Federally Funded Programs - Geriatric Mental Health Research
and Services
Background
President Bush’s budget request for the Department of
Health and Human Services (HHS) for Fiscal Year (FY) 2006
reflects the administration’s continued emphasis on
the war in Iraq, changes in the tax code, and homeland security
– and its efforts to impose tight spending lids on other
discretionary domestic programs in the face of a worsening
Federal deficit.
Overall, under the President’s proposed budget, HHS
would get $662.1 billion, an increase of $80.4 billion or
13.8 percent over FY2005. However, $573.5 billion is for mandatory
programs such a Medicare, which are not subject to the annual
appropriations process; only $68.9 billion is for discretionary
spending, a decrease of about one percent from FY2005.
Entitlement Programs
The Administration estimates an outlay of $345.5 billion for
Medicare, compared with an estimate of $295.4 billion in 2005.
The rise in spending for FY 2006 can be attributed to the
implementation of the 2003 Medicare prescription drug law
(Public Law 108-173) that will go into effect on January 1,
2006.
The Federal share of Medicaid and the State Children’s
Health Insurance Program (S-CHIP) spending would be a small
increase from $193.6 billion to $197.8 billion in FY2006.
But the budget shows a $90 billion cut in Medicaid expenditures
over the next ten years, reflecting the Administration’s
plan to shift these costs to the states, possibly through
a capping mechanism. There is great concern among advocates
for Medicaid beneficiaries that the most vulnerable beneficiaries,
including those in nursing homes, would see their benefits
cut or even eliminated.
NIH
The National Institutes of Health (NIH) budget, after doubling
in the five years between 1998 and 2003, would see an increase
of just 0.5 percent in FY 2006 to $28.6 billion. NIH projects
a decline in the number of research project grants for the
second year in a row, a problem that the research community
maintains will seriously curtail the research efforts that
have been undertaken in recent years.
The President’s proposed budget for the National Institute
of Mental Health (NIMH) would provide an increase from $1.412
billion to $1.418 billion, an increase of only .4 percent.
Comparable numbers for the National Institute on Aging call
for an increase from $1.052 billion in FY 2005 to $1.057 billion
in FY 2006.
SAMHSA
The Substance Abuse and Mental Health Services Administration
(SAMHSA) is now focused entirely on service delivery, with
services research programs having been moved to NIMH. The
President has proposed a $55 million budget cut for SAMHSA
– reducing funding from $3.268 billion in FY 2005 to
$3.213 billion in FY 2006. Most of these reductions result
from targeted cuts to substance abuse prevention and a school
violence prevention program run jointly with the Department
of Education. Most other programs at SAMHSA are proposed to
be “frozen” at their current levels, including
funding for evidence-based mental health outreach and treatment
for the elderly within the Center for Mental Health Services
(CMHS), an initiative that was first proposed to Congress
by AAGP and has been funded at $5 million for each of Fiscal
Years 2002, 2003, 2004, and 2005. Last year, the Administration
proposed eliminating this program, but advocacy efforts in
Congress by AAGP and other mental health organizations preserved
its funding.
HRSA
The Health Resources and Service Administration would, under
the Administration’s proposal, receive a funding reduction
of $800 million (12 percent). Of concern to the medical community
is the proposed elimination of all health professions education
funding under Title VII of the Public Health Service Act.
These programs include Geriatric Academic Career Awards, Geriatric
Training for Physicians, Dentists and Behavioral/Mental Health
Professionals, and Geriatric Education Centers. While Title
VII programs have long been targeted by the Administration
with Congressional action making sure that they survive, it
may be more difficult to restore the funding for FY 2006 because
of the size of the Federal budget deficit.
AAGP Position
AAGP supports increased Federal funding for research of mental
disorders of the elderly. Mental illness is one of the most
costly public health problems confronting the nation –
impacting both government budgets and consumer spending. The
personal and societal costs of mental illness are high. However,
advances in research and treatment will help save lives, strengthen
families and save taxpayer dollars.
As the population ages, it is critical that scientific research
and services be funded at an accelerated rate to ensure that
treatments and cures are found and available for some of the
most devastating late-life mental illnesses such as Alzheimer’s
disease and other dementias, anxiety, schizophrenia, substance
abuse, sleep disorders, and depression.
AAGP is concerned that Federal funding for mental health
and aging research as a percentage of the overall budget has
declined in recent years at NIMH. AAGP is also concerned that,
despite substantial funding increases for NIMH from 1998 until
2003, the Institute’s sponsorship of extramural research
on the mental health of the elderly has not kept pace with
its funding of research for other populations. AAGP is encouraged
that Congress took note of the need for more balance in this
area and, in the House and Senate Appropriations Committee
reports on funding NIMH for the last four years, explicitly
raised the issue. Congress has made clear its intent that
NIMH should devote additional resources to extramural research
on the mental health of the elderly. This action, in concert
with recommendations of NIMH’s Advisory Council Workgroup
on Aging Research, has led NIMH to take some steps to address
this need.
AAGP has also advocated for Congressional action in recent
years with respect to the relative decline in funding for
senior mental health services through the Center for Mental
Health Services (CMHS) at SAMHSA. An important step forward
in this effort was made in 2001. The Labor-Health and Human
Service (HHS) Appropriations bill for FY 2002 included $5
million to fund a new program to meet the mental health needs
of older Americans. This new program provides funds to CMHS
for mental health outreach and treatment to the elderly. The
program is intended to help bridge the gap between the progress
that has been made in developing effective approaches to identifying
and successfully treating a variety of mental disorders in
older persons and the routine clinical practice. The initiative
is focused on identifying the most effective ways to get state-of-the-art
research findings and practices into the hands of clinicians
in the community. Last year, when the Administration recommended
eliminating funding for this program in its FY 2005 budget
request, AAGP worked with Members of Congress and other organizations
concerned about geriatric mental health to restore this funding
in the appropriations process. The Administration’s
budget for FY 2006 recommends level funding for this program,
an important acknowledgement of the need to address the mental
health needs of older adults.
In addition to maintaining this initiative, AAGP believes
that efforts must be made, through both the legislative and
regulatory processes, to increase Federal funding for evidence-based
and outcomes research for the purposes of establishing best
practices and medical standards for utilization in medical
practices and quality patient care. This must be accomplished
through a multi-pronged approach that includes NIMH and CMHS.
The pace of new developments in the pharmaceutical industry
alone often makes existing research outdated within a few
years after its completion. The Agency for Healthcare Research
and Quality (AHRQ) has sponsored evidence-based research on
mental health issues (such as a 1997 survey on new pharmaceutical
and herbal treatments for depression) and the development
of practice guidelines for recognizing the early stages of
Alzheimer’s disease. However, to date, the vast majority
of evidence-based and outcomes research sponsored by AHRQ
has focused on physical illness, leaving much work still to
be done on mental health disorders, particularly among the
elderly. At AAGP’s request, the Senate Appropriations
Committee’s report on FY 2005 funding for AHRQ reiterated
its language from the previous year urging AHRQ to fund research
on evidence-based practices and the development of clinical
practice guidelines for the diagnosis and treatment of mental
disorders in the elderly. This would include dissemination
of evidence-based practice guidelines to physicians and other
health care professionals.
Finally, the Federal Government must remove specific barriers
to the participation of Medicare beneficiaries in clinical
trials involving treatment for mental illness. Medicare covers
routine patient care costs of beneficiaries enrolled in clinical
trials but specific problems have arisen as this coverage
is applied to mental health research. Under current law, many
mental health outpatient services are subject to a 50 percent
copayment – as opposed to a 20 percent copayment more
typically applicable for Medicare-covered services. AAGP is
concerned that participation of beneficiaries in a clinical
trial for the treatment of mental illness could result in
Medicare carriers’ misapplication of the higher cost-sharing
rules to all routine patient care costs associated with involvement
in the trial, thereby creating significant barriers to participation.
This mistaken application of the 50 percent copayment has
arisen in the area of physician management of a prescription
drug regimen, and AAGP believes that the infrastructure needs
to be strengthened to ensure that errors of this sort do not
effectively bar the participation of seniors in these trials.
March 2005
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