October 18, 2021

Reinvigorated Mental Health Commission Grappling With Same Issues Identified Over 20 Years Earlier

The Commission on Mental Health and Substance Abuse, established by the 2021 Legislature, is charged with making “recommendations on how to best provide and facilitate mental health and substance abuse services in the state.” One of its specific duties is to make recommendations “regarding the establishment of a permanent, agency-level entity to manage mental health, substance abuse and related services statewide.”

It's notable that another Florida Commission on Mental Health and Substance created by the Legislature in 1999 found that “…no one entity is attending to the overall system.” It recommended creation of a statewide Coordinating Council for Mental Health and Substance Abuse located within the Office of the Governor and “composed of leadership from across human service departments.” To Florida Policy Institute’s knowledge, no such Coordinating Council was ever established.

Comments made by the 2021 commissioners at their initial September meeting reinforce the ongoing urgent need for statewide strategies and better coordination of the multiple entities providing these services. Just as the 1999 Commission found:

The service system extends far beyond the original concentration of services within the Department of Children and Families and the “traditional” public mental health and substance abuse system. 

An essential starting place for coordination is between the two state agencies administering the largest portions of public funds for mental health and substance use disorder (MHSA) services: the Department of Children and Families (DCF) and the Agency for Health Care Administration (AHCA).

The Substance Abuse and Mental Health Program housed within DCF serves indigent, uninsured, and underinsured children and adults with serious mental illness or substance use disorder who need services through its “safety net” program. DCF contracts with seven not-for-profit regional managing entities (MEs), which administer and distribute state general revenue and federal funds (including Mental Health and Substance Abuse block grant dollars) to local providers of safety net services for over 320,000 Floridians. For fiscal year 2021-22, MEs were allocated $802 million for “safety net” MHSA services.

But this funding falls far short of need. As of December 2020 there were over 2,500 adults and children on waitlists for outpatient substance abuse and/or mental health treatment.

Far exceeding the scope of DCF's safety net program are Medicaid-funded services administered by AHCA. A significant change in the landscape since the 1999 Commission has been the growth in Medicaid managed care — now the largest provider of publicly funded MHSA services in the state. Over 3 million Floridians (including more than 2 million children) are enrolled in predominantly for-profit managed care plans. The plans are responsible for meeting the full continuum of care for of all their enrollees’ MHSA needs, as well as for other health care. The Medicaid MHSA services are intended to cover preventive and early intervention strategies for children and adults with less severe conditions as well acute care for people with serious mental illness.

This fiscal year, the Legislature appropriated about $22 billion for Medicaid managed care. It's unclear how many of those dollars will be specifically spent for MHSA.

As for unmet need, while DCF and the MEs have substantial public documentation of unmet need, on the Medicaid side, AHCA is more circumspect. However, recent quality assessments showing poor plan performance on multiple MHSA indicators raise red flags about the quality of service delivery on the Medicaid side. This includes important indicators such as failure to follow up with enrollees within seven days after an emergency department visit or hospitalization for psychiatric or substance abuse treatment.

The state has experience with both a single- and two-state-agency administrative model. At the time of the 1999 Commission, there was only one agency administering Medicaid and other funding for MHSA services. That changed with the creation of AHCA in 1992. AHCA was designated as the single state agency charged with oversight of the overall Medicaid program, including contracts with managed care plans. A significant change on the DCF side in 2008 was creation of the MEs. Under all these administrative models there have been daunting challenges for implementation of a statewide vision and coordination of care.

The 2021 Commission will be wrestling with the same issues. In the end, as the 1999 Commission noted, there needs to be a fix for the problem that “no one entity is attending to the overall system.” Some structure is needed with authority to facilitate development and implementation of a statewide MHSA services vision and to hold accountable the multiple players within the delivery system.

This is an essential foundation for ensuring Floridians get access to high quality MHSA care no matter which door they may enter.

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