Nevada May Repeat Other States' Mistakes in Privatizing Mental Health Services

Nevada is exploring privatization of its mental health services, citing the difficulty of finding psychiatrists for its state-operated psychiatric hospital and a shortage of mental health care services in rural communities. Yet, privatization is not the easy fix it's often sold as and raises concerns of accountability and quality inherent in contracting out public services to private firms.

In 2006, Nevada's mental health care services earned a D-grade from the National Alliance for Mentall Illness (NAMI), the nation's largest mental illness advocacy organization. The group, however, praised the state for its candidness, transparency, and other efforts to address the problems in its mental health care system, which largely stem from underfunding of programs and a lack of service infrustracture. This indicates that the culprit is funding, rather than public administration. NAMI does not offer privatization as a solution for Nevada's system, rather it urges lawmakers to focus on improving access to services for mentally ill people in rural areas, reducing the burden on emergency rooms for treating and housing mentally ill patients, and increasing housing for the homeless mentally ill.

Lessons in Privatization from Michigan and North Carolina:  Opinions on privatization vary, but experiences in a few states serve as a warning for lawmakers considering privatization of mental health care services. NAMI's Michigan chapter in 2002 cited years of privatization of the state's mental health services as a key reason for a dysfunctional, inefficient and unaccountable system:

...a policy of decentralization and privatization has resulted in a shifting of responsibility and control from the state to the local community mental health programs, and in turn to contracting agencies. This has produced multiple layers of administrative overhead, duplication of efforts, fragmented and ill-defined programs and loss of control over the management of public funds. The management of these funds is thereby removed from public scrutiny otherwise enabled by the Freedom of Information Act, the Open Meetings Act and competitive bidding.

The Michigan chapter made a laundry list of recommendations for improving the mental health system that centered around increased state oversight, management and accountability. 

Six years ago, North Carolina began a broad reform of its mental health services that hinged on outsourcing services and management to private firms. Recent news regarding the reform, however, are cause for concern. A consultant's report found that the neediest patients are falling through the "safety net privatization was expected to provide" and recent state audits show that privatization has led to overbilling the state by millions of dollars amid a breakdown of oversight. The audits found that up to 185 private firms providing direct care to patients as part of the community-support services (CSS) program overbilled taxpayers to the tune of $45 million since March 2006. Compounding the problem, ValueOptions, the private firm hired to run the CSS program and determine eligibility, has been cited by critics as failing in its management duties. Mismanagement resulted in thousands of residents, many of whom were children, waiting for treatment.

All of this led the Daily Advance of Elizabeth City, North Carolina, to editorialize:

Privatization of mental health services is a disaster. It's time to reform the reforms. 

In related news, North Carolina took a significant step forward this year to ensuring access to health insurance coverage for mental health illnesses by enacting mental health parity, which requires insurance companies to cover mental health needs the same way they cover physical needs. 

Nevada should look to these lessons before it repeats the mistakes of other states by buying into the idea that privatization is a simple solution to much deeper problems of funding and reform of its mental health services.

Banning Trans Fats in Restaurants

According to the Associated Press, 15 states have considered banning artery-clogging trans fats from restaurants this year, although the bans have only been enacted in local jurisdictions so far. Trans fats, which are linked to obesity, heart disease, and diabetes, are commonly found in fried foods and commercially baked goods, like doughnuts. According to Harvard researchers, 2 grams of trans fats per day are acceptable for the typical American diet. However, a 9-piece order of Burger King Chicken Fries with a side order of medium Onion Rings will saddle you with 7 grams of trans fats.  These higher levels of trans fat consumption can increase risk of heart disease by 23%.  

Cities are taking the lead on banning trans fats from restaurants. New York City enacted the first ban of the dangerous cooking oil and Philadelphia soon followed suit, although it later exempted bakeries after complaints that alternative oils yield a shorter shelf-life for pastries. This seems to be a weak argument, however, given that even a Twinkie, with a possible shelf-life of 30-years, surprisingly has zero trans fats. (The Twinkies' longevity likely earned it space in the nation's millenium time capsule in 1999.) Elsewhere, Montgomery County, MD, and Albany County, NY, have passed trans fats bans and the Louisville, KY, Metro Council is pursuing a ban along with a consumer education campaign. 

Opposition to banning trans fats has been driven by the National Restaurant Association, which has helped keep the state proposals off the books. Although the Association says outright bans are too difficult for restaurants to comply with, New York City's over 10,000 restaurants have already made the switch to safer cooking oils, like canola oil, with relatively little fanfare or protest. States where bans have been proposed include: California, Connecticut, Illinois, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, Ohio, Rhode Island, South Carolina, Tennessee, Vermont and Hawaii.

The Center for Science in the Public Interest (CSPI) is leading the fight against trans fats in our foods. Several lawsuits by CSPI have prompted national fast-food chains to switch to safer cooking oils, including McDonald's, KFC, and Starbucks. CSPI recently filed another lawsuit to force Burger King to make the switch.

Broader Policy Implications for Health Disparities:  Eliminating trans fats from restaurants is a key policy goal to reducing rates of obesity, diabetes and heart disease. This is especially important in low-income communities and communities of color where access to healthy food options is limited, compared to white and higher income communities. A comprehensive report, Healthy Food, Healthy Communities: Improving Access and Opportunities Through Food Retailing, by the non-profit research and action institute PolicyLink documents the racial, ethnic, and economic disparities in access to healthy food options. One multi-state study found that wealthy communities had 3-times as many supermarkets as low-income communities and predominantly white neighborhoods had 4-times as many markets as African-American neighborhoods.  Although the report focuses on food retailing, it makes clear that low-income communities and communities of color have less access to healthy food. These problems are compounded when limited access to mass-transit and other transportation needs of low-income communities are factored in.