Overview of the State Budget Process
If you are new to state budget advocacy the first thing you have to do is learn about your state's budget process. While every state has one, the way states go about the process can differ in important ways. Some states have a one-year budget, some do a two-year budget (and some do two one-year budgets at the same time). For information about your state's budget cycle see:
The budget cycle will dictate when you need to be prepared to do budget advocacy.
Recommendation: If you are new to state budget advocacy find someone from another advocacy organization who can "show you the ropes." Or consider asking to meet with an aide to your State Legislator and ask him or her to review the process with you.
The Budget Process
While the timing of the budget process varies from state to state the stages in the development of the state budget are fairly consistent. Advocates can, and should be, involved at each of these: (The Sample Advocacy Training materials in the Additional Resources section of the toolkit contains an example of the budget process.)
Agency Budgets: Usually each state agency develops a budget for their agency (based on guidelines they get from the Governor) for the coming budget period. This is a good place to get involved because it is beneficial if you can get your issues "in" the budget as early as possible, forcing someone up the line to actively remove them. Meetings with your state mental health authority Director and the Administrator of the state agency in which the mental health authority is located are desirable strategies at this stage of the process.
Governor's Budget: The Governor will collect the budgets from the various agencies and combine them into a budget he or she will present to the state legislature. It is important to meet with staff from the Governor's budget office to review your budget priorities. If the agency included them in its budget, ask that they remain in the budget. If they were not included, make the case for the Governor doing so. Or if something has been put in that you don't like, this is your first opportunity to advocate for its removal.
Legislative Process: If you have done your homework you will know what the process is for moving the budget through the legislature. There are often multiple opportunities in the process for advocacy: when the budget goes to the budget committee(s), when public hearings are held, when the full Assembly/House or Senate votes on the budget (see part Budget Advocacy Strategies for specific advocacy strategies). At this stage advocates need to be particularly attentive to proposed amendments to the budget which may be detrimental in addition to promoting your priorities (or opposing any negative things the Governor may have added).
Vetoes: This is the last kick at the can. If anything made it into the budget to which you object it is important to communicate with the Governor's office and request a veto. Unless you live in Wisconsin (where a "digit" veto authority allows the Governor to literally rewrite legislation) its too late at this point to get anything "in" the budget that was not already included.
It's impossible in this sort of document to get into the politics of the budget process. That differs in each state and from one budget session to the next but is, of course, critical to the outcome. Key issues are which party controls the two houses of the Legislature and the Governor's office and the particular policy preferences of key legislators. It is helpful to meet early with chairs of the budget committees (or their aides) as well as other members of the budget committees and leadership of the Legislature. Part of this is to get your message out to those folks and gauge their responses in order to determine where there may be the best opportunities for success. But another critical part of this is to identify legislators who may be allies and who, as a result, can help you as the budget process unfolds. Often these are individuals who have experienced mental illness among family or friends (or themselves!) and understand the need to provide access to services. Successful advocacy hinges on nurturing such relationships.
Recommendation: Some legislatures form caucuses of members interested in specific policy areas. Explore whether your state currently has a mental health caucus. If they do, get to know the members of this caucus; they are ready-made allies. If your state doesn't have one you might talk with supportive legislators about forming one.
Budget Areas to Pay Attention To
The budget is a huge document and, as such, provides many places for important policy to "hide". For instance, while federal Medicaid well child screening requirements might not appear to be immediately related to mental health, these requirements created a significant opportunity to increase access to mental health services. One of the advantages of working in broad-based coalitions, which will be discussed in Budget Advocacy Strategies (and having legislative allies), is to increase the likelihood that you will become aware of any items in the budget that could impact, for better or for worse, people with mental illnesses and/or their families.
Recommendation: Some state legislatures offer notification services where you can identify legislative items by key words and find out any new legislation with these words. Sign up for this as a way to track what's going on.
But while vigilance is important there are some critical areas that all mental health advocates will want to focus on:
Medicaid is the single largest payer for mental health services in the United States. The federal government sets the broad outlines of the program, including minimum eligibility requirements and mandatory services, but states have a considerable degree of discretion in the specific services they offer, who can provide those services and reimbursement rates. Medicaid shapes the public mental health system since upwards of 2/3 of people with mental illness in the public mental health system are on Medicaid. Are such, there are some key things that advocates need to examine:
Recommendation: While most mental health advocates know the people in their state mental health agency well, they do not know their Medicaid staff. While it is often more difficult to develop these relationships, for the reasons noted above it is worth the effort to do so.
Eligibility: Changes in how eligibility for Medicaid is defined will impact the number of people with mental illness who are eligible. Currently, while states are receiving the enhanced federal matching rate for Medicaid as part of the American Recovery and Reinvestment Act (ARRA) they are prohibited from reducing eligibility standards. But this will likely change in July 2011. With most states facing significant budget deficits, it is likely there will be efforts to roll back eligibility in states that go beyond the minimum required by the federal government. States will also be making decisions related to implementation of national health care reform that will significantly impact Medicaid coverage (for more information on health care reform see MHA's toolkit on health care reform at http://mentalhe.stage.bluewatermedia.com/issues/health-care-reform).
Covered Services: While there are certain mandatory services, such as physician services and hospital services, many of the core psychosocial rehabilitation services so critical to recovery of individuals with serious mental illness are not mandatory. And yet it is possible for states to cover Assertive Community Treatment for adults, wraparound services for children, crisis intervention services, and services by peer specialists. (Examples are included in Additional resources)
Provider Rates: Rate increases (or decreases) for Medicaid providers is a budget issue. Having services covered is not sufficient if rates are inadequate to engage a sufficient number of providers to assure timely access to services, even though Medicaid programs are required to assure just that. This issue can be even more problematic when Medicaid services are offered through managed care, since the provider rates are established by the managed care provider (although often based on Medicaid fee-for-service rates).
Recommendation: Ask your Medicaid agency for provider participation rates for fee-for-service Medicaid over time. If there is a decline that is not consistent with a change in the Medicaid population, you may be able to use this data (along with stories of access problems from consumers) to make a case for rate increases. Also, if people in managed care say they cannot obtain timely services, ask your Medicaid agency to investigate and hold the managed care company accountable for providing timely access.
Medications: Many states already have preferred drug lists (PDLs) which can limit access to certain psychotropic medications unless there is prior authorization. But budgets could have language to achieve more savings in this area or to institute PDLs where they currently do not exist. See the MHA toolkit on Access to Medications for more information.
General cuts: Legislators may simply order the Medicaid agency to achieve a certain level of cuts without dictating how that should be done. If this strategy is being pursued advocates should push for language requiring that the agency report back to one or both of the budget committees before implementing the cuts. This provides an opportunity to comment on the cuts if advocates are unsuccessful in forestalling what they view as bad policy at the agency level.
Following the deinstitutionalization of persons with mental illness in the 1950s and 1960s the inadequacy of community-based services led, over time, to an increase in the number of people with mental illness who were becoming involved with the criminal justice system. Jails and prisons are now the institutions housing the largest numbers of people with mental disorders. A variety of strategies can lend themselves to budget initiatives. For additional information see MHA's Criminal Justice toolkit.
Diversion: Diversion programs intervene before a person is incarcerated. These may take the form of mental health courts which have special expertise in understanding the alternatives that may be available to individuals whose crime may be significantly related to an acute phase of their illness. But diversion can be done in the absence of such courts if funds are allocated to agencies that can work on behalf of those coming before the court.
Utilization of national standards for correctional mental health care: It would be a safe bet that prisons in your state do not provide recommended levels of mental health professionals for the population they serve. Utilizing national standards you can support an increase in these providers to increase the likelihood that inmates with mental illness are getting adequate care.
Reducing recidivism: In part the large number of people with mental illness who are incarcerated is a function of the much higher recidivism rate among this population. If they are not provided with adequate services in the community after their release they will often reoffend. But if adequate funds are made available to probation and parole to purchase services for parolees with mental illness the recidivism can be reduced. Specialized case management or assertive community treatment programs for this population can also reduce recidivism.
Other: There are also things that can be done outside the budget process to improve the lot of people with mental illness in the correction system. Administrative segregation (isolation) can exacerbate mental illness: changes in how prisons utilize this practice with offenders with mental illness can positively impact these individuals. Also, reintegration into the community can be facilitated by timely reinstatement of Medicaid benefits (which are terminated when someone is incarcerated). Through planning and coordination the corrections system can do a better of job of ensuring that people can have access to Medicaid (and therefore to treatment) when they walk out the door.
Mental Health System
While one might think this should be the first area listed, in terms of the amount of funds related to persons with mental illness allocated in a typical state budget the mental health system often comes in well behind Medicaid and Corrections. With implementation of health care reform the number of people who have access to no insurance will decline and the need for a "public" system outside of Medicaid may decrease. However, there are still important services that may not be covered through Medicaid or private insurance that will only exist if States take action.
Funding Non-Traditional Services: Assertive community treatment, systems of care for youth (wraparound programs), consumer-run services (such as drop-in programs and consumer-run respite) are all core parts of a modern mental health system but are not services traditionally made available through insurance. Where states are covering these through Medicaid you will want to advocate there, as outlined above. But if not you will need to advocate for specific allocations to fund these programs. Even where such programs are currently funded they are often not available in sufficient numbers or geographic distribution to adequately serve the population that needs them.
Advocacy: Organizations like MHA and consumer and family support groups require funding to provide non-treatment related services to people with mental illnesses and their families. This will generally not come from Medicaid (although Medicaid may have specific "ombudsman" funds to provide individual advocacy to members enrolled in managed care) or private insurance. There is considerable value in making sure these organizations are funded because of the supportive role they play to the treatment system.
Recommendation: See the MHA website at http://mentalhe.stage.bluewatermedia.com/policy-issues for information about various policy issues and link to policy statements.
Community Integration Services
It's great to move people with mental illnesses out of institutional settings, be it nursing homes, corrections or psychiatric facilities. But if the appropriate supports are not available to support their reintegration into the community then community-living is jeopardized. Jobs, housing and educational opportunities are critical parts of the community infrastructure.
Vocational Rehabilitation: Vocational rehabilitation (VR) funding is matched at an 80%/20% rate by the federal government; for every $1 million the state invests, the federal government will pay $4 million. Is your state VR agency taking advantage of this very high matching rate? Is your VR agency serving appropriate numbers of people with mental illness (the requirements for VR to achieve a closeout of a case are sometimes problematic as they apply to people with mental illnesses). Is your VR agency working closely with your psychosocial rehabilitation providers on employment? Often this sort of collaboration is a win-win; the psycho-social agency has the expertise but not the funds, the VR agency has the funds, but not the expertise with this population. And the big winner is the consumer who can get a good vocational opportunity.
Housing: The vast majority of funds that support housing for people with disabilities are federal dollars from the Dept. of Housing and Urban Development. Some, such as Section 8, go directly to municipalities, bypassing the state budget process altogether. But some states have formed housing trust funds that can support the development of low-income housing for people with disabilities. For example see information about the State of Washington's housing trust fund at: http://www.commerce.wa.gov
Education: School funding issues are critical for youth with disabilities. As funding for schools gets squeezed special education is often the victim. School funding formulas differ from state to state. Learning about how schools are funded and the impact this has on providing specialized services to children with serious emotional disturbances is a critical area of advocacy. The Federation of Families for Children's Mental Health has chapters in most states; you can find them at: http://www.ffcmh.org/
Recommendation: These community integration services are of great importance to all disability groups. You may want to consider how to join with advocates for people with physical or developmental disabilities as you seek to advocate in these areas.
Budget Advocacy Strategies
Successful budget advocacy, like most advocacy, requires strong, broad coalitions. The more people you can involve, from more areas of your state, the more likely it is that you can ensure that all the members of your state legislature have heard from constituents about your issue. It also increases the likelihood that you are all sending the same message. As one Wisconsin legislator once said: "When I hear different messages [from different mental health advocates] I hear nothing.."
Consider coalition building at a number of levels:
State Planning and Advisory Councils: Each state must have a planning and advisory council as a condition of receiving federal mental health block grant funds. While at its narrowest the role of these councils is to advise the state mental health authority and Governor on use of these funds, in many states the Councils are empowered to provide recommendations on mental health policy more broadly. Because consumers, family members, advocates and providers are often part of the Council it can become a vehicle for developing consensus on state budget priorities and provide leadership in advocacy. State MHA offices are often already members of this Council. You can find out about your state Council from the National Association of Mental Health Planning and Advisory Councils at http://www.namhpac.org/networking.html If you go to the "resources" tab for this organization you will find brochures and toolkits related to various mental health topics that may support your advocacy.
Mental Health Coalitions: In those states where the planning and advisory council may not be empowered to take on a broader role (or chooses not to do so) consumers, family members, advocates, providers and other interested parties can form their own coalition. California's coalition was successful in promoting legislation that taxed millionaires and dedicated those funds to mental health services. You can find information about this coalition at: http://www.mhac.org/advocacy/ccmh.cfm
Cross-disability coalitions: As noted above, for many issues (housing, vocational rehabilitation, Medicaid) mental health advocates have common cause with advocates from other disability groups. These other groups may also have a stronger track record of success given the differing stigma attached to those disabilities. But people with developmentally or physical disabilities (and aging groups) also experience mental health disorders, so collaboration is not only possible but desirable.
When it comes to strategy there is no limit to how creative you can be. Here are some general categories to consider:
Documenting the Problem: Often before you can get people to look at the particular proposals you are promoting you must convince them of the need. You can find examples of such documents in Additional resources. There are a variety of sources of potential data for you to use:
- MHA state rankings; http://www.nmha.org/go/state-ranking
While the data in this 2007 report is now somewhat dated, it is a good example of how data can be used to support advocacy and you can search for updated information from the data sources that were used, some of which are identified below.
- National Survey on Drug Use and Health (NSDUH) http://oas.samhsa.gov/MH.cfm
While the majority of these surveys related to substance use/abuse, there are a number of recurring and special reports related to mental health conditions. Some of these reports provide only overall national data but others provide state by state comparisons that will give you prevalence estimates for your state.
- Center for Disease Control and Prevention (CDC): suicide data
This webpage provides access to a variety of data sources related to suicide, including a programmable database, WISQARS, which allows you to request a report for your state specifying demographic factors (age, gender). Make sure to look at the Youth Risk Behavior Surveillance Survey data, which has questions related to suicide and substance abuse. Comparisons between national and state data are available.
- National Association of State Mental Health Program Directors Research Institute: How State Mental Health Agencies Use the Community Mental Health Services Block Grant to Improve Care and Transform Systems [In Additional Resources section of this toolkit]
The mental health block grant is a rich source of data. The reports provide brief summaries of the data for each state.
- Impact of MH on chronic health conditions: http://www.cdc.gov/pcd/issues/2005/jan/04_0066.htm
As integration of mental health and health care becomes more the norm this paper on the impact of depression on the morbidity, mortality and costs associated with other chronic health conditions is especially relevant. Those people who are looking to "bend the cost curve" in health care know that they can't do that without reducing the costs associated with these chronic conditions; and you can't reduce the costs associated with these chronic conditions without addressing mental health. This paper makes it clear why that is the case.
- The Partnership for Workplace Mental Health: www.WorkplaceMentalHealth.org
Mental health disorders have a huge direct and indirect impact on costs to employers. The business case for better addressing mental health disorders can help neutralize some opposition to the "costs" of funding mental health care.
Budget Priority Document: When you advocate you need something you can hand to people that tell them what you want and why. And you need to have a manageable list of priorities: if you ask for 50 things people will tune you out quickly. It helps to organize in ways which makes the whole more digestable (e.g., by state agencies or by "children" and "adult" issues). (See examples in the Additional Resources section of the toolkit)
Public Awareness: Now that you've established your priorities and put your facts together, op-eds and letters to the editors are a good way to get this information in front of the public. Legislators and their aides pay attention to these as a way of gauging the thinking of their constituents.
Legislative Contacts: The cornerstone of budget advocacy is contact with legislators by their constituents. Part of the reason you put together a priority document is so that everyone going in can sing from the same hymnal. You may want to provide talking points to reinforce this. If you ask people to send emails or letters provide them with a Swiss cheese version or key points you want them to make (and provide information about exactly who to contact and how). Organization and follow-up are critical and not easy to accomplish.
Recommendation: See MHA's Advocacy 101: Getting Started for tips about contacts with legislators and additional advocacy strategies.
Rallies: Rallies can be tremendously effective when you bring together thousands of advocates. Wisconsin's cross-disability coalition regularly filled the state capitol rotunda with huge crowds, many of them in wheelchairs, underscoring the importance of maintaining Medicaid eligibility and funding and increasing options for community care. But rallies are also very time-consuming to organize and generally require significant expenditures to transport people to the Capitol. This is where that broad coalition is invaluable.
Legislative Breakfasts: A legislative breakfast in district is an easier way to get legislators and constituents together. Make sure to schedule on days when legislators are not at the Capitol (usually Mondays or Fridays). Take time for advocates to present their issues and give legislators a chance to respond. Seat legislators and constituents together at the tables. By working regionally you may be able to bring a sizeable number of legislators together during one event.
Messaging is an industry in its own right. Some of the examples of materials in the toolkit reflect the approach that various states have taken. You can hire a professional PR firm or you can brainstorm within your coalition.
Messaging in Hard Times: Right now it is especially challenging to be advocating in support of even maintaining current levels of funding much less asking for increases. (See Additional Resources for a paper that discusses how to shape your message in this area.
Report Cards: While much emphasis is put on the front end of the budget process-identifying your priorities and advocating for them-it may be useful to do some work on the back end, identifying how things went. A budget report card can actually be a first step in the next budget process by underscoring both what was and what wasn't accomplished. (An example of such a report card can be found in Additional Resources)
If you've got this all together consider providing training for your advocates, especially those who are not in professional roles. Consumers and family members are critical parts of the advocacy team because it is their stories that will move legislators. But they often have had little experience with legislative advocacy and need to understand the process and the procedures. (See a sample of materials that can be used in advocacy training in Additional Resources. Many of these relate to the areas discussed in the toolkit.)