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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
00;01;02;10 - 00;01;32;13
Kathleen Haddad
Hello and welcome to another episode of Health Affairs This Week, the podcast where Health Affairs editors go beyond the headlines to explore health policy in depth. I'm Kathleen Haddad. May is Mental Health Awareness Month and we devote today's episode to mental health care policy. With us to discuss the current mental health crisis and policy solutions is Dr. Tom Insel, former director of the National Institute of Mental Health and a national leader in mental health research policy and technology.
00;01;32;23 - 00;01;39;28
Kathleen Haddad
Last year, Dr. Insel published a book, Healing: Our Path From Mental Illness to Mental Health. Welcome, Tom.
00;01;40;15 - 00;01;46;13
Tom Insel
Kathleen, a real pleasure to be with you. I can't wait to bring this topic to the Health Affairs podcast.
00;01;46;14 - 00;02;12;16
Kathleen Haddad
Well, let's get going. Unfortunately, I'm starting with some grim statistics. A Gallup poll of 5000 Americans that was published just this week showed a 50% increase over the past decade in the rate of Americans ever diagnosed with depression. In 2015, 20% said yes. And in 2023, nearly a third of the population reported having a depression diagnosis at some time.
00;02;13;05 - 00;02;39;29
Kathleen Haddad
So, Tom, in your book, you discuss serious problems in our mental health care system. There's little accountability for quality in contrast to care for other illnesses. Effective care can be astronomically expensive and inaccessible to most people. The focus is on short term stabilization with drugs rather than long term recovery. And many people who need mental health care end up in the justice system or on the streets.
00;02;40;21 - 00;02;42;29
Kathleen Haddad
Where do we even start to fix this system?
00;02;43;17 - 00;03;07;20
Tom Insel
Well, it is fixable. I think the most important thing to recognize is that the solutions are really hiding in plain sight.
00;03;07;27 - 00;03;29;18
Tom Insel
Almost 50 years ago, the idea that a patient with schizophrenia would become homeless or be incarcerated was kind of unthinkable. And yet today it's become the default. It's become almost inevitable. It doesn't have to be this way. This has been one of those areas of health care that nobody has really wanted. It's kind of what I call the hot potato of health care.
00;03;29;18 - 00;03;59;20
Tom Insel
So it was for many years the domain of state institutions, the state mental health system, which was state hospitals until 1963. President Kennedy, in announcing the Community Mental Health Act, where he said people should no longer be alien to our affections or separate from our communities. And so to establish this national system of community mental health clinics, which was not entirely successful.
00;03;59;24 - 00;04;29;02
Tom Insel
1980 comes and President Reagan says, why are we in the business of providing health care as a federal government? That's not our job. It's up to the states. So he canceled out the funding for the community mental health system, and the states had long since left. So there's just been no money. At the same time that in that same period around the 1980s, there was this huge interest in building out jails and prisons.
00;04;29;02 - 00;05;06;21
Tom Insel
And so the jails and prisons, the criminal justice system became the new institutions for people with serious mental illness. And today, on any given night, you'll find about 360,000 people with mental illness in a jail or prison, and about 35,000 in a state institution or a public institution that is providing psychiatric care. So it's an extraordinary moment where kind of unimaginable for diabetes, hypertension, pulmonary disease, any other part of medicine where we would say, well, let's leave this one up to the criminal justice system.
00;05;06;21 - 00;05;16;20
Tom Insel
And it's okay that ten times more people with this brain illness are behind bars than in our beds. And that's where we sit in 2023.
00;05;17;03 - 00;05;51;07
Kathleen Haddad
So now that we're in this period, we know our mental health as a society is poor. We have these serious problems with people not getting care they need, especially those you just mentioned. The Biden administration has been throwing money at the problem and paid attention to it. They've increased funding for community mental health centers, school wellness clinics, suicide prevention, boosting the mental health care workforce and many other components are part of that program.
00;05;51;19 - 00;05;54;21
Kathleen Haddad
What do you make of these efforts and what else is needed?
00;05;55;04 - 00;06;20;23
Tom Insel
The first thing to say about those is that almost nobody knows about it. And I don't understand why. The federal government, and it's not just the Biden administration, it's been a bipartisan effort in Congress like that, the bipartisan Safer Communities Act from June of 2022, which is probably the most significant investment in mental health care from the federal government since 1963.
00;06;21;10 - 00;06;47;20
Tom Insel
Yet I haven't seen anyone writing or talking about this. It's an extraordinary moment when the federal government has said for the first time since ‘63, in 60 years, it said, hey, this is up to us. States have dropped the ball. We're going to figure out a better way. Americans deserve better than incarceration if they have a serious brain illness like schizophrenia.
00;06;47;26 - 00;07;27;05
Tom Insel
And what they've done is very reminiscent of what Kennedy was talking about in ‘63. They've created a federally funded national system called the Certified Community Behavioral Health Centers, CCBHCs, which will provide whole person care for those with serious mental illness or substance use disorder in the community. So this is really significant, really important. Now, to be clear, this program was already going in a pilot fashion in a grant developed way through SAMHSA (Substance Abuse and Mental Health Services Administration) with some demonstration projects.
00;07;27;05 - 00;07;55;03
Tom Insel
And so we have some pretty good proof points that this is effective and in eight states was really making a difference. So much so that in some states like Oklahoma, it's been adopted beyond the pilot to be the state mental health system. So it's really I think, very promising. Here's my concern, Kathleen. We need to make sure that this new effort is both integrated with other things going on.
00;07;55;10 - 00;08;26;09
Tom Insel
So all of the psychosocial rehabilitative services that are available in a community, and furthermore, that it's not just a series of 400 or 500 clinics, that we actually begin to think about doing what we've done so well in cancer: building a national network and learning health system. So this becomes a coherent system of care. What we don't have yet is a commitment to a national system of care, a coherent system.
00;08;26;29 - 00;08;51;14
Tom Insel
The FQHCs (Federally Qualified Health Centers) have done a little bit better on that, and I think ultimately that could happen for the CCBHCs. They will now be moving more into the CMS world. Now is the opportunity to rethink the program and to actually put the kinds of bones together that we will need if we really want this to work so that we bend the curve for morbidity and mortality and the need is there, it's urgent.
00;08;51;28 - 00;08;55;26
Kathleen Haddad
So President Biden, if you're listening, we need a mental health moonshot.
00;08;58;06 - 00;09;21;20
Tom Insel
Yeah, so we do. And the good news is that it's already, the pieces are there. We actually know what works. We've actually now, if I'm reading it right, it looks like that there's a $9 billion plan here from the appropriators to say this is how much money we're going to put in to the CCBHC program. That alone, just that, that's a big deal.
00;09;21;26 - 00;09;22;06
Kathleen Haddad
Right.
00;09;22;16 - 00;09;43;25
Tom Insel
Now, there are lots of other things that we will need a moonshot around. So youth mental health is a big, big issue. Substance use disorder, still a massive crisis. So it's not just the serious mental illness problem, but I bring that up because we've already got this commitment from Congress, from this administration. CMS is going to be taking this on.
00;09;44;06 - 00;09;46;27
Tom Insel
This is a big deal. Now, we've got to see the execution.
00;09;47;03 - 00;10;01;28
Kathleen Haddad
Yeah, you know, I worked for CMS kind of in a postdoc situation. And I'm wondering how you envision CMS turning this into a kind of accountable care situation.
00;10;02;01 - 00;10;23;04
Tom Insel
Well, they do need to think about a sort of value based model, right? They need to be in this space, particularly for serious mental illness. We're going to need to move to a world in which we are starting to pay for outcomes and those outcomes aren't going to be just symptom outcomes. We're going to have to be looking at all of those issues that I talked about as recovery issues.
00;10;23;20 - 00;10;52;16
Tom Insel
And a simple way for me to map it is what I call the three P's: people, place and purpose. Are the interventions that we're providing, giving people the social support, the environment they need? Like housing, and a purpose; whether that's work or family, whatever it happens to be. Now we've got to really lay out that plan and figure out how do you move payments to actually support the things that work.
00;10;52;17 - 00;11;08;07
Tom Insel
And here's the cool thing, Kathleen, is we know what works. We just have to begin to support it. We do in other areas, like in other parts of medicine, we pay for stuff that gives us good outcomes. Here we haven't been doing that and we're going to have to make that shift.
00;11;08;29 - 00;11;42;24
Kathleen Haddad
So you talk about the role of CMS in coordinating and making this happen, inspiring this new mental health care system. What is the role of schools, employers, other institutions in working with CMS? The U.S. Surgeon General issued a report recently. Several advisories on mental health in the workforce, youth mental health crisis and most recently one on loneliness in society.
00;11;43;12 - 00;11;47;28
Kathleen Haddad
How can these social institutions become integrated and the general solution?
00;11;48;12 - 00;12;15;22
Tom Insel
We're doing some experiments on that in California. And if you or Governor Gavin Newsom likes to say that we're America's coming attraction. I don't know if that's true, but we do things here often before others pick them up. And he's made this extraordinary investment in child and youth behavioral health, it’s a $4.7 billion commitment. So it's a serious effort.
00;12;16;09 - 00;12;41;28
Tom Insel
And if you look at what's in that, it's right to the question you're asking, Kathleen. It's saying, look, the traditional health care system, the clinics, the hospitals, the private offices, it's just not going to do the job that we need. For one thing, it's episodic, it's reactive, it's downstream. If we really want to make the impact that we need, we got to get upstream.
00;12;41;28 - 00;13;04;11
Tom Insel
We've got to look at youth mental health. We've got to be in schools or we've got to even be dealing with preschools, which are what this huge investment is about is literally shifting the center of gravity of our mental health care system for youth into the school system. Now, it's not asking teachers to become social workers.
00;13;04;11 - 00;13;37;02
Tom Insel
It's not asking even school counselors to become mental health counselors. It's creating a whole new workforce that we will train up that will be part of the community. These are people from the community. And we have the advantage here of having a very diverse community college system, which provides us with a fantastic talent pool. But we have a lot of advantages to do this in California, but also a huge number of needs because we have in some ways more poverty than almost any other state and certain pockets.
00;13;37;25 - 00;14;05;12
Tom Insel
So what we're trying to do is to say, if we really want to make a difference, let's figure out a way to (a) provide every child with the sort of basics of, that they'll need for resilience, for mental health, for what we like to call future proofing, so that they get the skills they need to manage emotional states and they get the kind of mental fitness that we used to talk about for physical fitness.
00;14;05;12 - 00;14;30;15
Tom Insel
So that's just like part of what happens in the, in our education system. But beyond that, it's also screening for kids who really are having difficulty and then making sure you've got a whole army of people who are there to both tie them to care when it's necessary to work with families to provide some of the basics. One of the great things we learned about mental health, it's a little different than cardiovascular surgery in the mental health space.
00;14;31;00 - 00;14;57;09
Tom Insel
Sometimes coaches, sometimes family members, sometimes grandmothers can be very, very powerful. A therapist can be really the tip of the spear for what you want to provide, not everybody has to have a number of degrees after their name to be helpful. And so creating that army of people who can work in the school system, work in the community, that's what we're hoping to do with this big investment in California.
00;14;57;09 - 00;15;15;16
Tom Insel
And, you know, it's still early days. We'll have to see how it plays out. But it's a good example of where the rest of the nation could learn about what works and maybe what doesn't, but hopefully what begins to really make a difference because we're making an investment early on before there is a crisis.
00;15;16;11 - 00;15;40;23
Kathleen Haddad
Well, that sounds so promising and hopeful. So we'll have to leave it there on a note of hope. Thank you, Tom, so much for joining us. I want to remind our listeners to take a look at Health Affairs coverage of mental health care, including a Forefront article out today on integrating mental health into primary care. Please leave us a review.
00;15;40;23 - 00;15;46;16
Kathleen Haddad
And if you liked the show, please tell a friend and subscribe to Health Affairs This Week wherever you get your podcasts.