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House bill prompts mental health treatment debate

Jun 6, 2024
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Illustration: Shoshana Gordon/Axios

A new bipartisan House effort to expand inpatient mental health treatment is rekindling a debate about the best ways to treat people with serious mental illness.

Why it matters: The measure could expand the number of psychiatric beds — which could be a big deal given the severe shortage of providers and treatment options.

  • But it could be expensive — and not everyone agrees that more inpatient treatment is the right way to go.

Zoom in: The legislation from Reps. Dan Goldman and Nicole Malliotakis takes aim at a long-standing policy known as the IMD exclusion that limits Medicaid funding to states for inpatient behavioral health.

  • It would allow Medicaid to cover stays at psychiatric hospitals, nursing facilities or other institutions with up to 36 beds, lifting the current cap of 16 beds.
  • Goldman told Axios the bill would "dramatically increase the availability of mental health care" while addressing homelessness and helping "defuse some of the security and public safety issues."
  • It's inspired by the 2022 death of Michelle Go, who was pushed into the path of a New York City subway train. A mentally ill person was charged in the killing and deemed unfit to stand trial.

The big picture: Lifting the IMD exclusion has been more of a Republican cause, so it is notable that a prominent Democrat like Goldman is sponsoring this measure with the GOP.

  • But Rep. Frank Pallone, the ranking member of the House Energy and Commerce Committee, is not on board and has expressed concerns about the idea in the past. That could complicate the bill's prospects.
  • Pallone, speaking at a substance use treatment hearing last year, warned against "warehousing" people and instead called for funding for treatment in "home and community-based settings."
  • E&C Chair Cathy McMorris Rodgers has not weighed in on this specific bill but has supported giving states the option to waive the IMD exclusion for substance use disorder treatment. She requested a CBO report on the matter.

What's next: Malliotakis told Axios she is trying to get as many E&C members as possible to sign on along with the Problem Solvers Caucus.

  • E&C members Gus Bilirakis and Tony Cárdenas are already on board.
  • Goldman said he hopes to "tee it up" for inclusion in a year-end legislative package.

Yes, but: Getting any health policy over the finish line has proved challenging in this Congress.

  • And beyond the debate over the right treatment approach, cost is a factor.
  • CBO has said full IMD exclusion repeal would cost more than $30 billion over 10 years. This bill would likely be significantly less, given that it is raising the cap to 36 beds, not eliminating the cap entirely.
  • Goldman said a CBO score is expected in a "couple weeks."

Between the lines: The issue of inpatient psychiatric care splits mental health groups. The measure has the backing of the National Alliance on Mental Illness and the Treatment Advocacy Center.

  • But some other experts are pushing back and echoing Pallone's concerns. They argue that inpatient treatment centers are the wrong approach and that people should get care in the community rather than be confined to facilities.
  • "This is the modern-day asylum," said Monica Porter Gilbert, an attorney at the Bazelon Center for Mental Health Law. "This is not a place where treatment is happening. This is a place where people go in and they don't come out."
  • She pushed instead for other measures to boost Medicaid funding for community treatment.
  • Michael Linskey, director of congressional affairs at NAMI, acknowledged that "safeguards" are needed on inpatient care, but argued, "Nowhere else in medicine, do we say OK, we're only going to pay for hospitals to treat 16 patients who have diabetes, or 16 patients who have heart disease."

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