THE ADMINISTRATION IS LIQUIDATING MENTAL HEALTH CENTERS PROGRAMS Testimony Before Senate Appropriations Subcommittee on Labor-H.E.W. (Sen. Magnuson, Chairman) On Fiscal 1971 Budget for National Institute of Mental Health 10 AM Tuesday, June 16, 1970 Room 1114, New Senate Office Building by MIKE GORMAN, Washington, D. C. Executive Director, NATIONAL CITIZENS COMMITTEE AGAINST MENTAL ILLNESS Member, JOINT COMMISSION ON MENTAL HEALTH OF CHILDREN Member, NATIONAL ADVISORY MENTAL HEALTH COUNCIL, U.S.P.H.S. Fellow, AMERICAN PSYCHIATRIC ASSOCIATION (HON, ) Fellow, AMERICAN PUBLIC HEALTH ASSOCIA TION Mr. Chairman and members of the Committee: I have been testifying on the budgets of the National Institute of Mental Health for close to twenty years, but I state in all candor that the Administration budget for fiscal 1971 is the most stringent and regressive I have ever examined. The disappointment of all of us in the mental health field in the proposed budget is even more keen because we expect some reward or encouragement for dramatically re- ducing the tax burden formerly exacted by mental illness in this country. In fiscal year 1969, we achieved the highest reduction in the number of patients confined in our state hospitals -- a drop of more than 31,000 below the figure just a year ago. This is the fourteenth straight year in which the number of patients residing in our state mental hospitals has declined sharply. As of June 30, 1969, there were only 367,000 patients in our state institutions, as compared to 558,000 patients in 1955. Furthermore, preliminary figures for the current fiscal year indicate that we will exceed the record drop of 31,000 patients achieved last year. ( page two We have achieved these reductions, Mr. Chairman, through the combined efforts of federal, state and, in some cases, county government in applying the tranquilizing _and anti-depressant drugs and other dividends of research to the intensive treatment of patients formerly regarded as incurable. In addition, the impact of the community mental health centers is now beginning to be felt ina reduction of admissions to state hospitals adjacent to these centers and, even more importantly, in a significant drop in readmission of mental patients because the new centers are now able to care for them in the community. Apart from humanitarian considerations, the continually shrinking size of our mental hospital plant has meant the saving of billions of dollars in capital construction and operating costs which would have been necessary if we had continued along the old custodial lines. If the seemingly inevitable pre-1955 pattern of increasing resident patient population had continued uninterrupted, there would now be more than 746, 000 patients in our tax- supported mental hospitals -- 379,000 more than is actually the case. This number would have required additional expenditures since 1955 of 6.1 billion dollars for patient care and more than six billion for the construction of hospital beds. Careful statistical studies substantiate our point that for every additional dollar you in the Congress have invested in research, training and treatment over the past two decades, you have received a return of approximately six dollars in reduced con- struction and hospital operating expenses for the mentally ill. Frankly, we don't know of any comparable government activity which even approaches our sustained performance in returning dividends to the American tax-payer. page three In light of the aforementioned savings, we think we have made a pretty persuasive case for a heavy investment in the activities of the National Institute of Mental Health in order to accelerate this exciting trend away from the expensive hospital bed. However, the first Nixon budget last year was ten million dollars below the sum Congress appropriated for fiscal 1969, and his budget for fiscal 1971 is a similar ten million dollars below the amount he requested for fiscal 1970. In order to capitalize on the extraordinary progress made over the last fifteen years, we propose a realistic and progressive budget of $483,106, 000 for the National Institute of Mental Health during the coming year. May I remind you that this figure is only about 25 percent of what the states spent last year just for the operation of their mental hospitals. It does not include the significant additional monies spent by the states in that same year for mental retardation, community mental health centers and other related programs. In the body of my testimony, Mr. Chairman, I have chosen to concentrate on two major programs which are so severely underfinanced in the proposed budget that they threaten to bring to a halt all of the painfully acquired progress we have made during the past two decades, 1. STATE AND COMMUNITY PROGRAMS A. Staffing of Community Mental Health Centers The Administration recommends 60.1 million dollars in federal staffing for community mental health centers during fiscal 1971. The backward nature of this recommendation is highlighted when one compares it with the 64.3 million dollars the page four Congress voted for the very same purpose in fiscal 1969. Furthermore, throughout fiscal 1970 the Administration kept cutting back in actual staffing monies available so that only 47 new staffing awards have been made, as against 81 last year. Because of these actions, we were told at the March meeting of the National Advisory Mental Health Council that we would not be able to fund 30 new centers whose applications had already been approved. We have also been informed that, at the forthcoming June meeting of the Council, we would be faced with the prospect of turning down an additional 50 centers which meet all the professional criteria but won't be able to open their doors. In stark financial terms, it is estimated that we will have a backlog of approxi- mately $22,000, 000 in approved but unfunded applications at the close of fiscal year 1970. It is therefore obvious, Mr. Chairman, that the 60.1 million dollars recommended by the President will only partially cover the federal obligation for centers already in being -- it will provide not one cent for new staffing grants in fiscal 1971, and it will come nowhere near picking up the approved but unfunded applications moved forward from the current year. As an example of the severe stringency of the Administration proposals, let me list for the record the impact of these cuts upon those states represented by members of this committee. According to charts supplied to me as a member of the National Advisory Mental Health Council, if the President's recommendation for staffing is sustained, 29 centers in the ten states represented on this committee will not be funded, depriving close to six million people of access to modern psychiatric care. In a number of these cases, private fund-raising efforts combined with county and state tax monies to match the federal contribution for the construction of the centers. Now we face the prospect of gleaming new buildings devoid of the staff necessary to institute treatment programs. page five Earlier this year, as you know, the Congress passed legislation renew- ing the community mental health centers program. This legislation expanded the level of federal participation in the centers program and it is pertinent to list here some of the provisions of S. 2523 which the Administration has refused to finance: 1. The new legislation authorizes 45 million dollars in new staffing grants for fiscal 1971. The Nixon Administration budget provides not a single dime to implement this authorization. 2. For centers in urban or rural poverty areas, the Congress authorized a much higher level of federal staffing paricipation, starting at 90 percent for the first two years and dropping gradually to 70 percent in years six, seven and eight. We have received documentation to the effect that this provision alone would require at least twenty million dollars more than the President has requested, and this is tased upon avery strict interpretation of eligible poverty areas. 3. For those centers not eligible for poverty funding, there is a somewhat higher federal participating percentage; extension of federal staffing support to eight years as against the original 51 months, and a broadened definition of kinds of personnel eligible for staffing subsidies. Obviously, this will require additional money. No such ad- ditional money is provided in the Nixon budget. page six 4. The new legislation also allocates up to five percent of total staffing money for initiation and development grants for the planning of services in previously unreached rural or urban poverty areas. Obviously, money used for this purpose comes out of the total staffing allotment. 5. One of the most significant provisions of the 1970 renewal of the Community Mental Health Centers Act was the inclusion of higher preferential funding for the establish- ment of children's units in community mental health centers. Testimony before both House and Senate legislative committees made the pot that the Congressionally funded Joint Commission on Mental Health of Children had recently reported that there were four million emotionally disturbed children in need of psychiatric care, but that less than one-third were getting even token care. Center Directors appearing before the legislative committees talked of the enormous public pressure to treat these children, but they explained that treating a child costs two and one-half times as much as treating an adult patient. On the basis of this testimony, the Congress authorized twelve million dollars for the establishment of these desparately needed children's facilities in community mental health centers in fiscal 1971. However, there is nota dime in the Nixon budget to finance this authorization. page seven 6. The 1970 law also authorizes five million dollars for the first year of a three-year program to help the centers provide education and consultation services to all agencies in the community having any contact with mentally ill people. The authorization is there, but the appropriation request is not. Mr. Chairman, we are not asking the Federal Government to assume an unfair share of the burden of supporting these community mental health centers. On the contrary, As I pointed out in my testimony in both 1968 and 1969, it is the states, the counties and private efforts which have kept this program in being. Last year, our national government contributed only 30 percent of the total costs of these centers, and the new budget being proposed will drop it to about 25 percent. Figures don't begin to project the frustration I have observed among our citizens as I have toured the country these past several years. In many city and rural areas, it has been a tough three and four year effort to get the matching money required to make an application for federal funding. Having accomplished all of this, these hard working citizens are then told that their application is an excellent one, but there is no money for new staffing awards. When the original legislation was up for consideration by the Congress in 1963 President Kennedy, in his historic mental health message in February of that year, proclaimed the goal of 2,000 community mental health centers by 1980 leading to eventual elimination of the custodial snake pits which have housed our mentally ill in this country for almost 200 years. We got off toa pretty good start, but the last three years have been very discouraging. We have only 225 centers currently in operation, and page eight the Nixon Administration projects only 59 more centers during the coming year. In order to really do the job, we should be adding at least 150 centers each year. We therefore propose $110,000, 000 in staffing grants so that a modest amount of new awards can be made, some centers can be started in poverty areas as envisioned by the Congress, and important components of the center such as children's services and educational and consultation services can extend their reach to people in need. B. Construction of Community Mental Health Centers In recommending not one single dollar for the construction of community mental health centers in fiscal 1971, the Administration clearly reveals its intent: To - try to severely limit, or phase out, the entire community mental health centers program which was supported almost unanimously in both houses of Congress in the original 1963 legislation and in the 1965, 1967 and 1970 expansions of that legislation. Again, in this instance, the Administration ignores the clear-cut intent of Congress when it authorized eighty million dollars for the construction of mental health centers in fiscal 1971. However, the Administration -- still playing the old shell game which I complained about in last year's testimony -- froze twenty million dollars in construction monies this year, and now has moved this forward to fiscal 1971. As a result, this carry-over money is the only support available for construction of com- munity mental health centers. However, the real impact of this cut will hit in fiscal 1974. There will be no carry-over from the previous year, and we know it takes at least a year to get a construction application developed and approved. Even if the Administration sends up a request for construction funds for centers in fiscal 1972, it will be almost impossible to use these funds properly because of the lead time involved. page nine In visiting a number of states these last few months, it has been a most disheartening experience to tell governors, state legislators and citizens that the Nixon Administration thinks so poorly of the community mental health center program that it will not request any money for construction of new centers. In some parts of the country, sucha statement on my part is greeted with shock and disbelief, since 30,000 people were involved in the planning of these centers in the early 1960's. We therefore recommend 40 million dollars for the construction of community mental health centers in fiscal 1971. Our major thrust is still toward the staffing of centers because we feel that many communities can postpone construction for oo a period of time while they develop a competent center staff. Cc. Alcoholism Programs In 1968, the Congress amended the Community Mental Health Centers Act by authorizing 22 million dollars over a two-year period for the construction and initial staffing of units within the centers devoted solely to the prevention and treatment of alcoholism. The Congressional authorization was a response to lengthy hearings which highlighted the fact that many existing community mental health centers were being swamped with alcoholic patients-- in many of the centers, alcoholics comprised 25 to 30 percent of the total number of patients handled. The actual appropriations for this activity are quite another matter. In fiscal 1969, we received no money whatsoever. In fiscal 1970, although the Administra - tion recommended no funds, the House recommended four million dollars and the Senate eight million dollars. However, after the conference worked its will and the two percent cut was put into effect, the appropriation for alcoholism activities was reduced to page ten $3,175,000. Due to the lateness of the passage of the appropriations bill, it is doubtful that even this small sum will be spent by June 30th of this year. For fiscal 1971, the Administration recommends only six million dollars for all alcoholism activities within the community mental health centers program. By way of contrast, the Community Mental Health Centers Act of 1970 authorizes 30 million dollars during the coming year for both alcoholism and drug addiction activities, In addition, the new act for the first time authorizes preferential funding for alcoholism activities in all centers, and an even higher ratio of federal matching for alcoholism activities in centers located in urban or rural poverty areas. Other sections of the new bill also provide special funds for initiation and development grants in the field of alcoholism and special grants to community agencies for training personnel, evaluating programs and carrying out demonstration projects relating to effective treatment and rehabilitation services for alcoholics. It is fairly obvious that the six million dollars recommended by the Administration will hardly make a dent in reducing the incidence of alcoholism in this country. In fact, the Administration admits that the total sum it recommends will provide treatment services for approximately 15,000 alcoholics. Senator Harold Hughes, who is chairman of the Senate Subcommittee on Alcoholism and Drug Addiction which has conducted exhaustive hearings on these problems over the past year anda half, estimates that there are a minimum of nine million alcoholics in this country, most of whom receive no treatment whatsoever. We therefore recommend that the alcoholism activities of the National Institute of Mental Health be funded at a level of fifteen million dollars during fiscal 1971. page eleven D. Narcotic Addiction Units Since various Congressional Committees have been engaged in hearings on this problem over the past several years, I will not take up the time of this Committee in presenting the justification for a much larger research and treatment attack upon drug addiction. For fiscal 1971, the Administration recommends $9, 900, 000 for the Narcotic Addiction Rehabilitation Program of the National Institute of Mental Health. This is only about two million dollars more than the amount voted a year ago, and itis approximately 10 percent of the amount voted by the New York State Legislature this year to support drug addiction research and control activities. We therefore recommend that fifteen million dollars be appropriated for the National Institute of Mental Health drug addiction work during fiscal 1971. 2. MANPOWER DEVELOPMENT A. Training Grants High officials in the Department of Health, Education, and Welfare are constantly out on the road making speeches about the need for more health manpower. When they are criticized on the matter of the inadequacy and inaccessibility of health services in this country, their stock reply is that we must wait until we tool up our health manpower programs. Those of us who have watched two Administration budgets go by are still waiting for the tooling-up process. For example, the President recommends $107,650, 000 for the National Institute of Mental Health training grant program for fiscal 1971. This is almost the identical sum recommended last year, and actually a lesser amount than was obligated in fiscal 1969. page twelve It is almost impossible to exaggerate the demoralizing impact of this kind of a recommendation. For example, because of the rising costs of training and other uncontrollable items, the fiscal 1971 recommendation will mean a severe cut of 70 percent in new mental health training grants to medical schools, universities, hospitals and other institutions. In its own budget narrative, the Administration admits that in the coming year it will award 2,000 less training stipends than two years ago. Because of this cut, people we desperately need in our state hospitals, mental health centers, drug addiction, alcoholism and suicide prevention programs will be lost to the mental health field. In 1966, Congressman John Fogarty asked the National Institute of Mental Health for a five year projection of the mental health manpower needed to staff the rapidly expanding community mental health center programs and also to meet burgeoning mental health demands in other areas within its purview. The carefully documented NIMH report which was presented to the Congress early in 1967 pointed out that an increase of fifteen million dollars a year in training funds was needed to keep up with rising costs and new demands for services. In actual funds appropriated, we have never come close to achieving these carefully worked out projections. | For example, in the current fiscal year it is estimated that we will not be able to fund approximately twelve million dollars in training grants already approved with a high priority rating by the National Advisory Mental Health Council. At the last meeting of the Council, we were told that the backlog in approved but unfunded training grants will approach twenty million dollars in fiscal 1971 if the Administration recommendation is sustained. We therefore recommend $140, 000, 000 for the training activities of the National Institute of Mental Health during fiscal 1971. -30- SELECTIVE INCREASES PROPOSED BY STATE AND COMMUNITY PROGRAMS: (a) Construction of Community Mental Health Centers (b) Staffing of Community Mental Health Centers (c) Alcoholism Programs (d) Narcotic Addiction Units MANPOWER DEVELOPMENT: (a) Training Grants TOTAL REQUEST FOR NIMH: CITIZENS IN NIMH FISCAL 1971 BUDGET 1971 President's Budget $60,100, 000 6,000, 000 9,900, 000 107, 650, 000 $346, 656, 000 Citizens' Budget $40, 000, 000 110, 000, 000 15,000, 000 15, 000, 000 140, 000, 000 $483,106, 000