1.  1. Higher Mortality of SMI – 29 years  2. ACE Study & Long-term Implications  3. Large Increases in Texas’ Population  4. Increased Diversity in Population  5. 10 Mental Hospital Beds per 100,000  6. Overall Size of the State  7. Slow Science to Practice Transition  8. Highest % of Uninsured  9. Major Workforce Shortages  10. Major Innovations: service & research  11. Significant Federal Dollars for Innovation  12. Difficult to Qualify for Medicaid  13. Emphasis on Integration, Recovery, Resilience

2.  1. Put ACA in Historical Context  2. Summarize the Contents of ACA  3. Tie ACA to Disparities  4. Illustrate the Role of Public Policy  5. Offer a Challenge to Create a Different Future  6. Be done by 4:00!

3. Virginia House of Burgesses What policies should the state develop to manage mental illness? 1760 Policy Solutions: 1. Invest in Institutions 2. Limit State Funding 3. Segregation ______________ Assumptions: 1. Family Responsibility 2. Immune Populations 3. Commerce as Cause 4. Recovery & Cure Implications 1.Structural Disparities 2.Delayed Help Seeking 3.Silos 4.Institution Centered

4. 1760 1870 1912 1933 1945 1963 1965 1973 1993 2010 The Affordable Care Act: 2025

5.  1. Why are so many in need of Medicaid? Who are they?  2. What causes the early mortality of SMI?  3. Why are so many uninsured?  4. Why did 27 states sue to prevent the ACA?  5. Where does Texas rank on other measures?  6. What is the state of our science?  7. Do we need different policy direction?  8. What role does university education & research play?  9. How much profit in health care is enough?  10. Is state funding for mental health adequate?

6. Institutions1760-19631stCMHC/FFSMedicaidMedicare1963-19802nd Managed Care Fee for Service 1973-2009 3 rd Integrated Care 2000 -2013 4th Patient Protection & Affordable Care 2010 5th State Control County Control Pastoral Care State Hospitals County Hospt. Segregation Warehousing Mortality Rates Length of Stay Recidivism Employer Ins. Poor Services Community Control States Rights Federalism Non-profits Competition Federal Funding Private Providers Insurance NAMI Consumers Racial Integration Homelessness Uninsured Private Control Federal Funding CMHC Human Rights Profit Oriented State Authorities Advocacy Consumer Organiz. NAMI Uninsured Accreditation Cultural Competence Jails Homelessness Cult. Competence Service Information Collaborative Care School Based Care Health Care Ins. Use of Primary Care General Hospitals Early Identification Medical Homes Use of Technology Psychiatric Recovery Long Term Care Policies Family Support Peer Support Evidence Based Serv. Incorporates All Health Exchanges Medicaid Expansion Pre-existing Condit. Parity Children Up to 26 Yr Accountable Care Mandated Care Increased Demand Prior Reforms

7.  1. Long Term Disparities by class, race, language, ethnicity, residence, employment, region;  2. Limited availability of quality treatment;  3. Insufficient focus on culture in care;  4. Limited content in university education & research;  6. Limited understanding of help-seeking behavior;  7. Fewer people in institutions for life;  8. Medicaid and Medicare as primary sources;  9. Conflicting policy directions at federal & state levels over role of government;  10. Increased recognition of the relationship between all aspects of physical health, mental health, social determinants, and public policy.

8. Theodore Roosevelt 1912 Universal Health Insurance

9. The Social Security Act National Health Insurance The New Deal

10. National Health Insurance Hill Burton Act

11. Medicaid Medicare Community Mental Health Centers

12. The Health Maintenance Act

13. The Health Security Act

14. The Patient Protection and Affordable Care Act

16.  MH as an Essential BenefitDependent Coverage  Medicaid ExpansionPre-existing Conditions  Health HomesNo Rescission of Care  Interdisciplinary Care TeamsNew IT Efforts  Medicaid Home/Care OptionWorkforce Support  Co-Location of ServicesEvidence Based Care  Collaborative CareServices for Children  Extends InsuranceEmergency Services  ReimbursementsAccess to Health Care  Co-Morbidity Coverage

17. Barriers to Change Commodification of Health CareUnhealthful Life StylesWorkforce Shortages Profit Orientation & PotentialSocial DeterminantsState Hospital % of GDPStatus of ScienceHousing Opportunity for FraudCorporate InterestsDated Concepts Focus on Treatment/SicknessLobbying InfluenceComplexity Professional SilosIneffective Policy ProcessInsurance/Employer Corporatization of Health CareProfessional Education Absence of PreventionState Federal Conflict Understanding of DisparitiesAbsence of Racial Dialogue

18.  1. Recognize that the Affordable Care Act is but a partial victory in health care; there is a critical need to build on the current ACA as the basis of a more comprehensive policy by 2025;  2. Petition for a White House Conference on Health/Mental Health Care in 2014;  3. Close State Mental Hospitals and Shift Care to General Hospitals and Funding to Communities;  4. Re-examine education in mental health in all the disciplines and move towards more cross disciplinary education;  5. Identify what it would take to move Texas’ per capita expenditures in mental health from 49 th to 40 th in 5 years;  6. Insist on the expansion of Medicaid as an investment in the population and as a means of lessening long term costs;  7. Automatic provision of health insurance for individuals who are diagnosed with severe mental illness;  8. Address the issue of early mortality of persons with severe mental illnesses; Texas is leading on this issue;  9. Address the issue of jails that have become the mental institutions of the 21 st century;  10. Change the delayed help seeking and non-belief in the value of mental health care within minority populations.