The Supreme Court’s affirmation of the Affordable Care Act (popularly known as the ACA or “Obamacare”) two weeks ago was a landmark decision, bringing the United States closer to achieving—as supporters say down here in Georgia—health care for y’all.
Across the country, “health care” today means more than primary care. The passage of the Wellstone-Domenici Mental Health and Addiction Equity Act in 2008 established parity for mental health and addiction treatment, which means that private insurance providers are required to fund these services in much the same way that they cover care for more traditional physical ailments. Thanks to this precedent, more health care coverage should mean increased access to mental health and addiction services.
In a recent article in Health Affairs, behavioral scientist David Mechanic argued that the ACA, along with the now-endangered Medicaid expansion, has the capability to “begin to fulfill the many unmet promises of community mental health care.” To meet the increased demand for behavioral health services, the Obama administration’s planned implementation of the ACA will continue to boost federal support for Community Health Centers that integrate mental health, crisis support or substance abuse treatment into their suite of services. Given this expensive (and still controversial) plan, it’s worth re-examining the large-scale social project we might be reviving. What are the “unmet promises of community care”?
The 1960s were an era of federally supported, community based health reforms. The idea was that community based health service providers could leverage federal funds to implement local solutions for providing health and social services to under-served populations. The new organizations would be staffed and governed by community members, or by individuals with a close affinity for the population they served. Reformers gave us Community Health Centers for primary care, Community Mental Health Centers for psychiatry, and Therapeutic Communities for addiction treatment, each with their own social movement, history, and funding mechanisms.
Many of today’s health centers combine all of these: primary care, psychiatry, and addiction treatment. This makes the delivery of services more affordable, and accessing services more convenient for clients. The centers are governed by local boards, a managerial choice that helps neutralize the politically charged perception that the centers extend the federal government’s reach.
For these reasons, the integrated Community Health Center was—as recently as just a few years ago—a well-received bipartisan project. One study estimates that the number of federally funded community health centers increased 43% during President George W. Bush’s administration. The Bush Administration’s health center initiative doubled funding (from $1 billion in 2001 to $2 billion in 2007) and awarded $7.2 million for mental health service expansion. After Bush’s initiative, community health centers were significantly more likely to provide addiction services; by 2007 more than half of federally funded community health centers offered some form of substance abuse treatment. If the ACA is implemented as planned, funding for integrated health centers will probably continue to increase.
Still, there are critics of the philosophy behind this approach. Financial journalist Megan McArdle has offered an eloquent critique of the hubris that occasionally accompanies efforts to “scale up” local solutions. The critique is relevant to the changes that face substance abuse service providers that work with un- or under-insured populations. For today’s addiction treatment or recovery support service providers, the push to integrate into—or partner with—existing health centers threatens to push peer- or faith-based approaches into a biomedical model in the name of grassroots reform.
While there is no shortage of health center success stories, past experiments with community-based care are also riddled with cautionary tales. For many individuals suffering from mental disorders, de-institutionalization led to homelessness and incarceration. In the 1970s, therapeutic communities fought charges that their form of addiction treatment lacked an evidence base and professional ethic. These stories discouraged the hope that community-based care would do a better job of serving disenfranchised and stigmatized populations than large institutions like hospitals.
There are two historically simplistic critiques of the unfulfilled promises of the sweeping turn to “community.” Number one: the promises weren’t achieved because the idea didn’t work, and the idea didn’t work because it came from the federal government. Number two: the idea was good, but insufficient government funding and support have given us limited results. Actually, this mixed legacy of community-based care is not just a matter of funding: it’s also the result of historical and local contexts, of capacity, and perhaps most importantly, of client perception.
Historian James Colgrove discussed the limitations of community-based public health reforms in New York City’s implementation of Great Society programs. In his article, Colgrove noted that reformers’ efforts were limited by powers “above” and “below” (his quotation marks). Most researchers and advocates frame the “unfulfilled promises” of community based care as the result of limitations from “above”—in particular, of political economy or just plain economics.
But efforts are also limited from “below,” and I think that how this happens has not been sufficiently historically interrogated. It’s unfortunately understood that working with populations of clients who have addictions or mental illnesses poses challenges because the clients are, well, difficult—divorced from reality, alienated from familial or social support systems, or ambivalent about seeking and maintaining care.
Rather than affirming this prejudicial popular wisdom, researchers should aim to understand the lived reality of the clients expected to access community-based care. Combining policy-level natural experiments with ethnographic client-level data produces more comprehensive results that better accounts for actual (rather than assumed) forces from “below.” Researchers can also take a second look at history: how did client perceptions and demands work from “below” to support or undermine previous efforts to provide community-based, integrated care for people struggling with substance abuse?
For example, historian Eric Schneider has described how methadone clinics meant to serve heroin addicts in 1970s New York City contended with local forces. The clinics met with resistance from community members, and were thrown into controversy when it was discovered that some addicts were delivering the medication to the illicit drug market.
I can think of other challenges that might be specific to clients struggling with substance use who might enter community health centers for treatment today. Neuroscience research affirms the importance of removing people with addictions from environments that they associate with substance use, suggesting that supportive housing or residential treatment outside the local community might be desirable to clients. One anthropological study suggested that some potential clients viewed their local health centers as less “professional” than hospitals, at least initially. Finally, substance abuse treatment is a minefield of ideologies, so deciding which treatment model to integrate into a community health centers can be contentious. As the nation moves toward ACA implementation, it’s time to ask clients—past and present—which promises they want fulfilled.
The Supreme Court’s decision confirmed that we live, as one recent NIDA funding announcement phrased it, in “An Era of Health Care Reform.” Without a more nuanced understanding of social history, it won’t be the last.