N.H. risks reneging on mental health commitment

It’s concerning that state’s history of underfunding may be repeating itself

The state’s mental health settlement with the U.S. Department of Justice and funding in 2013 for elements of the 2008 10-year mental health plan are regularly cited as examples of how well New Hampshire is meeting its obligations to citizens with mental illness. However, while $28 million was appropriated two years ago, it appears that nearly $12 million of that investment has not been made. The programs which were authorized and funded – but which have not been implemented – include:

 • An additional 16-bed acute residential psychiatric treatment program.

 • Ten new Assertive Community Treatment teams, six of which would be children’s ACT teams (five have been made operational as of this date).

 • The creation of 74 new community treatment beds.

As nonprofit community mental health providers, we are concerned that the funding for these programs could be at risk of being absorbed into other areas of the new state budget, now being developed by the Legislature.

This concern comes from a history of the state underfunding the system, imposing rate reductions on providers and adding to administrative and payment system burdens for community mental health centers.

It also comes from the sense we have that the legislators setting budget priorities in 2015 face a tougher challenge than they did two years ago.

Release of the 10-year plan in 2008 was almost immediately followed by a downturn in the economy, which led to state budget reductions. The community mental health system was forced to respond to fewer dollars and more costs by reducing services and triaging care. Lower acuity mental illnesses were left untreated and worsened, and more residents’ conditions worsened to the point of crisis; many turned to their local hospital emergency departments for help.

By 2013, the daily wait list for beds at the state hospital emerged as both the measure of the crisis and the consequence of starving the mental health system for nearly a decade. The wait list continues today.

The critically important programs approved two years ago need to be given a jump-start now, in this new budget year, so that funds are not diverted to other areas.

In the midst of this, the community mental health system faces additional challenges that should be addressed, including a Medicaid “spend-down” requirement that results in $8 million each year in uncompensated care; continuing challenges with workforce recruitment and retention that have been exacerbated by more competition for the same pool of candidates as integrated care expands; and new administrative and payment requirements under the state’s Medicaid care management.

The Medicaid spend-down is similar to a deductible in commercial policies, but most clients must accrue the spend-down amount each and every month before their Medicaid is activated. Most, if not all, cannot afford to pay the full amount of the spend-down, so collection rates range from zero to pennies on the dollar, leading to millions of dollars in uncompensated care for the community mental health centers. This is a problem that should be solvable.

The decline of the workforce was cited in the 10-year plan, but no real progress has been made in the past seven years. How is the community-based system supposed to be rebuilt when the people needed to carry out the work aren’t there?

Finally, the incorporation of managed care organizations into the Medicaid system in New Hampshire is still getting organized, and the centers have recently adopted payment reform to comply with the new program. The amount of staff and administrative time to do so has been considerable and has taken away from our core mission. Some relief from these requirements should be provided as the new program advances.

Jay Couture is executive director of Seacoast Mental Health in Portsmouth and president of the New Hampshire Community Behavioral Health Association.