The Substance Abuse and Mental Health Services Administration's state survey shows that persons with serious mental illnesses served by public mental health agencies have the HIGHEST mortality rate of ANY population ANYWHERE in America's public health system. Specifically, the average life expectancy for this population now rivals people living with HIV/AIDS. In addition, among psychiatric patients, the probability of dying is 55% higher for patients diagnosed as having substance use disorders than among those without a substance use diagnosis.

Community behavioral health organizations provide care to many individuals with mental illness and substance use disorders who are uninsured, many of whom are well below the poverty level. Approximately 22% of adults with mental illness and/or substance use disorders are uninsured.

In addition, about 30% of individuals with co-occurring mental illness and substance use disorders lack any insurance. In addition, one in three uninsured adults with mental illness and/or substance use disorders is under 100% of the federal poverty line.

Since many who receive care in the public community mental health system are low income uninsured (or underinsured) individuals, these community providers stand to greatly benefit from coverage expansions.

Integration of Primary and Behavioral Healthcare

One important aspect of healthcare reform for community behavioral health is the co-location of primary care capacity in Community Mental Health Centers and other community-based mental health and substance abuse providers. This integrated treatment approach is aimed squarely at reducing the mortality and morbidity rates among clients in the public behavioral health system.

Since insurance coverage for all physical illnesses including disorders of the brain will be greatly expanded, people will have a choice and more people will find a healthcare home that Is all encompassing. However, the likelihood of finding an effective treatment home for persons with serious mental illnesses, both youth and adults, is unlikely for the simple reason that their care is more complicated and many of the most effective treatments will not be covered even under an expanded healthcare reform package. It will be important that there are specialty providers who are accustomed to working with this population and who can guarantee a high degree of success.

Focus on Serious Mental Illness and /or Addiction

Resources for these specialty services will continue to be provided by targeted federal, state, and local funds earmarked specifically for this population. The general population's needs for low acuity behavioral health services will eventually be met in primary care settings that are appropriately expanded to meet that need. But youth and adults with serious mental illness will not be welcomed because of the nature of this illness that is resistant to the general course of treatment and is often the result of social factors that exacerbate their physical symptoms; trauma, poor nurturing, neglect, generational poverty, criminal justice involvement, and homelessness.

The community behavioral health system will become ever more focused on this specialty population and all of the public resources will be targeted to their treatment as healthcare reform expands insurance coverage to include millions more.

Specialty Services not Covered Elsewhere and Focused on Outcomes

The focus will be on psychiatry, community support, housing, vocational, supported housing, support groups, and a host of nontraditional treatment modalities that have proven effectiveness. This will mean continued implementation of evidence-based practices and increasing provider accountability. Specifically this will involve: a.) provider accountability for clinical outcomes; b.) systemic application of evidenced-based interventions, c.) reduced reimbursement for sub-optimal outcomes, and d.) specific reporting of detailed encounter data.

Summary

Over the course of the next few years will emerge a new community behavioral health system that is characterized by:
1. Focus on youth and adults with serious mental illness and / or addiction
2. Integration of primary and behavioral healthcare in a single setting
3. Implementing evidence-based practices
4. Performance based reimbursement contracts