's recognized in the state of Ohio from its other cabinet level departments as being an integral broker of treatment and prevention services to help reduce the barriers of drug and alcohol addiction.
One of the primary challenges is understanding that collaboration -- and I heard grass roots effort mentioned here several times today -- has to happen not just at the state level, but at the local level, where partnership must begin first. I was happy last Friday when I opened up our Columbus Dispatch to find that the Columbus United Way also understands the issue of addiction.
On the back page of an insert that they put in the Columbus Dispatch, I'd like to read you something that really hits home. It's a picture of a small boy, and it says, this is James. Sometimes, he sits here when he should be in school. But that's not the problem. The problem is, James's mother is depressed and can't give him enough attention. But that's not the problem. The problem is that James's father is an alcoholic and forgets to come home. And that's the problem.
Addiction affects all of us. It affects children; it affects families; it certainly affects individuals. I am here today to tell you that addiction is in all forms. It's from tobacco, to alcohol, and to drugs. Unless we combat those issues, we're not going to get to the root of any of the other problems, such as poverty, welfare reform and education.
One of the things that Ohio is very excited about, and that I think plays very much into Healthy People 2010, is our binge drinking effort. We had the pleasure of having Dr. E. Gordon Gee, then President of the Ohio State University, as well as Dr. Barbara Ross-Lee, the Dean of the College of Osteopathic Medicine at Ohio University, back in 1996, help kick off the state's initiative for binge drinking. At the present time, we have 50 college presidents and also 36 state leaders involved in this initiative.
One of the things that has been remarkable is the overwhelming commitment that colleges have made to reducing the factors for binge drinking in their student population. Currently, the Ohio Department of Alcohol and Drug Addiction Services has $1.12 million involved in this initiative. As a result of that, we have 13 communities building on this coalition.
Part of the effort with binge drinking is recognizing that there must be a strategy. So part of the strategy -- and we have employed the help of the Ohio Parents for Drug-Free Youth to help focus on this initiative with the colleges. The initiative focuses on factors contributing to alcohol and drugs and the widespread belief that high risk behavior is normal behavior in college students. Also, understanding that alcohol is available at a very inexpensive cost and that the liquor outlet stores are very aggressive in its promotion.
But on top of that, laws and policies are not consistent, so the state of Ohio has looked at improving for Healthy People 2010 the enforcement of laws against under-age drinking. That enforcement has to do with looking at public policy and also prevention awareness in education. And certainly, the media, as has been discussed today, need to be a part of this marketing approach. The message in Ohio is that in Ohio under-aged drinking is illegal; it is unhealthy; and it is certainly unacceptable.
To date, Ohio has received, as I have said, $1.12 million from the United States Office of Juvenile Justice and Delinquency and Prevention. We've employed nine of our communities, four of which have linked together with universities to help combat this issue.
Besides doing that, the other piece that the Ohio Department of Alcohol and Drug Addiction Services has built upon is our relationship with communities and treatment providers. We have 94 women-specific treatment providers across the state, which are allowing for families or mothers to come in to treatment with children, concentrating on tobacco reduction, concentrating on literacy and education, and certainly employing recovery as a strategy towards self- sufficiency.
The other part of our work has been to expand adolescent treatment. Recently, the Governor has discussed with a number of Cabinet-level departments the need for us to expand adolescent treatment and prevention services. Part of those monies will be gathered from the tobacco settlement. I'm happy to say that that also plays into Ohio's strategy to look at Healthy People 2010.
It's also understanding the need for minority awareness and outreach. The Ohio Department of Alcohol and Drug Addiction Services has 12 specific minority outreach programs that occur in all of our 12 large cities in the state of Ohio. This is an organization that reaches African-Americans, as well as the Hispanic population in public housing, in senior citizen centers, in churches, in schools, as a grass-roots effort, again at the local level.
It has been a pleasure to work with these persons that are so highly committed to the same goals that we are talking about here today but, essentially, it starts at the local level. The cooperation that has been had at the collaboration at the state level certainly has helped to be the umbrella for keeping things moving or framing the issue. But without the local level involvement, I don't know where we would be today.
For the last 11 years, this department has maintained that the proper attention to alcohol and drug addiction would go a long way towards reducing teen pregnancy, school dropouts, domestic violence, and mental retardation. When alcohol abuse is acknowledged as the primary preventable cause, there's something we must be doing about it. That doesn't just mean understanding. It means employing, it means taking on, the charge from a local level, from a state level, and here at the national level.
I have tailored my presentation only because I have a 1:30 air flight back to Ohio, and I'm very appreciative to be here. So if there are other questions towards drug and alcohol, I'd be happy to take those.
DR. KIRSCHSTEIN: Since you have to leave soon, maybe we should ask if there are specific questions to Ms. Givens before we move on to the last speaker.
DR. SATCHER: I was in New Hampshire Friday. We met with a roundtable of high school students to talk about alcohol. I was really amazed, as we get back to the point about looking at statistics as opposed to looking at the faces -- they talked about how easy it was to get alcohol, and how almost no party that they attended was without alcohol flowing freely. There was always an older person there who supplied the alcohol to the children.
We know from data that kids who begin to drink at age 15 are four times more likely to be alcoholic than people who begin to drink after 21. But those students really -- and they started off being flippant about the problem of alcohol, but then later on they started to talk about what it means when there's a family member who's an alcoholic, and how that impacts upon them. It was an interesting discussion, which we videotaped, by the way.
DR. MASON: The question I have relates to all three -- mental health, environmental health, as well as alcohol and substance abuse. When these most commonly are outside of a state health department, they tend to come together at the local health department. How does the state health department pull this all together in terms of their planning under Healthy People 2010? How does it all get together at the state level and at the community level?
MS. GIVENS: One of the things in Ohio that's fairly unique is that the cabinet-level departments are all separated. That has worked well in Ohio. Particularly drug and alcohol has a very strong relationship with the Department of Health, surrounding the prenatal issue and then on through some of the tobacco and other issues that Ohio has to adhere to. The cabinet meets once a week.
All the governors since the inception of our department in 1989, from Governor Celeste to Voinovich and now Governor Taft -- it has been a major commitment for all the departments to be able to collaborate with each other. There is a major investment from the general assembly into each of our budgets. In particular, ODADAS receives $37 million in state dollars, coupled with our federal dollars, which amounts to about $65 million.
So our relationship is ongoing, it's a collaborative effort. Staff is meeting daily, if not hourly, between each department. Forty-six percent of our population are criminal justice referrals, so we have inter-agency agreements with the departments to broker prevention and treatment services.
From a drug and alcohol perspective, I will tell you that it has made it much easier, given the fact that the general assembly can recognize that it's a separate, identifiable illness. As to mental health, we have an ongoing relationship around the issue with the Department of Mental Health, with about three million dollars invested in treatment and prevention from that standpoint.
So in Ohio, that's how that has worked.
DR. KIRSCHSTEIN: The third topic is mental health. The goal is to improve mental health and assure access to an appropriate quality of mental health services. Our speaker is Oscar Morgan, who is Director of the Mental Hygiene Administration of the state of Maryland. He has a Bachelor's degree from the University of Colorado and a Master's degree from George Washington University.
Mr. Morgan.
Oscar Morgan, Maryland Mental Hygiene Administration
MR. MORGAN: Hello, everyone, and thank you for the introduction. I want to answer your question about how we integrate. Dr. Benjamin is my boss, and you heard him describe the process. I think that that's important, that mental health needs to be at the table. We have not always been at the table, and then at times we have to fight to be there. But I think it's important that somehow, some way, the mental health director find a means to be at the table.
With the planning processes that we have in Maryland, that's been a very easy thing for me to do. I would like to acknowledge Dennis McDowell, who is staff in mental hygiene. He is actually the one at the table representing me, so a lot of what I am going to be discussing today is because of his vigilance and his commitment to make sure that mental health has a voice.
As I sat here today and listened to all the presentations, it was like, well, they've said what I was going to say. So I have been thinking about what I need to say and want to say. I have sort of thrown out my entire presentation; I'm going to ad lib this.
What I wanted to talk about, because we heard the need for involvement and partnerships -- I think it's important for state mental health directors to figure out how they are going to change their systems to allow for those partnerships to occur. Obviously, if the goal is to provide a system of care where people can get services that are culturally competent, people have access to those services, and we have to find outcomes, the question is, is your system able to do that?
In Maryland, what we did is, we took a very close look at ourselves. We held a mirror in front of us and we looked at the good, the bad, and the ugly. We realized there were a lot of good things that we were doing, but we also realized there were things we needed to do better.
We formed coalitions. We identified every single mental health provider and trade association in Maryland under the auspices of the Mental Health Association. We hold monthly meetings. Our goal is this: to speak with one voice, because when we are advocating for those dollars, or we are trying to figure out what we need to do, we found that -- as we go out and everybody is competing, as Dr. Benjamin said, because Maryland is very active -- if we weren't speaking with one voice, it diluted our ability to achieve our united goals.
So we -- what Dr. Benjamin says is literally true; we have been -- one day I went to meet with the Speaker of the House and these groups of people. He literally told us to go into his chambers and stay there until we figured out the solution. So we went into his chambers about 3 o'clock in the afternoon, and we came out about 4 o'clock in the morning with the solution. But that is what you have to do. You have to work at it and work at it and work at it.
My job is described sometimes as being the baloney in the sandwich. I get eaten up by the federal government and by the locals if I don't do the right thing. So let me tell you what we try to do in terms of the right thing, to acknowledge Healthy People 2010 and give our locals the ability to do what they need to do in order to have an outcome, because clearly, I couldn't do it alone as Director of the Mental Hygiene Administration.
The first thing we did was acknowledge we needed partnerships, as I said earlier, and we needed local involvement. What I found as Director, it's better to go and put these things -- although sometimes it's very complicated -- in statute, because if I put it in statute, it takes a lot of the noise away when those people come back and say to their general assembly members, this isn't working. So we have a very public process, where we go through the general assembly. I say to them, this is what I need, and would you put this in the statute. So everything I am describing to you today is in statute.
I could say, it gives me pleasure, because when the advocates and others start complaining, the general assembly members say, well, Oscar, you know -- and I say, you bought off on this; this is your plan. It's not my plan; it's the plan of the state of Maryland. So if there's anything we need to do, we need to sit down and work it out together. Just don't point the finger and say it's my problem. It's all of our problem. That's a very important message.
We wanted the locals to be involved. The question was, how? Someone said earlier, you give them the responsibility, but you don't give them the money. So we went and created for Maryland local mental health authorities that basically said, your job is to plan, to coordinate care for your local jurisdictions.
Then we gave those locals the monies necessary to do that. We gave them nine million dollars for the infrastructure. Their job is to do a needs assessment on an annual basis, to identify for their local community what their needs are for mental health services and then figure out strategies to close the gap, as Dr. Benjamin said.
They then submit a report to me. I incorporate their needs into a statewide plan, and that plan becomes my budget. I then go to Annapolis and lobby for it. And so, when I'm talking about the mental health budget, it's not my budget. It's the citizens' budget of Maryland.
The one thing we need to do -- one thing we made clear to our locals is, the budget will not be accepted, their plan will not be accepted, unless it's signed off by the community. So we have in statue those community organizations and people who must participate in the development of that plan, sanction the plan before it comes up to me, so it really is reflective of what the community needs and wants are. If they don't have that little signature page on it, the plan never gets to stage one.
So what happens is, when we go to Annapolis once again, you're not seeing only the bureaucrats at the table. You're seeing the citizens there who are commenting on and arguing for and lobbying for their plan, because it represents what the locals want.
The second thing we had to do was acknowledge that our system wasn't very welcoming. If you're going to have good outcomes, you have to have the people come to the services. We talked to our consumers and family members, and it wasn't welcoming. It wasn't culturally competent. We asked, what's wrong here?
Once again, through many, many meetings, we decided, we have to change our system. So in 1997, we literally threw out our whole system and introduced in statute a new system. The goal was to have a 24-hour, seven-day-a-week, 365-day responsive system that was culturally competent and reflective of consumer needs, not my needs or any particular agency's needs.
That was a very different way of thinking, because heretofore, our system was provider-driven. If you wrote a grant and you wrote a good grant, you got funded. We weren't that concerned about the people. We were more concerned at that point about whether or not we had providers.
We looked at our system. We had 200 providers. Today we have 4,000. So access became a very important issue for us. People had to get to the services. We have one number you call, an 800 number. You can call that number 24 hours, seven days a week, and a mental health professional will answer the phone and guide you -- consumer, family member, or provider -- through our system and help you identify a provider of your choice who is able to meet your needs. We have a provider profiling system, where we ask providers in our system to tell us who they are in terms of their skills, their hours of work, their handicap accessibility.
If you call in and say you want to see -- we have had this situation, where a parent called in and wanted her son, who was in a wheelchair, to be seen by a physician who was also wheelchair-bound. She wanted him in a particular community, at a particular time in terms of hours. We were able to find her a match of seven psychiatrists who were able to meet her needs.
So that's the type of system that we have tried to effect. One that is culturally competent; one that's respectful; and one that meets the needs of the individuals.
The second thing we decided to do was to make sure that as we planned -- while there were differences in the plans -- we also had some similar goals. So the two goals that we worked on in terms of Healthy People 2010 - one was depression. We have incorporated that into our planning activities as of today. This will go over a 10-year period.
The thing we realized was that we could not put forth a particular model for any particular jurisdiction. So every jurisdiction has decided what their performance standards will be. How they get there is unique to that particular jurisdiction.
Baltimore City, for example, has decided that the faith community is very important in terms of how certain people access their care. They may go to the faith community before they come to mental health professionals. So as a result, we are providing consultation, videos, training to the faith community. On my part, we have actually changed our statute to be able to reimburse the faith community for the work they are doing in terms of providing mental health services to people who come to them, with the acknowledgment that, if it gets to the point where they need a professional to step in, we can partner them up with that.
The other thing that we have done in terms of changing the system is making sure that we identify all the persons in our system who have different, unique needs. In Maryland, we have a large deaf community because of Gallaudet College here in Washington, so we are providing services in a very unique way, based upon how the deaf community wants that. The Hispanic community, Korean community, Russian community -- all of our materials now are in the languages of the people who are in our community and are reflective of that. We have identified people who have the ability to speak their language or at least know something about their culture, so that we can then design the system accordingly.
We have a very fluid system. What we hope to achieve with this is that the money will follow the individual. The individuals select what they want and, as a result of having a system that is culturally competent, flexible, welcoming, we can achieve the Healthy People 2010 goals. In fact, we've seen a significant increase already.
The last thing I want to talk about is how we measure this. We have put together a data system where, on any given day, any given moment, we know who is in our service system, why they are there, who they are getting the service from, how much is that service costing, and was it beneficial to that individual. Then we can string that daily service along with the services they got yesterday, the day before, and we can also project, based upon the consumer's needs and wants, what they will need two months from now, three months from now. Then at the end of the year, we go back and ask the consumers, did it make a difference in your life?
We are looking at it not only in terms of their diagnosis, in terms of did it help your mental illness, but did it affect you overall? Are you able to work now as a result of the services you got? Did you increase your involvement in the criminal justice system? Did you improve your functioning, yes or no? If not, we get feedback from the consumers and we find out what we need to do differently in order to make not only the clinical services better, but also their ability to function in society and in Maryland.
So that's a little bit about what we are doing. I can answer any questions, if you have any.
DR. KIRSCHSTEIN: Thank you, Mr. Morgan. Comments? All three of our speakers, including Ms. Givens, are still here. Are there questions?
DR. SATCHER: Mr. Morgan, what is the status -- I don't remember -- in Maryland in terms of parity of access for mental health services?
MR. MORGAN: Maryland was one of the first states on parity. It is probably now one of my major headaches. What we have seen is, parity was defined as having the financial benefit. In other words, if your premium was 80 percent and the deductible was 20, then that was the parity.
What we missed the boat on is the benefit package. So what we are beginning to see is -- in the public mental health system, our benefit packet includes everything from in-patient to housing. We are now seeing a significant migration, particularly of children who are insured, into our system, because the private insurance companies will say, we don't pay for that.
So this question of parity now has taken on a different meaning for us. It's not just financial parity, but I think we need to go back and look at benefit parity.
DR. KIRSCHSTEIN: I can remember when, in the state of Maryland -- Julie probably does, too -- people specifically moved to the state of Maryland to get mental health coverage.
DR. RICHMOND: I can't let this opportunity go by, when we are talking about mental health and substance abuse and related issues, of acknowledging our indebtedness to
Dr. Satcher for having put out a Surgeon General's report, the first, on mental health. I guess I would like to ask the question of, what has been the impact of that report on programs in the states?
MS. GIVENS: In Ohio, we have built from that report. Actually, we started with Healthy People 2000, building on the initiative when it was earlier brought about in 1989 with the inception of our department, helping people be aware of the issue of addiction, also including tobacco.
So I think we are building from what historically has been there, and then emphasizing through the 2010 piece the essential pieces that we are trying to roll out with binge drinking and certainly enforcement against illegal drugs.
MR. MORGAN: The report has acted as a catalyst to have dialogue with the media, with the citizens in general, related to the need for mental health. I think it has been used to educate people that mental health is treatable, and as a result, it has also gotten us into a dialogue about science-based practices, which I think is very exciting, because now we move to, what does the data show, what does the science show?
With the University of Maryland and Johns Hopkins we are actually starting a science-based research institute. We're going to be asking those scientists to look across the country for best practices and then figure out a way to disseminate those best practices to family members and providers, so that we are not constantly re-inventing the wheel.
So I think it has really helped in terms of dialoguing about mental illness.
DR. KIRSCHSTEIN: Would you like to comment about the local level or not, in terms of the mental health report? No? Okay.
DR. KANG: I have a question for Mr. Morgan. To the extent that you were revising the mental health systems in terms of accessibility and cultural competency, how did you end up dealing with people who were commercially insured and it was a covered benefit, but still they showed up in your system because of the access issues? What kind of dialogue or discussions did you have with the other insurers?
MR. MORGAN: What we did is, from the very beginning, we put in dollars toward what we call the uninsured. So in our system, if you have insurance, of course we're able to find that out, and we will send you back. But we also realized -- because as I said earlier, there are some things that we'll fund that the insurance companies won't fund, and we didn't want to exclude people from that list. So we actually have money.
Dr. Benjamin said to me, "I finally figured it out; you created a universal access," -- because that is what it is. In order to get into our system, you have to have one thing, and that is a mental health need. If you have a mental health need, then you're entitled to the services that we offer.
DR. KANG: Did you attempt to get any of your providers, actually network providers of the insurers?
MR. MORGAN: Yes, we did. In fact, we sent out a letter to every single mental health provider in the state of Maryland, saying it was their fiduciary and moral responsibility to provide services to individuals who were either on Medicaid or uninsured. So we have enrolled in our system about 90 percent of all the licensed mental health professionals in Maryland.
DR. SATCHER: Why don't we give this panel a hand? Thank you. We are scheduled to break at 1 o'clock, and I think we are about back on the schedule.