Community Support and Political Action
Publicly operated community-based services can become a reality and remain in existence only if there is support from the community, the legislature and the governor. Where public officials are resistant, the support of parents, community, advocacy and professional groups is invaluable in influencing officials.
In part, such support is based on a belief that a publicly operated continuum can guarantee permanence, adequate funding and quality care. Those states and counties that decide to directly operate community services soon realize they provide a quality clinical service and fill critical needs of communities.
MINNESOTA
There are currently very few clients in the state’s Regional Treatment Centers (RTCs) for the developmentally disabled, probably less than 200. Deinstitutionalization in the state facilities began as early as the 1960s. As the state began to downsize with the intent of sending the patients to the community, private providers saw an opportunity to provide services in the community-based programs. Council 6 successfully resisted state institution closures, even while client movement continued. At the same time, it became evident that state-operated care delivery, and the members’ jobs, were in serious jeopardy.
"Public facilities afford residents, their families, and taxpayers in-depth knowledge and access to procedures and operations to ensure that residents are receiving the care they need. They set the standard of care for the community." — Rep. Lee Greenfield, chairman, Health and Human Services Finance Division, Minnesota House of Representatives Health and Human Services Committee
As a result, Council 6 had to deal with a major philosophical shift in considering that state institutions were the only viable place to provide treatment services for people with developmental disabilities and the only way that they could sustain employment. Instead of only resisting the client movement to the community, they had to determine a way to follow-the-work. They came up with the idea of convincing the state to initiate community-based services using the Rhode Island model as an example. After extensive negotiations with the state and legislative officials, Council 6 convinced them to visit Rhode Island’s state-operated, community-based services (SOS) and asked Rhode Island officials to visit Minnesota to discuss the implementation of its SOS. Finally, the commissioner was convinced to begin strategizing with Council 6 to begin the process of establishing state-operated, community-based services.
There were few community coalition or patient advocates supporting Council 6’s effort to follow the work into the community. In fact, there was a lot of resistance from private providers who accused the state of giving the unions unfair advantage and taking away their business. There were public hearings which included representatives from Rhode Island, supporting the notion of state-operated facilities. Overcoming historic hostilities, the major advocate group, Association for Retarded Citizens (ARC), gave Council 6 lukewarm support. Although ARC’s trust level for AFSCME was not high, they agreed to explore the possibility of state-operated’0 community-based services and gave the union an opportunity to initiate this project without opposition. Today, over 1,000 AFSCME members work in state-operated community services.
Minnesota is in its infancy in establishing state-operated, community-based mental health services. There has been virtually minimal resistance from all quarters in expanding these services in the community, because the state and Council 6 have already established a track record in providing competent quality services in MR/DD. Minnesota is starting to go forward with some state-operated community-based mental health programs, which range from daily living assistance to more intensive crisis intervention. The state recently purchased two 16-unit apartment buildings in metro areas.
NEBRASKA
When state mental health officials sponsored a “Search Conference” in 1994 to plan for the redesign of the public mental health system, the outcome was a commitment to move mental health services toward a more community-based, consumer and family-focused system. The state was being advised by a for-profit managed behavioral health care company, and the initial plan was to finance community services through savings achieved by closing beds in the state psychiatric hospitals. The Nebraska Association of Public Employees (NAPE)/AFSCME concluded that the plan had been guided toward a pre-conceived conclusion: to privatize jobs held by state workers and to turn the system over to managed care by contract.
The goal was to maintain and eventually increase funding for mental health care, maintain the state's psychiatric hospital capacity and the development of a mental health care delivery system for Nebraska that includes state-operated community-based services.
Over the next several years, the union continually asked and probed state mental health officials for information. Union members met with state senators in their districts to develop a relationship. Members met with local law enforcement officials, mayors, city councils and medical professionals to ensure they understood the implications of the mental health redesign. The union identified and sought out people who might be allies in their struggle for an improved mental health system — organizations that advocate for individuals with mental illness, ex-patients and family members. The state AFL-CIO council and press contacts were kept informed. The goal was to maintain and eventually increase funding for mental health care, maintain the state’s psychiatric hospital capacity and the development of a mental health care delivery system for Nebraska that includes state-operated, community-based services.
With the support of a broad community coalition, a bill was introduced in the 1998 legislative session that calls for maintaining the state psychiatric hospitals’ services at a level that meets demand until appropriate and adequate services are available at the community level. It also provides for the development and use of state-operated, community-level services. NAPE sponsored radio ads in support of the legislation. Five hundred people turned out for field hearings sponsored by the legislature’s Health Committee. As the result of this union and community pressure, the bill was passed and signed by the governor on April 18, 1998.
The story is not complete, however. The union sees the legislation as only one step in the process of the development of state-run, community-level mental health services. The union is determined to keep the pressure on and ensure that state mental health officials follow through on the intent of the legislation.
NEW YORK
It took political muscle to reverse a state policy that had most MR/DD clients going to community-based, private-sector (“voluntary”) providers after the wave of deinstitutionalization in the 1970s. the settlement of the class action lawsuit “the Willowbrook consent decree,” which began the mass migration to the community, had also mandated significantly higher inpatient staffing levels for the remaining residents in the state MR/DD institutions. The state achieved those staffing levels by retaining direct patient care staff even after clients left the institutions. By 1986, however, those court-ordered staffing levels had been reached. The relatively stable state workforce was then threatened by job loss as institutional residents continued to be moved into community settings run by the private sector.
The Civil Service Employees Association (CSEA)/AFSCME successfully lobbied the chairs of the New York State Senate and Assembly Mental Hygiene Committees for a change in state policy and development of state-operated community-based services.
The Civil Service Employees Association (CSEA)/AFSCME successfully lobbied the chairs of the New York State Senate and Assembly Mental Hygiene Committees for a change in state policy and development of state-operated, community-based services. The voluntary sector had continuously taken from the institutions those who were easiest to serve, leaving for last the more difficult and, at times, more dangerous clients. As a practical matter, CSEA argued that the experienced state workforce—who had served the hardest-to-serve residents so well for so long—was best prepared to continue providing services to them in the community. CSEA also made it abundantly clear to legislators that the virtual elimination of state-operated institutions without the re-establishment of any other state-operated programs would have spelled economic disaster in many upstate communities.
The Mental Hygiene Committee chairs exhorted the Commissioner of the Office of Mental Retardation and Developmental Disabilities to take a whole new approach to future closures of facilities. The approach was that 90 percent of all future community MR/DD bed development would be state-operated and all employees affected by institutional closures would be allowed to transition to the community or would be assisted in obtaining re-employment in other state agencies. The state fully adhered to this commitment.
GENESEE COUNTY, NEW YORK
The Genesee County CSEA/AFSCME General Unit is currently engaged in a fight to keep mental health services public, a fight that includes making the public and the county legislature more aware of the services that could be lost. Concerned by the rising cost of mental health services, the Community Services Board of Genesee County decided to investigate the possibility of privatization. This rural county is experiencing the domino effect the downsizing the state psychiatric centers, the lack of sufficient planning for the needs of the chronically mentally ill in the community and decreases in state aid.
Union members and leaders are meeting with each member of the county legislature and the county Community Service Board to provide detailed information on the quality services now provided by the county mental health clinic and the true needs of individuals with mental illness, i.e., why some individuals need more intensive case management, the impact of poor discharge planning, the limitations on treatment in managed care, etc. The union is issuing press advisories, writing letters to the editor and calling into radio talk show programs. The message is: The county clinic provides a wide range of needed services, many of which would surely be lost if a private, profit-driven provider took over; county employees are doing a great job, and with some adjustments to enhance revenues, can do it as cost-effectively as a private provider.
PHILADELPHIA
Pennsylvania has county-run, community-based mental health programs. The city of Philadelphia’s Department of Public Health (DPH) manages the city’s Medicaid behavioral health program through its Community Behavioral Health (CBH), a creation of the city-county government’s public health department. This project provides $350 million a year in behavioral health services that cover more than 400,000 city residents. This includes 240 community-based providers — many of them single person providers — and more than 30 hospitals. Philadelphia is the nation’s first municipality to move toward a fully integrated behavioral health system that controls all Medicaid state hospital and community dollars for mental health and addiction treatment.
Council 47 developed allies on the city council, who questioned the commissioner's motives for excluding the unions from the implementation process.
The DPH began secret plans to implement the CBH without alerting its staff. AFSCME Council 47 members alerted the local leadership when rumors surfaced that the DPH was privatizing the mental health system. Members worried whether or not their jobs were in jeopardy. The county told council 47 that they were under a “gag order” mandated by the state to keep quiet about their plans to implement managed behavioral health because they were still working out the details for managing the system and the final plans were not approved. Meanwhile, CBH began developing its managed behavioral health system without the inclusion of the unions and effectively began squeezing them out of the process. Council 47 filed an unfair labor practice charge, thereby forcing the DPH to negotiate conditions of employment. Initially the DPH ignored the union’s attempt to be included in the development of behavioral health services. However, the union received help on two fronts. First, the City Council had questions concerning the DPH’s ability to manage a behavioral health system. Also, through extensive lobbying efforts, Council 47 developed allies on the City Council, who questioned the commissioner’s motives for excluding the unions from the implementation process. Second, they developed alliances with patient advocate groups who wanted behavioral health to remain a county-operated system. With pressure from these areas, the commissioner was forced to discuss the union’s role in the development of managed behavioral health.
DPH needed to demonstrate their ability to develop and manage a competent behavioral health system without the need to turn operations over to a private organization, as the City Council intended. The compromise agreement for the union was that no one would lose their jobs, but that CBH could hire additional people who would not necessarily be union members. There are currently 150 Council 47 members employed by the city health department doing mental health work and they remain city employees. However, there are an equal number of CBH employees that are not union members and whose jobs mirror many of the services the union provides. Council 47 believes that CBH’s intent is that there be no distinction between union and non-union members and to demonstrate that unions are not necessary.
In the mean time there is a public relations campaign being conducted by CBH which consistently points out that all of the problems they are experiencing in the system are union generated. Council 47 continues to strengthen its credibility with political officials and the general public by demonstrating their competence in managing the database system used by CBH, which is a critical aspect of the managed care system.
