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Fostering Federal-State Innovation in Mental Health
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  1. Fostering Federal-State Innovation in Mental Health NAMI Conference 2005 Stuart M Butler

  2. The Climate for Action • Medicaid is under pressure. • Health in competition with education etc. • Mental health must compete with acute care, long-term care • Little public or congressional enthusiasm • Partisanship and gridlock in Washington • States are the drivers of policy

  3. Improving Mental Health • Focus on effective outcomes • Place greater control in hands of patients and families • Allow greater use of non-traditional service delivery and support • Foster state innovation with beneficiary protections

  4. Keys for Improvement • Tax and insurance reforms for health insurance • Tax benefits for insurance through non-employer groups • Insurance reforms to spread risk and encourage insurance specialization • Foster enhanced federalism

  5. Aims of Enhanced Federalism • Test major federal-state initiatives in willing states • Break the political logjam in Washington • Enable Members of Congress to accept approaches they would block for their state • Test rival strategies

  6. Core Elements • Congress sets goals for coverage and protections • Congress enacts a la carte policy toolbox • Proposals that states can try – not mandates • States and federal government agree on policy covenants • Congress pays for performance. New funds or savings for: • Technical assistance • Federal component of approaches to be tested • Monitoring and data collection • Bonuses to successful states

  7. Some Issues to Consider • The mental health dimension • Community-based approaches • Family-based care • Preventive and management drugs • “Cash and counseling” • Integrating long-term care • Outreach to the homeless

  8. Some Issues to Consider • Process for selecting the state initiatives • Base closing commission approach • Composition of commission critical • Procedure for selecting initiatives • States propose initiatives with state and toolbox components • Commissions reviews and negotiates within budget • Slate sent to Congress for up-or-down vote

  9. Some Issues to Consider • Designing the toolbox • Turns demonstrations from appeasement items to core of approach • Importance of ideological symmetry and logrolling

  10. Some Issues to Consider • Rewarding Success • Trust but verify: third-party evaluation • A formula for federal contribution to proposals? • Maybe a bidding process