The hallmark of Rick Snyder’s tenure as Michigan’s governor has been his relentless drive to run government like a business.
Many believe that putting the bottom line first is what helped cause the Flint water crisis.
Privatizing state services to cut costs has led to failures. Think of the recent scathing audit of the Grand Rapids Home for Veterans and the many problems with bringing in Aramark to feed prison inmates, from rotting food to food service employees having sexual encounters with prisoners in food coolers.
So it's understandable that the governor’s proposed budget for the new fiscal year has caught the collective attention of Michigan’s mental health community.
Snyder is eyeing the state’s $2.4 billion mental health care system. He proposes turning a large part of the funding to Medicaid HMOs, the largest of which are for-profit.
To see what cutting mental health costs could mean, we turn to Kevin Fischer, executive director of the National Alliance on Mental Illness of Michigan.
As it stands, Fischer tells us that mental health services are delivered by community mental health coalitions, “which consist of either mental health authorities or in certain parts of the state they’re referred to as PIHP’s, prepaid insurance health plans.”
Under the governor’s plan, Medicaid would go through HMOs rather than straight to community mental health departments.
Fischer tells us it was suggested that the governor’s proposed plans would save over $200 million, but there’s some uncertainty as to how the Snyder administration arrived at that number. He says organizations like the Michigan Association of Community Mental Health Boards “have started to delve into that and say, we don’t see those savings.”
He adds that it’s also unclear to many legislators how the $200 million figure was arrived at.
"Mental health care is ... one of those services that there's more to than just the bottom line."
In the name of savings
Fischer tells us that above all else, the governor’s plan focuses on saving money.
“It simply comes down to trying to run this service like a business,” he says, “and mental health care is ... one of those services that there’s more to than just the bottom line.”
Fischer tells us the proposal raises many concerns, first and foremost being the loss of public oversight.
“Whenever there’s a for-profit that’s managing the purse strings ... they are headquartered somewhere else, and they serve a board of directors and shareholders,” Fischer says. “I like to say by definition, the business of a for-profit is to make a profit and return shareholder value.… Insurance companies tend to minimize risk so they can enhance shareholder value."
Public mental health services, Fischer says, "are designed to run toward risk. We seek out the persons who most need those services and bring them into the system. So at the end of the day, the entire community benefits when you have persons with mental illnesses receiving services and they’re able to live thoughtful, productive lives.”
Historical lessons
It’s no exaggeration to say that these people are among Michigan’s most vulnerable. We’re talking about people who are mentally ill, developmentally disabled, battling substance abuse and so much more. Looking ahead to how might things change for those folks under Snyder’s plan, Fischer asks us to take a lesson from history.
“Imagine going back to the early 1990s under the Engler administration, when we closed all of the state hospitals. We experienced an explosion in homelessness because those persons were intended to be sent home,” he says.
Sending those folks home sounded like a simple solution, but it didn't always play out that way.
"It doesn't specifically immediately privatize mental health services, but it opens the door for privatized mental health services."
Fischer tells us that when a person with a mental illness is sent home, the parent or caregiver may not know how to manage that individual’s needs. They may not know what services are available to help or how to access them.
“Either the caregiver’s frustrated or the person receiving or in need of service is frustrated, and they leave. And they end up on the street … or in prison, which is the highest-cost place to put them,” he says.
Supporters of the governor’s plan have said it doesn’t really privatize mental health care because most of the Medical HMOs are nonprofit, and that it would allow a bigger pool of money to find its way to actual treatment.
“What ends up happening is that – and the Lieutenant Governor [Brian Calley] explained this to those of us in the newly-formed work group – it doesn’t specifically immediately privatize mental health services, but it opens the door for privatized mental health services, and that’s where the concern came in for persons like myself, the advocacy community, and many, many families and caregivers.”
Finding alternatives
After some pushback from parents and stakeholders in the mental health community, Lt. Gov. Calley called together a group of individuals representing community mental health organizations and advocacy groups to try to work through the plan and come to some kind of compromise.
“I give the lieutenant governor credit because his focus was, we don’t want to talk from the top down to the persons who receive the services and tell them what they should be,” Fischer says. “We should be asking them what makes [them] successful, and build the system from the way up.”
"We don't want to and don't need to make such a drastic change and then find out what the repercussions are. That's not a good way to run business or the state."
Fischer tells us that though this open and collaborative approach is promising, the state’s budget is usually approved in early June, so the group is feeling some pressure.
“When the lieutenant governor formed the work group, he said … the budget process is going to continue to move forward with an anticipated completion date late May, early June,” Fischer says.
“The concern many of us in the work group had was, is there truly enough time to consider thoughtful, fact-driven, data-driven alternatives to what the governor has proposed? And, for lack of a better term, are we working with a gun to our head to the point that if we’re not able to produce an alternative that the governor approves, then are you telling us the original boilerplate language stays?”
He tells us that some members of the Legislature agree that there might not be enough time between now and June to examine “thoughtful, data-driven alternatives” to Gov. Snyder’s proposed changes to the mental health care budget.
Fischer says there’s also been “a lot of suggestion” that the state should consider doing some pilot tests in both urban and rural areas to better determine what sort of plan would work best, “rather than flip the whole system at one time not knowing what the alternatives would be.”
“We don’t want to and don’t need to make such a drastic change and then find out what the repercussions are. That’s not a good way to run business or the state,” Fischer says.
Kevin Fischer tells us more about Gov. Snyder's proposed changes to the mental health care system in Michigan in our conversation above.
