October 27, 2020

Florida's Lukewarm Commitment to Investing in Behavioral Health 

While Florida policy leaders have acknowledged the need for greater investment in community mental health and substance use disorder services (behavioral health), actions to address these needs fall far short.

The numbers speak for themselves: 

  • For fiscal year 2018-19, the Department of Children and Families (DCF) reports that an average of 1,343 Floridians per month were placed on waiting lists for behavioral health services. This included 118 individuals who were homeless and 220 individuals who injected drugs. Only about one-third of Florida children experiencing a major depressive episode received treatment.
  • Mental Health of America recently ranked Florida 48th nationwide on access to mental health care. It specifically noted that 633,000 Florida adults with mental illness and 116,000 youth with depression had unmet treatment needs.

Since the pandemic, these numbers are likely worse. In particular, communities of color have been disproportionately affected by increased rates of depression, anxiety, and suicidal ideation.

And despite these unmet needs, Florida's per capita funding for behavioral health, as compared to the rest of the nation, ranks in the bottom.

But it is not just the level of funding that is problematic. Inadequate funding is exacerbated by the state's overreliance on time-limited, uncertain funding to support core services, and an extraordinarily fragmented administrative structure for distribution of and accountability for these dollars.

Current Investment in Behavioral Health is Short Term

The Legislature annually appropriates funds to DCF for behavioral health services, including through multiple specific appropriations to designated local private providers of these services. These are typically funded through “non-recurring” general revenue, which means that every year these providers must go “hat in hand” to legislators to justify the ongoing need for these funds. While this keeps a good number of lobbyists employed, it adds to the overall expense and uncertainty that Floridians will be able to get and keep the services they need.

For example, non-recurring funds are used to support crisis stabilization units (CSUs). CSUs provide brief psychiatric interventions, primarily for individuals with low income who are in an “acutely disturbed state.” It is worth noting that local communities are also required to contribute a substantial portion of funding for these services. These are clearly ongoing essential services for which the need is not going away. They are vital to the health and safety of local communities and certainly merit an annual “recurring” state investment.

Another source of funding for core behavioral health services are time-limited federal grants, such as  grants to combat the opioid epidemic. While these are extremely important sources of support, too often the state puts little or no complementary investment in these services.  When funding is not guaranteed year to year, providers are understandably hesitant to expand services and make long term investments in new treatment sites. Once the federal grants dry up, the state faces a fiscal cliff, which again puts at severe risk critical services necessary to address ongoing community needs.

Administration and Distribution of Behavioral Health Dollars in Florida is Too Complex

It is a daunting task to fully track and account for how much Florida is investing in behavioral health. Part of the complexity is that dollars are appropriated and administered across multiple state agencies, including the Agency for Health Care Administration (AHCA); DCF; education, corrections, juvenile Justice, and health departments; and the courts. Appropriated dollars are then passed through these agencies to a myriad of private local providers. There is no single comprehensive plan or budget for these dollars and no single coordinating agency assigned to track disbursement and use of these funds.

The largest portions of behavioral health funding are separately administered by two state agencies: AHCA, through the Medicaid program, and DCF, through the Office of Substance Abuse and Mental Health.

Most Medicaid funding for behavioral health services flow to multiple Medicaid managed care plans (MCOs), which serve over 3 million Medicaid beneficiaries statewide, including children and adults.  The MCOs are paid on a capitated basis, meaning they receive one flat monthly payment for each enrollee. In return, the plans are responsible for providing their enrollees the full range of medically necessary physical and behavioral health services. Notably, the capitated payments flowing to the plans are unrelated to the services actually provided to an individual enrollee.

There is no separate line item in the state budget that designates Medicaid funding for behavioral health services. This was not true in the past. The separate accounting for these funds changed when Medicaid managed care went statewide in 2014.

Adding to the complexity is that these Medicaid dollars are further passed from the MCOs to individual providers in their network that deliver behavioral health services.  Accounting for how much of the lump sum payments to MCOs translates to actual behavioral health services provided is less than transparent both to the public at large and policymakers.   

On a totally separate track are dollars that flow to DCF. DCF is responsible for administering a statewide system of safety-net behavioral health services for children and adults who are otherwise unable to obtain these services. This mostly includes uninsured individuals and, to a lesser extent, Medicaid beneficiaries who require services not covered under Florida Medicaid.

DCF contracts with seven regional managing entities (MEs) to administer and distribute these funds to local providers. Availability of services widely varies around the state. The complexity of this patchwork is demonstrated through DCF's “Behavioral Health Catalogue of Care,” which enumerates hundreds of contracts MEs have with local providers.

Coordination between the DCF and AHCA systems of care is challenging. There is no integrated way of accounting for the behavioral health funding flowing to these two agencies or any of the other state agencies responsible for delivery of these services. And this siloed, fragmented system of care makes it enormously challenging for consumers and their families attempting to link up to needed care. 

Policy Recommendations

Now more than ever, the state needs to invest in behavioral health services, not only to shore up its capacity to respond to public health emergencies, but also to build broader long-term resilience for Florida families and their communities.

FPI recommends the following policy actions to support future strategic investments in behavioral health services:

  • Investing more recurring state funds into behavioral health services. An increased investment of year to year “recurring” state funding for behavioral health services is essential to stability and certainty within the delivery system. Many behavioral health conditions require long term treatment and interventions that cannot be effectively supported through sporadic resources.  
  • Expanding the state's Medicaid program. Millions more in recurring federal funds could be accessed for behavioral health if the state opted to expand Medicaid. A 2016 AHCA report found that more than 130,000 of DCF's uninsured clients with serious mental illness could gain coverage this way. Expansion would allow the state to draw down federal funding to support 90 percent of the cost of care for these clients, freeing up millions of state dollars that could be re-invested  to support other needs for these clients, such as housing. 
  • Improving accounting and transparency on state investments in behavioral health. There are numerous questions that remain: How much is the state spending on behavioral health services across all state agencies? What services are being provided through each agency? Where are the gaps in services? How can there be better coordination across all agencies for delivery of these services? Is there a single consolidated state plan for needed future investments? Currently, policymakers would have a very difficult time answering these questions. Answers are desperately needed for Florida to make wise investments going forward.

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