The United States has a very unusual system of government that is unique in the world. We are one united nation, but the individual states still have a huge amount of governing power.
The United States government has three million employees. That’s minor compared to the 20 million people who work for local and state governments.
Yet federal laws are supreme and trump state laws. That’s part of our Constitution, article five.
One peculiar way the federal government exercises its supremacy is through the federal judicial branch — federal lawsuits.
From a federal perspective, this is an efficient way to exercise power. The feds don’t have to hire a huge remote administrative force, they just sue the states and make them do as the feds tell them to.
Here in Jackson, we can see the effects of this process in numerous ways.
One such situation that is ongoing involves the U.S. Justice Department suing Mississippi’s Department of Mental Health (DMH), an independent state agency with its own independent governing board.
DMH is funded by the state legislature, but the state legislature has no direct control over the agency. So not only do the feds have no direct control over mental health in Mississippi, but neither does the state legislature. It’s a great way to decentralize power, but it’s not so great at achieving objectives.
The federal order is that mental health be treated as a disability.
In 1999, the United States Supreme Court, in the Olmstead Decision, ruled that failure to place mental health people in appropriate community-based treatment programs violates the Americans with Disabilities Act (ADA).
In 2016, the U.S. Department of Justice sued Mississippi’s Department of Mental Health, accusing the state of failing to offer appropriate community-based treatment for mental health.
It’s important to note the DMH is a very big state agency with a budget of $600 million of which about $220 million comes from the state general fund. It operates five big facilities throughout the state and many more smaller regional facilities.
But the feds want even smaller group homes or, better yet, in-home treatment of patients. The feds also want implementation of jobs programs to get mentally disabled people working and living independently.
This is a big order and quite different from the state’s approach of placing mentally disabled in larger facilities.
Ironically, community-based treatment could save the state money, because often these programs are covered by Medicaid and other federal funding while the state facilities are paid from the general fund.
One problem with group homes is they face huge opposition from neighborhoods who fear a decline in property values.
These ongoing federal lawsuits are big business and employ tons of lawyers, both for the feds and the private local firms that state hires to defend. They go on for years. Adding to the disconnect, the Mississippi Attorney General controls the lawsuit, not the Mississippi Department of Health. It’s a big bureaucratic mess.
All parties involved seem to agree the community-based treatment is better, aside from a small percentage of severely mentally ill. It’s just hard to get a huge bureaucracy to change its ways.
Right now, federal district judge Carlton Reeves has appointed a “court monitor” to move the process along. Dr. Michael Hogan has decades of experience, including serving as New York’s mental health commissioner for five years.
Hogan’s report noted much progress toward community-based mental health, but also much that still needs to be done.
I have read the report. To me, it seems obvious the essence of the problem is caused by our decentralized system of government that employs dozens of local, state and federal programs. Getting them to all work together cohesively is difficult at best. Therein lies the rub. Not only do we have dozens of different programs but each one is funded in a dozen different ways.
The biggest issue in this regard is Medicaid, which pays for most treatment costs. Yet Medicaid is an extremely complicated federal program not controlled by the state’s DMH. So there is a gargantuan disconnect between the money and the management.
Hogan writes: “It is hard to overstate Medicaid’s importance for people with mental illness in Mississippi, and in sustaining the State’s mental health system. For disabled individuals, Medicaid’s comprehensive benefits cover most key elements of treatment, except hospitalization in a state hospital. However, Medicaid is a public program covering many other healthcare services, and the largest item in many state budgets. It operates under complicated federal rules and is subject to the ongoing legislative scrutiny that its size and scope suggest. Medicaid also has constraints and limitations that affect the services it can cover.”
In other words, without syncing complicated Medicaid’s reimbursement process with the DMH’s regulation of community-based mental health services, progress will be difficult.
The solution is a total revamp and consolidation in our mental health services, linking management and funding, something that the federal courts don’t have the will or competency to achieve. So the legal show will just go on and on while progress will continue to be slow and incremental.
Our decentralized federal system has many advantages, limiting power and abuse being the main one. However, this has a high cost in efficiency. This is evident in our struggle to improve mental health in Mississippi.
Wyatt Emmerich is the editor and publisher of The Northside Sun, a weekly newspaper in Jackson. He can be reached by e-mail at email@example.com.