Legislation and Political Context

The Children’s Mental Health Accessibility Act 2012 was introduced by senators John Kerry and Chuck Grassley (Varner, 2012). This act seeks to expand and provide more strength to the mental healthcare services offered to children under Medicaid. Specifically, the bill seeks to extend the authority of the waiver to cover for young people receiving home and community-based services. Among the major changes that the bill proposes is to restrict case managers from providing both case management and direct services. To eliminate a possible conflict of interest, the bill seeks to prevent the case manager from providing direct services. In this manner, the children and their families will be provided with a true freedom of choice (Varner, 2012).

The bill has 5 sponsors, including Roger Wicker, Chuck Grassley, Mark Begich, Scott Brown and Thad Cochran (Kerry, 2012). The bill was given to the Congressional Committee in June 2012. The Congressional Committee will go through it before forwarding it as a whole to the Senate or taking it to the House (Kerry, 2012). As it stands now, the bill only has a 4% chance of being enacted into law (Kerry, 2012). In all the bills that have been forwarded to the Senate, between 2009 and 2010, only 3% of the total was enacted. This means that the chances of the bill being passed are extremely low. Unlike most bills, this bill is not bipartisan. There is at least one co-sponsor from the majority party and the other co-sponsors are from outside the majority party (Kerry, 2012)

Problem Analysis

South Carolina is one of the first 10 states to have received a grant in 2006 from the CMA for a demonstration waiver. By the year 2008, the pilot program in 3 counties had started serving children and youths (SCDHHS, 2012). By the second year, the waiver had been expanded to cover three additional counties in the state. Financial difficulties could only allow for 50 slots in the 6 counties. Because of the administrative requirements of the waiver, the Department of Health and Human Services was given the responsibility to oversee all administrative duties. In the duration that the waiver had been in place, since 2008, more than 100 youths and families have opted to receive community and home-based care instead of finding placements in the Psychiatric Residential Treatment Facility (PRFT) (SCDHHS, 2012). This has been facilitated by the Children’s Health Access Community Environment (CHANCE) which gives the youths and their families the chance to choose between PRTF and home-based services. During the same time, practitioners have realized that children with mental health problems and need to be cared for in home-based and community settings appear to have positive treatment outcomes (SCDHHS, 2012). Besides, it has been established that community based services are not only cost effective for the federal government, but also for the state (SCDHHS, 2012). Although the community might be defined in various ways, in this case, the community is taken as the immediate neighborhood where the child or the youth lives. The community, thus, refers to the people that the child will interact with frequently and the people that the child might be familiar with.

Out of the realization that home and community based services are more beneficial to the children while, at the same time, more cost effective, the Children’s Mental Health Accessibility Act was introduced for discussion in the US congress. The main purpose of this legislation was to change the PRTF from demonstrations to being permanent.

The prevalence of mental health problems is remarkably high in the United States. At least 57.7 million Americans are faced with mental health problems each year (Henderson, 2006). The main purpose of the Children’s Mental Health Demonstration Waiver is to ensure that the current demonstration programs are made permanent. Thus, this waiver will provide children diagnosed with mental health problems to receive home and community based services. If passed, the waiver will also provide families with the opportunity to be close to their children with intensive mental health needs (CMHNetwork, 2012). Before the demonstration waiver, families had to take their children to the Residential Treatment Center facility, most of which are located far away from home (CMHNetwork, 2012). One of the major problems with this trend is that the children are separated from their families, and it takes time before they are reunited (1 in 5 kids, 2012). But even when they are reunited, the union only takes a short time before they are separated again.

The demonstration waiver ended on the 30^th of September, 2012. This means the families no longer have the option to decide the type of treatment that is provided to their children. Perhaps, the greatest negative impact of this development is on the families with private health insurance. Under the waiver, the eligibility of a child to enter the program did not consider the level of income of the parents. If the Children’s Mental Health Accessibility Act is passed, the state conducting the demonstration waiver, such as South Carolina, will be allowed to continue with home and community-based services to support the children who are enrolled in those programs already. Besides, this bill will also allow all states to come up with new waivers (CMHNetwork, 2012). Further, the passage of the bill will allow the neutrality rules of the home and community-based Medicaid waiver to continue (CMHNetwork, 2012). Courtesy of the Children’s Mental Health Accessibility Act, children and youth with mental health problems will be provided with comprehensive healthcare in the comfort of their own homes. Further, the bill has sought to clarify various issues relating to mental health care which is being used in Medicaid. One such clarification is the scrapping of the phrase ‘mentally retarded’ by Medicaid and replaced it with ‘intellectually disabled.’

Existing resources to deal with the problem

There are various financial mechanisms and community services for youths and children struggling with mental problems. Among these financial mechanisms are the HCBS, case-rates by CMEs, medical rehabilitation options and the provisions for TEFRA. While these financial and community based services have done a great deal in improving the lives of the youth and children with mental problems, they have had their fair share of problems. It is out of the realization of the inadequacies of these financial mechanisms that the Children’s Mental Health Demonstration Waiver has been proposed. The following are some of the financial mechanisms that are being used to help children with mental problems.

HCBS Waivers

HCBS Waivers provides the states with the benefits of sidestepping federal restrictions on the scope, amount, and duration of Medicaid. In other words, courtesy of HCBS Waivers states, this will enable the provision of specialized waivers that are not covered by Medicaid to particular individuals and their families (Medicaid, 2012). The HCBS Waivers also lifts the requirement that states should apply a mental income on children. In this sense, the HCBS Waivers allows all children to get access to healthcare and medical services, including those children who would have, otherwise, been locked out by the criteria for financial eligibility (Ireys, Lee & Pires, 2006).

While HCBS Waivers may have done well to take care of children with medical and mental health problems, it has failed to adequately meet the needs of such children. Currently, HCBS Waivers often takes into consideration children with high-needs or those considered as being high-risk (Ireys et al., 2006). However, there are no interventions that prevent the children from moving into such categories. Second, the bureaucracy surrounding HCBS Waivers has made it possible for only a small proportion of children to get access to this financial service. Lastly, HCBS Waivers alone cannot meet the home and community services required by children with severe mental problems. For instance, although HCBS Waivers has brought together state mental health and Medicaid agencies in its efforts to increase the scope of services provided to children with mental problems, the practices of such agencies have not been brought together. Thus, there is usually a lack of motivation with various agencies in carrying out their responsibility to the targeted children (Ireys et al., 2006).

Case-rates used by CMEs

In various local jurisdictions, counties, and states, there are approaches that have been implemented to serve the interests of children with mental health disabilities. More often than not, such approaches used risk-based and managed care financial systems (Ireys et al., 2006). One major benefit of such services is that they provide individualized intensive care and support to the children and their families. Examples of such approaches include Indiana’s Dawn Project and Wisconsin’s Wraparound Milwaukee (Ireys et al., 2006). While these approaches are beneficial in the sense that children with mental problems get access to comprehensive medical services, these approaches are inadequate in various ways. First, they require a lot of expertise in financial management, supervision of clinical services, and organizational development. Such skills can only be developed at the local level through comprehensive technical support and training (Ireys et al., 2006). Second, states that have implemented such strategies at the local level have faced problems rolling out such programs statewide. This is because it takes time and many other resources to develop such programs at the state level.

The TEFRA Provision

The provisions for the Tax Equity and Fiscal Responsibility Act (TEFRA) provide states with the ability to waiver the requirements needed in consideration of the income of the parents before a child can be eligible for Medicaid, such as those who are live at home but would have otherwise qualified for Medicaid in an institution. This provision is beneficial in that it extends the scope of Medicaid for children to access treatment outside of mental health institutions. Without the provisions for TEFRA, many children with mental health problems living at home may not have adequate healthcare coverage. However, this provision is restrictive in various ways. For example, it requires the state to determine that the child in question suffers from a mental disability that requires the same level of care provided in institutions (Ireys et al., 2006). Besides, there is a need to provide proof that home care is the most appropriate and that the cost of home care should not surpass that of the institution (SCDHHS, 2012)

From the analysis of the available resources, it is clear that although the current interventions have attempted to provide some sort of financial care to children with mental disabilities, more needs to be done.  As is evident from these interventions, most of them are initiated by local and state governments. Even within the states where they are implemented, there are problems in providing such services statewide. Thus, the scope of most of these interventions is limited to localities where they have been initiated. Based on this evidence, there is a need for the legislation of a statewide policy that handles the needs of children with mental health problems as well as the associated needs of their societies. Although there are some national financial interventions that cover such health problems, for example, Medicaid, there is a need for a specific financial service that deals particularly with the plight of children with mental disabilities. In this regard, the Children’s Mental Health Demonstration Waiver will come in handy.

The bill has received very minimal opposition both from the civil society and the politicians. On 13 July, 2012, for example, the proposers of the bill, John Kerry and Charles Grassley, received a letter of support from a host of organizations dealing with child and mental health care (Truhe, Stine, Gruttadaro & Fiermonte, 2012). In the letter, the organizations stressed the need for the demonstration project to be made permanent by pointing out the achievements that have been accomplished. In June 2012, the U.S. Senate had the senators sponsor the Children’s Mental Health Accessibility Act (Kerry & Grassley, 2012). In the letter to the senators, Sen. Kerry and Sen. Grassley indicated that the waiver will provide more options in the services for children to receive community and home-based services instead of being treated in residential psychiatric facilities. To this end, members of the Senate were asked to support and co-sponsor the bill. By September 20^th, four Senators had come out to co-sponsor the bill (Kerry, 2012). The fact that four senators, from within the majority and minority parties, were willing to co-sponsor the bill is an indication that has been accepted regardless of political affiliations.

The stakeholders

The bill has attracted the interest of national, regional, state, and community-based organizations. In particular, organizations working with children have advocated for the enactment of the bill. Groups, such as the Voices of America’s Children, have emphasized the positive impacts that the bill seeks to have on the welfare of children with mental problems. The same sentiments have been echoed by faith-based groups that have called for the continuation of the demonstration programs. By the time the comments on the bill came to a close on August 24, 2012, the bill has not received any substantial disapproval from the public, political, class or civil groups. It can, therefore, be said that the bill received an outright approval from all the stakeholders involved. All eyes will, therefore, will be on the Senate to enact the bill. With the reviews on the bill having come to an end on September 3, 2012, the final decision rests with the Senate. If approved, the new waiver will take effect on January 1, 2013.

References

1 in 5 Kids (2012). Coordinator provides testimony to state senators. 1 in 5 Kids: The Campaign for Children’s Mental Health. Retrieved October 10, 2012, from http://1in5kids.org/2012/09/04/coordinator-provides-testimony-state-senators/

Children’s Mental Health Network (CMHNetwork) (2012). Support the Children’s Mental Health Accessibility Act. Children’s Mental Health Network. Retrieved October 10, 2012, from http://www.cmhnetwork.org/news/support-the-childrens-mental-health-accessibility-act

Henderson, A. (2006). Mental illness: Facts and numbers. National Alliance on Mental Illness. Retrieved October 10, 2012, from http://www.nami.org/Template.cfm?Section=About_Mental_Illness&Template=/ContentManagement/ContentDisplay.cfm&ContentID=53155

Ireys, H. T., Lee, M. & Pires, S. (2006). Public financing of home and community services for children and youth with serious emotional disturbances: Selected state strategies. ASPE.hhs.gov (Assistant Secretary for Planning and Evaluation / Health and Human Services). Retrieved October 10, 2012, from http://aspe.hhs.gov/daltcp/reports/2006/youthsed.htm#strengths

Kerry, J. (2012). Children’s Mental Health Accessibility Act of 2012 (S. 3289). GovTrack.us: Tracking the U.S. Congress. Retrieved October 10, 2012, from http://www.govtrack.us/congress/bills/112/s3289

Kerry, J. F. & Grassley, C. E. (2012). Improve mental health treatments options for youth; support the Children Mental Health Accessibility Act (S.3289). Bazelon Center. Retrieved October 10, 2012, from http://www.bazelon.org/LinkClick.aspx?fileticket=b9RjvPuvG3U%3d&tabid=272

Medicaid (2012). Quality of care home and community-based services (HCBS) waivers. Medicaid.gov. Retrieved October 10, 2012, from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Quality-of-Care-HCBS.html

South Carolina Department of Health &Human Services (SCDHHS) (2012). Psychiatric Residential Treatment Facility (PRTF) alternative Children’s Health Access Community Environment (CHANCE) waiver: Proposed changes for 1915c waiver renewal. Retrieved October 10, 2012, from http://www.scdhhs.gov/sites/default/files/PRTF%20Alternative%20CHANCE%20Waiver%20Public%20Meeting%208-2012.pdf

Truhe, N., Stine, L., Gruttadaro, D. & Fiermonte, C. (2012). Letter of support for the Children’s Mental Health Access Act addressed to Senators John Kerry and Charles Grassley. National Foster Care Coalition. Retrieved October 10, 2012, from http://www.nationalfostercare.org/uploads/8/7/9/7/8797896/s_3289_support_letter_july_2012_with_names-final-1.pdf

Varner, Y. (2012). Children’s Mental Health Accessibility Act of 2012. The Children’s Monitor. Retrieved October 10, 2012, from http://childrensmonitor.wordpress.com/2012/06/15/childrens-mental-health-accessibility-act-of-2012/

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