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Why mental health services in Michigan vary from county to county

Jul 28, 2016

Don Williams is from Holland, Mich., and recently, he posed this question to Michigan Radio’s MI Curious project: Is it just his perception, or do mental health services vary widely in different parts of the state?

“I have close friends I know who are mentally ill,” Williams said. “And I have in my coffee group a County Commissioner, well-informed on this issue. And we often discuss it. And I soon became aware that the funding for mental health issues and mental health issues was uneven, rather chaotic, and I decided that I’d pose this question and see if I was right.”

It’s not just Don’s perception -- there are substantial differences between the levels of mental health care a patient might receive in one county as opposed to another. So to get him a clearer answer, we spoke with Bob Sheehan, the CEO of the Michigan Association of Community Mental Health Boards.

The problem, Sheehan said, stems from the way Michigan’s mental health system was designed.

“There’s been this discrepancy for about 30 years,” Sheehan said on Michigan Radio's Stateside. “It’s shrinking -- I should tell you it is shrinking, the state’s making incredible efforts to shrink the financing (differences) for Medicaid and non-Medicaid financing across the state, but there’s still a long way to go.”

But why does the quality of services vary in the first place? In short: Michigan’s mental health system wasn’t designed from scratch, and wasn’t designed with the sole goals of efficiently and fairly serving the state’s population.

“I think if you were to build the system today -- it’s a $3 billion system, by the way, so there’s a significant amount of money -- if you built it today, you’d say, ‘What does everybody in the state need?’ Let’s build a uniform treatment, service and delivery platform across the state,’” Sheehan said.

That’s not exactly how the system was built, because as it often does, politics played a role. Many state-run mental hospitals closed in the last several decades, some of which came after budget cuts instituted by former Governor John Engler.

Those cuts left behind a trail of empty buildings, unemployed mental health professionals. Simple geography and resource availability changed the way the system was designed going forward.

“That’s not how it was built,” Sheehan said. “It was built based on where state hospitals were located. You may remember, when we closed state hospitals, a lot of those employees or the money for those employees went to the local CMHs around the hospital. So if you lived in a town with a state mental hospital, the CMH was funded better from then on.”

Other factors, Sheehan said, included some appropriations chairs in the state Legislature who funded their own districts’ mental health systems better. A third factor was how good community mental health services (CMHs) were at getting reimbursed by Medicaid.

“Medicaid wasn’t billed until the early ‘80s,” Sheehan said. “‘Some CMHs said, 'Let’s bill this and see how this goes, and some did not.’ In 1997, that became frozen under a financing system that hasn’t modified much except for the last few years.”

While some CMHs are better than other at reducing overhead costs, Sheehan said each agency’s individual efficiency doesn’t play a major role in determining service levels, either.

“It is a variable, but it’s small,” he said. “Even if you cut (overhead costs) in half, you’d have 3% more dollars. The disparities are large. The disparities are 200% or 300% different.”

Sheehan did say the situation is improving -- if not in overall quality of care statewide, at least in equality of services provided.

“There has been some movement,” he said. “I want to applaud the state. But it’s hard politically. If you don’t add money to the system, you end up having to cut the better funded to fund the more poorly funded. I don’t think that’s the way to do it, by the way. Over the next year, you will see cries across some parts of the state when the cuts happen that will even things out.”

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