Tuesday, September 18, 2012

Medicaid expansion and addresing severe mental illness through the justice system

A friend forwarded me a handout being circulated at the Harris County Criminal Justice Coordinating Council detailing a pair of studies of "Kendra's Law" out of New York, which provides court-ordered outpatient mental health treatment to a small subset of probationers in the "most desperate need for psychiatric treatment."

According to the handout, "Taken together, the two reports establish that assisted outpatient treatment (“AOT”) drastically reduces hospitalization, homelessness, arrest, and incarceration among people with severe psychiatric disorders, while increasing adherence to treatment and overall quality of life. The independent evaluation further indicates that the effectiveness of Kendra’s Law is not simply a product of systemic service enhancements, but is in part attributable to the value of AOT court orders in motivating treatment compliance." In particular:
During the course of court-ordered treatment, when compared to the three years prior to participation in the program, AOT recipients experienced far fewer negative outcomes. Specifically, the OMH study found that for those in the AOT program:
• 74 percent fewer experienced homelessness;
• 77 percent fewer experienced psychiatric hospitalization;
• 83 percent fewer experienced arrest; and
• 87 percent fewer experienced incarceration.
The related findings of the independent evaluation were also impressive. AOT was found to cut both the likelihood of being arrested over a one-month period and the likelihood of hospital admission over a six-month period by about half (from 3.7 percent to 1.9 percent for arrest, and from 74 percent to 36 percent for hospitalization).
What's more:
Kendra’s Law also resulted in dramatic reductions in the incidence of harmful behaviors. Comparing the experience of AOT recipients over the first six months of AOT to the same period immediately prior to AOT, the OMH study found:
• 55 percent fewer recipients engaged in suicide attempts or physical harm to self;
• 49 percent fewer abused alcohol;
• 48 percent fewer abused drugs;
• 47 percent fewer physically harmed others;
• 46 percent fewer damaged or destroyed property; and
• 43 percent fewer threatened physical harm to others.
Even more encouraging, such improvements were to some extent sustainable beyond the time participants received intensive services. For those who spent more than six months in assisted outpatient treatment, increases in use of medications and reductions in hospitalization "were sustained in the post-AOT period, whether or not intensive services were continued."

Who knows if these outcomes would be replicable in Texas, but these data - particularly the bit about outcomes sustained beyond the probation period - made me think once again about the proposed Medicaid expansion under the federal Affordable Care Act. And since we're on the subject, I should reference a recent report referenced at Sentencing Law and Policy titled, The Affordable Care Act: Implications for Public Safety and Corrections Populations. That analysis noted that "About half of all people in jails and prisons have mental health problems and about 65 percent meet medical criteria for alcohol or other drug abuse and addiction," so clearly Medicaid expansion would impact many people who cycle through the justice system. What's more, "Pre-release and reentry programs might also be better able to connect people who are leaving jail or prison with community-based intervention services," which would definitely have implications for folks mandated to receive intensive services under some version of Kendra's Law (not to mention folks receiving psychiatric meds leaving prisons and jails). The report concluded that:
The ACA is not a panacea – it will not eradicate the societal factors that contribute to excessive poor health among African Americans and other minorities, nor will it eradicate other biases within the criminal justice system that contribute to disparate rates of incarceration. It does, however, pose an opportunity to level at least one dimension of the playing field – access to treatment for mental illness and addiction – two problems that increase the likelihood of arrest and recidivism. In doing so, it may help reduce racial/ethnic disparities in incarceration.
Mandating mental health services for folks with the most severe psychiatric problems could reduce the frequency with which they cycle through the criminal justice system, as is depressingly common, and if the NY results are any indication, could also prevent a good deal of crime and substance abuse among those with the most severe mental health needs. And if Texas were to expand Medicaid eligibility in 2014, it would present an opportunity for financing such services that at the moment seem fiscally out of reach.

And yes, I know Gov. Perry has said he opposes Texas expanding Medicaid eligibility, so maybe such musings are just a pipe dream. But these are recurring dilemmas and it's rare that an opportunity such as the ACA presents itself to plug such gaping holes in the system. In any event, it's worth a discussion.


gravyrug said...

Sounds like an excellent idea, but it would require a large improvement in the state of mental health care in TX to make it work. Even private mental health care here is very hit or miss when it comes to correctly diagnosing and treating problems. My family's experiences seem to suggest that TX needs a great deal more in both quality and quantity of mental health professionals before implementing such a system.

Gritsforbreakfast said...

True enough, gravy, but the additional money from the ACA could spur expansion of such services. Without a way to pay them, there's no incentive for the private sector developing MH resources.

Anonymous said...

Just to clarify AOT is a civil court process not a criminal court process in Texas. Participants are not on criminal court probation.

Gritsforbreakfast said...

Thanks for the clarification, 7:25. But it seems like the same principles of mandatory, court-ordered treatment could still apply, no?

Unknown said...

Nice post. While I agree that mandated outpatient care is the best option for mental health patients, I worry that it may impede on the patients' right to autonomy. This is a concern because many people with severe mental illnesses are subject to electro-shock therapy which they detest. Seems horrible to force them to doing something they hate, rather than guiding them to treatment that is less harsh.