Why is it so hard to put better mental health policies in place? Part I

A look at what it takes to make mental health reform a reality, plus recommendations on where to focus our efforts.

“Nobody knew that health care could be so complicated.”

Former president Trump and every single person who has ever had to encounter the health care system

It’s true, health care is complex. And the policies that often support health care are equally if not more complex because we just keep building policy on top of policy, with each added layer intending to do something fundamentally different if not in conflict with the one before it.

My friend, who has also become one of America’s trusted sources on COVID-19, Dr. Ashish Jha, provides a great example and explanation of why this is problematic in a beautiful piece in JAMA he wrote on deprescribing policies. His basic premise is this: sometimes we keep policies around that don’t work, or, even worse, that make new programs or policies more difficult to implement.

He writes, “The failure to learn from ineffective policies and to prune policies that are not succeeding has become a major impediment to improving our health care system. It leads to wasted time, potential harm, and loss of faith in the policy making process.”

In the mental health world, we have so many policies that don’t work. We limit where a person can get access to care. We have different rules and policies for mental health coverage, financing, delivery, and so much more. And yet, despite our poor outcomes , we don’t question enough or disband our approaches in large part because we keep perpetuating a system that’s dependent on them. We keep building programs on top of programs which all use these policies, creating a web of dysfunction that’s hard to deprescribe and difficult to untangle.

So, how do we go about getting rid mental health policies that don’t work and replacing them with better ones? It’s a process that honestly can’t be contained in one post, so I’ll spend the next few posts breaking it down for you.

WHAT IS “POLICY” ANYWAY?

Let’s start by defining exactly what policy is. In a manuscript my colleagues and I wrote about how to write a health policy brief, we put it this way, in part because this definition was drilled into my head by my friend and mentor, Dr. Larry Green.

“If policy may broadly be considered movement in a direction for a reason, a policy brief would in turn be a focused discussion of an action to achieve intentional and purposeful movement.”

Movement in a direction for a reason.

Moving in a [different] direction for a reason is what I hope my last post – which called on you to help seize the “crisitunity” before us by banding together with other passionate people and sharing solutions with your elected officials – inspired you to do. Right now, we as a country are moving in the wrong direction for our mental health. We need robust change, we need it now, and policy change is no longer just a good idea, but a fundamental requisite.  

OK, SO NOW WHAT?

With that definition in mind, the next thing I want to offer is a theory of action – well, it’s not mine, but the often-cited Kingdon’s who taught many a policy wonk the three core principles or streams for policy change:

1. Identify the policy barriers or problems that prevent people, communities, states and the country from achieving your goal

2. Assess the best solutions for solving the problems

3. Apply these solutions, at the right time, to help bring about the change you want to see. 

The application part is where things get really complicated, and what I’ll discuss more in future posts. Because the truth is, the path to changing policy can be hard and significantly more complex than what’s covered in Schoolhouse Rock’s overview of our country’s legislative process, “I’m Just a Bill.” 

The good news is that the more you know about all that goes into this process, the more strategic you can be about the amount of time, energy and resources you dedicate, and the more successful you’ll ultimately be at putting better mental health policies in place at the local, state, and federal level. 

WHAT DOES THE POLICYMAKING PROCESS REALLY LOOK LIKE?

Following the abovementioned theory of action, step one is figuring out exactly what kind of change you want to make. Perhaps it’s something uniquely impacting you or your community, like the inability to get timely access to mental health services or the lack of mental health parity enforcement.

A very close step two is researching which state senators and state representatives have aligned interests, and reaching out to them about what your requested mental health reform is. Why? Two reasons:

First, all pieces of legislation – the majority begin as bills, but there are also joint resolutions (not agreements made between the House of Representatives and the Senate, but basically a bill with a preamble), concurrent resolutions for issues affecting both the House and Senate, and simple resolutions for issues only impacting one chamber – must first be sponsored by a representative or senator. If just one of those state senators or representatives agrees with what you’ve laid out, they will draft, sponsor, and present a bill about that issue to their chamber. Or, sometimes, they may work with you on drafting what that bill looks like. Don’t forget, students in Oregon helped draft their own legislation so that they could have mental health sick days!

Second, the more passionate about your issue the sponsor is – and the more demonstrated success they have in attracting cosponsors to such legislation – the better, because what comes next is a process that can stretch on for weeks, months, or go on indefinitely without the proper support.

In my next post, I’ll pick up with an explanation of how the majority of our state governments are structured, where and why bills die, and examples of mental health bills that have already gone through this very process. I am sure many of you have stories about this, so feel free to share them below and comment more generally on this post. Who knows, maybe comments will start to make their way into future posts!

Until then, stay tuned and be well.