Part 6
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ACT:  reform is "easy" Once you realize there is No quick fix

TO PARAPHRASE JOHN LEGEND:  

PROVIDE THE INTENSIVE COMMUNITY MENTAL HEALTH TREATMENTS PEOPLE NEED NOW

ACT NOW

Historical Context

•        One of the reasons why de-institutionalization turned out to be such a failure is that there was great hope at the time that the new psychotropic medications would pretty much solve all the problems of community living for pretty much everyone with serious mental illness.
• The fact is medications have helped a lot of people.
•  Some incredibly inconvenient facts are that psychiatric medication and individual difference are much more complicated than we knew at the time, current psychiatric medication is not able to target specific brain circuits but acts on the brain globally and that leads to wide-ranging and individualized side-effects, some people are essentially genetically intolerant to certain medications, etc.
• Our corollary to some of this:  Not so ironically some of the people with the most perceived severe mental illness may also present with some of the most idiosyncratic nervous systems and biologies, making pharmocogenetic testing and other "evidence-based practices" such as Assertive Community Treatment essential.
•  [Parenthetically, trauma gets individually dealt with and internalized by our biology.  Additionally, we are admittedly at the beginnings of pharmocogenetic testing and we believe at least for some medications and genes it is an evidence-based practice] 
• So much incredible research is being done in neuroscience, the micro-biome, and general biology that huge advances are very likely this century, this half- century, this quarter-century, 10-years from now, and who knows how long that is going to take to get to anyone.
• People with mental illness have a long history of health care discrimination and the failure to adequately provide Assertive Community Treatment is right up there because it isn't "cheap."                                                                                                                                          But it is "evidence-based" and "effective" and can be done in a "person-centered" way respecting civil rights.

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For Some-- taking medication can be like pouring oil all over their mental engines --- yes some gets into the right place, and all over one's mental engine block in some cases doing more harm than good. ---see Caltech Neuro-scientist David Anderson's TedxTalk below.

The Bottom Line:  Our Brains Are More Than Bags of Chemical Soup.

How Minnesota does it.

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It's Medicaid:   You Knew It Was Going To Be Complicated -- It's A Mixed Bag
A Tale of Two States:
ACT:  Colorado & Minnesota       

        What makes Assertive Community Treatment so effective is that it is pretty much everything and the kitchen sink, including:

• psychiatric care
• social work
• supported employment
• peer services
• 24/7 support
• etc.

Now traditional Medicaid pays for some of that, and doesn't pay for some of that like supported employment.

[Parenthetically, some of that such as supported employment which isn't covered by Medicaid is often included in US Dept. of Justice Olmstead Settlement Agreements]

What is a State to do?

        Well, for most States, including Colorado, if Medicaid, doesn't pay  for all of it, the State isn't going to either.

          Medicaid does have what it calls Non-Medicaid Services Waivers to help fund what Medicaid won't fund with respect to things like supported employment, unfortunately Colorado has it funding everything ACT.
  
             Additionally, the money for Colorado's Non-Medicaid Services Waiver is limited to the "savings" from Colorado's  Medicaid Mental Health Managed Care Program -- and the services are not entitlements. (See 1915(b)(3) Non-Medicaid Services Waiver
https://www.medicaid.gov/medicaid/managed-care/authorities/index.html )

​              Our understanding is that Colorado has also tried to increase its ACT capacity through the Colorado Dept. of Human Services and the acquisition of various grants.  We think that very praiseworthy.

                AND the Bottom Line for people needing intensive community mental health treatment in Colorado,  Assertive Community Treatment which is the Gold Standard in intensive community mental health treatment is NOT an entitlement in Colorado. That really is crazy.

                 AND in fact that is not the only way to do it.  Minnesota provides ACT as a "rehabilitative service."    We were originally concerned that ACT as a rehabilitative service might be too limiting but we were pleasantly surprised to see how Minnesota defines this:

"The U.S. Psychiatric Rehabilitation Association defines psychiatric rehabilitation as services that promote “recovery, full community integration and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs their ability to lead meaningful lives.

"Psychiatric rehabilitation services are collaborative, person directed and individualized. These services are an essential element of the health care and human services spectrum, and should be evidence-based.

​ "They focus on helping recipients develop skills and access resources needed to increase their capacity to be successful and satisfied in the living, working, learning, and social environments of their choice.”


                   (Note that Minnesota provides supplemental grants to ACT teams to support activities that are necessary but not Medicaid-reimbursable.)