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April 8 — Senators are still negotiating the future of a broad bipartisan mental health reform bill, and stakeholders are hoping potential floor action won't get derailed by a debate over guns or funding.
The Mental Health Reform Act (S. 2680) was approved in March by the Senate Health, Education, Labor and Pensions Committee, but more work needs to be done before the Senate can have a vote. The bill was approved without any funding elements. It also is expected to be combined with legislation from the Senate Judiciary Committee (S. 2002), which addresses the link between mental health and the criminal justice system.
Democrats have objected to a provision in that bill about background checks that they say would make it easier for mentally ill people to get guns.
“We certainly don’t want a debate over firearms in an election year,” Andrew Sperling, director of federal affairs at the National Alliance on Mental Illness, told Bloomberg BNA. One way around that would be to limit the scope of the Judiciary bill.
Sperling said ideas like assisted outpatient treatment and pre-booking diversion programs—moving low-level drug offenders away from jails and into treatment programs—are in the bill, and have all been proposed in the past. However, the bill's sponsor, Sen. John Cornyn (R-Texas), has said he doesn't understand Democrats' objections, and plans to keep the provision about gun background checks.
Sen. Chris Murphy (D-Conn.), one of the main Democratic co-sponsors of the HELP mental health legislation, told reporters April 7 that conversations with Cornyn and other Judiciary Committee members are just starting.
“The bill got out of committee two days before we left [for a two-week recess], so we’re just starting the process of sitting down and talking,” Murphy said. “We’re still talking to him about whether we can move forward without those [gun] provisions. Obviously I can’t support a bill on the floor that has those provisions in it.”
“One of the decisions senators will have to make is whether we want to have a gun debate in connection with the mental health bill,” HELP Committee Chairman Lamar Alexander (R-Tenn.) told Bloomberg BNA April 5. “I think most of us would prefer to focus directly on mental health and leave the gun discussion for another day.”
Alexander has said he's waiting to hear from Senate Majority Leader Mitch McConnell (R-Ky.) and Minority Leader Harry Reid (D-Nev.) about a possible floor vote.
“We’re waiting for Sens. Reid and McConnell to make a decision about when to bring it to the floor and how to do it. We’ve done our part,” Alexander said.
The mental health reform bill would require the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the Department of Health and Human Services, to hire a chief medical officer and report to Congress every two years on its activities.
It would increase access to care for individuals including veterans, homeless individuals, women and children. It also would improve training for those who care for people with mental illnesses, and promote better enforcement of existing mental health parity laws—making insurance companies reimburse mental health treatment the same as for treating physical health.
A manager's amendment to the legislation would authorize block grants to states for mental health services, as well as for the prevention and treatment of substance abuse disorders, although the exact amount will be subject to appropriations.
Other provisions will be added to the bill once it gets to the floor. Alexander has said he expects an amendment from Sens. Roy Blunt (R-Mo.) and Debbie Stabenow (D-Mich.) expanding the number of community mental health centers from eight to 24.
Senators also will seek to include a repeal of the prohibition on Medicaid paying for the inpatient care of anyone over the age of 21 and under 65 who resides in an institution for mental diseases (IMD), even for treatment unrelated to mental illness. The so-called IMD exclusion would be very costly to repeal, but is seen by many advocates as a major barrier to treating mental illness.
During the HELP Committee markup, Sen. Susan Collins (R-Maine) offered, and then pulled, an amendment to repeal the IMD exclusion. Finding a way to pay for the IMD exclusion repeal is in the jurisdiction of the Senate Finance Committee. Sperling said Collins is pushing Sen. Orrin Hatch (R-Utah), Finance Committee chairman, to work with her.
A repeal of the IMD exclusion was included in a House mental health reform bill, and the Congressional Budget Office said the change would cost between $40 billion and $80 billion over 10 years. Murphy and mental health advocates say that number isn't realistic and are working with CBO to bring the cost down.
Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities, told Bloomberg BNA April 8 that repealing the IMD exclusion would mean the federal government would start paying for treatment that previously was left to the states. When the policy was first enacted, people who needed mental health and substance abuse services weren't eligible for Medicaid. However, as a result of the Affordable Care Act's coverage expansion, many of those people are newly eligible and states want help paying for them, Solomon said.
However, she cautioned against a complete repeal without first studying the implications and finding a policy that can take its place.
The IMD exclusion has been in place since 1965 and is “a blunt instrument” because it hasn't adapted to the current behavioral health system. But “repealing it would be a blunt instrument too, without thinking through what gets put in its place,” Solomon said.
Because the mental health bill advanced to the floor without any funding elements, finding the necessary offsets for any provision after the fact is no easy task.
“It won’t surprise you that there’s not a lot of appetite for big new expenditures, and we’re going to be competing with other bills that have pay-fors which might be moving to the floor before the mental health bill,” Murphy said.
One prominent example is the Senate's medical innovation package. The final bills in the Senate's version of the House's 21st Century Cures legislation were approved by the HELP Committee April 6 .
“If that bill comes to the floor before mental health it could gobble up some pay-fors that we would be looking at,” Murphy said. “Pay-fors are always pulling teeth in this Congress. I’ve said from the beginning it’s questionable if the mental health reform bill is worthwhile without additional resources. My bottom line is somewhere, somehow we’ve got to have a conversation about expanding resources.”
The other obstacle facing senators is time. McConnell has said he is willing to spend 12 weeks on floor consideration of appropriations bills. That potentially would take up most of the remaining legislative calendar before the November elections.
Sperling said he realizes once the Senate starts on appropriations bills, the chances of passing mental health reform are remote.
“Once they get into appropriations, there's not a lot of time left,” Sperling said. “We feel fortunate the majority leader made a commitment, to even be mentioned as a candidate for a floor vote.”
While acknowledging the uphill battle if the bill doesn't advance before the summer, Murphy said he doesn't think there's a hard deadline.
“I think there’s very little partisan heat on this bill. If you imagine the tiny list of things that could get done in a June or July session, this would be on the list,” Murphy said.
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More information on S. 2680 is at https://www.congress.gov/bill/114th-congress/senate-bill/2680.
More information on S. 2002 is at https://www.congress.gov/bill/114th-congress/senate-bill/2002.
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