Monday, June 15, 2009

How Big a Lever Do You Have? Advocating in the Two Halves of the Mental Health System

As you have noticed, most of my posts over the past few weeks have focused on either the evolving settlement of the Rosie D case (in which the judicial branch is telling the executive branch what to do) or the passage of Yolanda's law (in which the legislative branch is telling the executive branch what to do).  It is interesting to compare these efforts a bit, especially in terms of how they will affect the actual mental health services for children in the Commonwealth.

The Children's Behavioral Health Initiative (the public response to the Rosie D remedy) is actively building a new system in response to the court mandate.  There is a lot of negotiation over the details, but noone can argue that the state is building something that is new.  ALL of it is result of the entitlement that is EPSDT;  without that lever, it seems likely that the Commonwealth would have continued to implement incremental change that would perhaps have gotten us to this point by 2025.  That is one powerful lever (the force of court), that makes us all drop what we are doing and attend to this particular issue in a forthright and effective way.

The Children's Mental Health Campaign (Yolanda's Law) is a slower and much more limited process.  The bill sets out a number of processes and reports to hold agencies and more providers accountable for the care they is provided through private insurance plans;  it's power is in the creating of paper trail in most cases, and yet, since 75% of the children in the Commonwealth not on public insurance, it has a much greater potential to impact their mental health.  But it lacks the "teeth" of the court to enforce compliance;  the reports and plans and discussions will work to create a consensus.

My observation, however, is that we are dealing with two very different size sticks.  The lawsuit gives us LOTS of leverage for change.  We can build new systems with that kind of leverage.  The question that one must ask is, will the change last once the court declares the case resolved.  So, even with the force inherent in a court order, care must be given to ensure that there is some consensus and process developed to make the change stick.  The bill opens the door for leverage, but really must be seen as an effort to begin a lengthy reform process.  With a long enough lever, as in the Rosie D. case, we really can affect major change.  Legislative change requires more time and patience, to build a consensus around structural change.  One hopes that the structure will last;  the structures that do last seem to be the ones that afford some measure of political power to those who benefit from the change (ie Social Security lasts because the elderly resist attempts to change it).  So, when the Court is gone, and the Campaign is over, who will stand for the rights of children in the mental health system?  Not an easy question for those who would make this sort of policy.
Talking in Waltham tomorrow.  Hope to see you there.

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