Target Population

Many of the recommendations relating to mental health contained in this Report are predicated on the availability of effective mental health services in the community. In any year, millions of American adults have a serious mental illness-about five to seven percent of the adult US population, according to several nationally representative studies. ^[1]   The overlap in the populations that the corrections and mental health systems serve is significant: the US Department of Justice reported in 1999 that about 16 percent of the population in prison or jail has a serious mental illness. ^[2]   Frequently, the symptoms of mental illness contribute to individuals becoming involved with the criminal justice system in the first place and keep them incarcerated longer than other people. In addition, the stressful setting of a correctional facility can exacerbate mental illness and disrupt treatment.

Key Problems

Co-occurring substance abuse disorders affect over 70 percent of prisoners with mental illnesses. ^[3]   These prisoners are also more likely to have histories of homelessness and sexual and physical abuse. ^[4]   Addressing this spectrum of needs is critical to ensuring adequate treatment and promoting recovery, but requires a high level of coordination among corrections, mental health, and other systems-a level which, by and large, these systems have not yet achieved. These overlapping needs must be identified through screening and assessment, and met through services provided within and outside of correctional settings.

Stigma around mental illness presents another major obstacle to effective mental health care delivery. Bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance can deter individuals from seeking-and the public from wanting to pay for-mental health care. Stigma also reduces patients' access to resources and opportunities (such as housing and jobs), both through outright discrimination by providers and the public and by isolating and discouraging individuals with mental illness from pursuing full participation in society. ^[5]  

The mental health system today has powerful and effective medications and rehabilitation models with which to work, and the professionals in the system know how to meet the needs of the people it is meant to serve. But many individuals with mental illness still fail to access mental health services and many others are not provided with the quality of care necessary to facilitate their recovery and successful community integration. In 2003, the President's New Freedom Commission on Mental Health issued an interim and then a final report that together provided an unvarnished assessment of the nation's mental health care system, characterizing the delivery of mental health care across the US as fragmented and in need of fundamental transformation. (See sidebar, "Resources for Understanding Mental Illness and Treatment Systems," for more on the New Freedom Commission report.) While many jurisdictions are already making strides towards implementation of the Commission's broad array of policy goals and recommendations, it is critical that any policymaker preparing to engage with mental health administrators and practitioners on a re-entry effort recognize the complexity of the organizational structure that currently exists.

The fragmentation of this structure raises issues in two distinct areas. Issues in access to care include location of providers, exclusions (for example of people with criminal justice involvement, or with co-occurring substance abuse disorders) from particular programs or services, and funding-a particularly complex issue for mental health care (see sidebar, "Mental Health Care Funding"). Issues in quality of care include developing and promoting evidence-based practices and quality standards, including licensing, regulating, and monitoring care providers. While federal and local entities play significant roles in mental health care financing and delivery, it is primarily state agencies that must coordinate the disparate elements of the mental health system and address access and quality issues. These roles, and the organizations that assume them, are described briefly below.

System Organization and Funding

Understanding how to address the array of issues relevant to individuals with mental illness who are released from prison or jail requires some familiarity with the dramatic shifts in mental health care over the course of recent decades. Few systems have attempted so complete a change over the previous 40 years as has the nation's public mental health system. Once based predominantly on institutional care and isolation, the system has shifted its emphasis almost entirely to the provision of community-based support for individuals with mental illness. In 1955, state mental hospital populations peaked at a combined 559,000 people; in 1999, this number totaled fewer than 80,000. ^[6]   There are many reasons for this change; fiscal reality, political realignment, philosophical shifts, and medical advances have all played a part. These forces and others have converged to create a reality that few could have envisioned when the Community Mental Health Centers Act was signed into law in 1964. ^[7]  

Federal involvement in mental health care delivery occurs primarily through the relevant divisions of the US Department of Health and Human Services (HHS): the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Medicaid and Medicare Services (CMS). SAMHSA's Center for Mental Health Services (CMHS) administers the Mental Health Block Grant to states for providing mental health services to people with mental illnesses; this funding totaled $434.7 million in 2004. ^[8]   Medicaid and Medicare (administered by CMS) represent the greatest share of the federal contribution towards mental health care, though those funds are disbursed through state benefits agencies (rather than going directly to providers) and must be matched by state dollars. Veterans Administration health and cash benefits support mental health care services for individuals with military service records. The Social Security Administration oversees entitlements to individuals meeting poverty or disability criteria that enables them to obtain access to needed services and supports. The Department of Housing and Urban Development supports several housing programs targeted to persons with serious mental illnesses. Other federal agencies within the Departments of Labor, Education, Agriculture, and Transportation fund programs to assist persons with mental illnesses within community settings. In addition, the federal government plays an important role in promoting, implementing, and disseminating research through the National Institutes of Health, specifically the National Institute of Mental Health (NIMH).

Two recent federal initiatives have focused attention on the plight of individuals with mental illnesses and the nation's system of care. The US Surgeon General's 1999 Report on Mental Health has served as a comprehensive resource for administrators and providers alike. In 2002, President George W. Bush took the further step of establishing the President's New Freedom Commission on Mental Health to determine, and to make recommendations for improving, the state of mental health care delivery across the nation. (See sidebar, "Resources for Understanding Mental Illness and Treatment Systems," for additional information on these federal initiatives.)

State mental health agencies administer federal and state mental health dollars, certify and regulate mental health care providers, and frequently serve as providers themselves through hospitals, correctional institutions, or even some outpatient facilities. States have historically assumed, and currently maintain, responsibility for the development, implementation, and monitoring of public mental health services. As such, it is important for policymakers engaging with mental health systems to understand state standards, which vary widely.

As brokers of federal Medicaid and supportive services dollars, and through dissemination of state-specific funds, state agencies also serve as the primary financial supporters of mental health care. Typically, state mental health directors must forge close partnerships with state Medicaid directors and other benefits administrators, as well as state substance abuse treatment and physical health administrators.

Mental health services are primarily delivered at the community level, however, and it is there that policies prove to be effective or not. Policymakers and partners seeking change in community responses must be aware of the structure of the community mental health system in the towns and cities where they live. They should focus not just on what exists, but most intently on what a community mental health system could look like if all the pieces were in place. These pieces include providers of community-based and corrections-based (jail) mental health care, substance abuse treatment, housing, social services, and wraparound services.

In addition to governmental agencies, important organizations and participants in the mental health care delivery system include advocacy organizations, consumers of these services, and family members. Whether representing themselves alone or organized in associations, these individuals are a key component of the mental health system in any jurisdiction, and often serve as boundary-spanners between systems and jurisdictions.

Coordination among this diverse array of stakeholders, across multiple levels of government, can be complicated. Policymakers should seek to capitalize on advances in communication and information technology to serve as tools for mental health systems to deliver the best treatment and to empower consumers and their families to become involved in their own care. Such tools can create efficiencies by bridging geographical gaps as well as by eliminating redundant information gathering.

Mental Health Care Funding

The majority of funding for mental health care is public. Public funding serves as the overwhelming source of care dollars for individuals with mental illnesses coming out of prison or jail, few of whom have any access to private insurance. And public funding for mental health services involves an exceptionally complicated mix of local, state, and federal monies. To provide the full spectrum of services to meet the needs of distinct individuals with mental illnesses, a local provider agency must weave together funds derived from sources that may have different guidelines, fiscal years, and stated purposes. Some funding comes to agencies on a per capita basis, some on a "fee for service" or reimbursement basis, and some comes in the form of grants for specific sub-populations with specific objectives. Some services are paid for regardless of who accesses them, while most require clients to qualify for programs by demonstrating poverty or disability. In some states, funds are funneled through federally approved managed-care frameworks while others adhere to federal program guidelines. In some states, counties present an additional level of administration.

It is important for those who use this Report to consider, at a minimum, three funding issues as they contemplate implementation of its recommendations regarding mental health care systems. First, are there sufficient funds available to the system for it to meet the expectations of its various constituents? Second, are funds allocated appropriately to ensure the system's priorities are met? And third, is there a mechanism to determine whether allocated funds are achieving the outcomes appropriators think they are purchasing?

Source: US Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999), Figure 6-6. From T. Mark, D. McKusick, E. King, H. Harwood, & J. Genuardi, National expenditures for mental health, alcohol, and other drug abuse treatment, 1996 (Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998).