Tom Foley, the leading Republican candidate for governor, has a vision for helping people with mental illness: finding more of them beds in long-term institutional care.
That view—expressed in a broader interview about his views on health care—challenges the view of many mental-health advocates, who have pushed for more community-based alternatives.
Foley (pictured) also called for considering requiring Medicaid patients to pay for some of their care. He was less inclined to support assisted suicide or more health insurance mandates.
Foley touts his experience in business as a way to mend government, and his faith in private sector approaches is clear in his positions on health care issues.
During Foley’s unsuccessful run for governor in 2010, he said he could lower the state’s health care costs by 15 percent and advocated allowing some employers to offer bare-bones health plans that didn’t cover state-mandated benefits.
This time, his stated goals aren’t quite as ambitious, but Foley still believes he can use private sector strategies to tackle health care costs and quality.
He’s also spoken more this year about mental health, a topic he views through a personal lens.
On the campaign trail, Foley regularly fields questions about his views on the gun control measures passed after the Newtown shootings. He often replies that more needs to be done about mental health.
Foley’s views are shaped by personal experience. He has a sister with mental illness and has been responsible for her care since the 1970s. He said he understands the struggles families face getting problems diagnosed and dealing with the gaps in care.
To Foley, the biggest gap is in institutional care for people with chronic, serious mental illness. In his view, the closure of institutions—which Connecticut began in the 1990s—left holes in the mental health system that weren’t filled and can’t be adequately addressed with community-based services.
“Most people [with serious mental illness] need to be medicated. They often need an institutional environment for their own care but also to make sure that they’re not harmful,” Foley said. “And that’s what’s missing. There aren’t really places for them.”
Foley thinks the private sector should build up institutional care for people with mental health problems, with the public sector also providing some care facilities.
Advocates for people with mental illness generally agree that the state hasn’t invested enough resources into building a comprehensive system of supports for people with mental illness. Some mental health providers say the state needs more inpatient psychiatric beds for people in crisis.
But few, if any, in mental health share Foley’s goal of having more institutions. Instead, they favor services in the community, such as supportive housing or intensive programs in which case managers and other professionals work with people living independently.
Jan VanTassel, executive director of the Connecticut Legal Rights Project, which serves people with psychiatric disabilities, said long-term institutionalization isn’t necessary and can be harmful.
“You don’t need to be in an institution to have people checking on you, monitoring your status,” said VanTassel, who also serves as co-chairwoman of the Keep The Promise Coalition, a network of mental health advocacy groups. “And in fact, legally, you can’t be in an institution unless you’re a danger to yourself or others or gravely disabled. We don’t, in a free society, keep people locked up.”
And while medication can help some people, VanTassel said it’s not a simple solution and doesn’t work for everybody.
Sheila Amdur, a longtime advocate for people with mental illness, questioned Foley’s understanding of current treatment.
“What people need are the supports and access to treatment that they need to stay in the community,” she said. “Modern treatment of serious mental illnesses is such that people with the right kinds of supports, who aren’t abandoned to the streets and who have support and treatment and housing and friends and they’re helped even to find work…and have a place in the community, they can manage their lives like anybody else can.”
But Foley said that some people with serious mental illness need to be in a long-term care, institutional environment—though not necessarily in locked-down wards. They could hold jobs in the community and be socially active when things are going well, he said.
“But they need to be monitored, they need to be in a place where people can see when things have started to tip over. When they do, the care is right there, and medication’s available,” he said.
Foley said those who haven’t been exposed to people with serious mental health problems might not appreciate the need.
“When somebody’s psychotic, it’s a big deal. It’s important to get them medicated, get them restrained if they need to be, or at least in an environment where they can’t hurt themselves or hurt somebody else,” he said. “But you can’t just have these people wandering willy-nilly around the community. Cause I’ll tell you, when the service providers find it, it’ll be after the person’s wrecked their car and they’re walking into the ocean or something.”
Outpatient Commitment “Gets Into A Person’s Rights”
In the aftermath of the Newtown shootings, some called for the state to consider allowing court-ordered treatment for people with mental illness who could be dangerous—a concept known as outpatient commitment or assisted outpatient treatment. Nearly all states allow court-ordered treatment, but most mental health advocates and officials in Connecticut oppose it.
Asked about the idea, Foley didn’t offer an immediate position.
“That’s tricky ground,” he said. “It gets into a person’s rights.”
“A lot of people don’t think they need the medication, or don’t want to take it or they’re so low-functioning they forget to take it,” he said. “And to what extent can you force somebody to do something they don’t want to do?”
Foley said the issue will likely be fought in the courts. “I don’t think that’s for a policy team to bear,” he said.
State Employee Care
Foley believes it’s possible to save money on what the state spends on health care for employees and retirees, a price tag that’s currently about $1.2 billion. He says it’s doable without changing benefits, by working with health care providers to improve services, reduce wait times and errors, and lower costs.
Key to doing that, he said, is leveraging the state’s buying power, since it covers so many people. The state could “cut a better deal” with health care providers to pay lower rates, he said.
How much room for savings is there?
The state comptroller’s office, which administers the state employee and retiree health plans, has already been working to encourage health care providers to make changes in how they deliver care. And Comptroller Kevin Lembo told The Mirror recently that initiatives to address costs in the state employee health plan have already helped to bring down cost growth from almost 9 percent in 2013 to 2 percent in 2014.
There’s also already an effort underway to change the way health care is delivered and paid for statewide. State officials have been leading the effort and working with representatives from insurance companies, medical groups and others.
Foley said he wasn’t familiar with that effort and wanted to know whether the people leading it were “people with no business experience? Politicians and bureaucrats?”
“That wouldn’t be where I’d go for figuring out the solutions,” he said.
Where would Foley turn?
Consultants and experts in the private sector, he said.
Obamacare: No Specific Changes
Foley says he thinks the Affordable Care Act—the health law commonly known as Obamacare—has been “not very impactful” in Connecticut so far, but believes it will soon lead to double-digit insurance premium hikes.
Are there things Foley would change about the way the law is implemented in Connecticut?
“No specifics,” he said. “It’s not really something that the voters seem to be…nobody seems terribly upset yet about the impact of Obamacare or the availability of coverage through the exchange because there were so few people who weren’t covered.”
The health law calls for states to expand their Medicaid programs, although the U.S. Supreme Court ruled in 2012 that doing so was optional. Connecticut expanded the program, and nearly 156,000 poor adults without minor children are now covered by Medicaid because of it.
Would Foley maintain that expanded Medicaid eligibility?
Foley said he didn’t have an opinion yet because he hasn’t looked into it carefully. He said it has pluses and minuses.
“If that’s an opportunity to lose costs overall in the government, it’s something that we would look at,” he said.
Medicaid: Cost-Sharing An Option
Connecticut spends $2.3 billion a year —13 percent of the state budget—on Medicaid, which covers more than 725,000 people. Foley believes he can save money in the program by reducing the cost of delivering care.
One way to save, he said, is to introduce incentives from the private sector to keep people from over-consuming health care.
Does that mean things like cost-sharing, requiring patients to pay something toward their care? Yes, he said.
“If you can create a situation where people are making intelligent economic decisions about their medical care, that’ll help bring down the cost and relieve the strains on the system,” he said. “There isn’t enough of that.”
Cost-sharing—like copayments and deductibles, which require people to pay a portion of the cost of their care—are mainstays of private sector health plans, but they have been controversial in Medicaid, which serves people who are poor or have disabilities. Both Gov. Dannel P. Malloy and his predecessor, M. Jodi Rell, tried to require some Medicaid clients to pay copays for certain services.
But patient advocates fought the proposals, arguing that they would lead poor people to avoid needed care that could save money in the long run. And advocates say that for Medicaid clients, the bigger problem is inadequate access to care, rather than overuse.
Legislators rejected both governors’ attempts to impose cost-sharing in Medicaid.
Hospital consolidation: Not Government’s Job
Connecticut’s hospital landscape is changing rapidly. Once-independent hospitals are joining larger networks, and five nonprofit hospitals are poised to become for-profit after being purchased by a national hospital chain. Some observers wonder whether all 29 of Connecticut’s hospitals will survive the coming years.
What would be Foley’s approach to handling hospital consolidation? Would he let the market drive what happens, or take a more interventionist role?
Foley described his philosophy as “performance-related.”
“Whatever results in the best services being provided to those communities, at the best cost, is what I support,” he said.
He believes that when the market forces decisions, the system is healthier long-term.
Previous debates about hospitals haven’t focused on those issues, Foley said. Instead, he sees the debates as centered on whether jobs will be unionized, whether a particular community will have a hospital and how far people would have to travel.
Whether a hospital is for-profit or nonprofit—a heated debate in recent years—is not an important factor to Foley. “The decision ought to be the quality of care and how much does it cost,” he said.
How much, as governor, would he weigh the concerns of people who want services to be available nearby?
Foley likened the situation to the airline industry after it was deregulated, when many localities no longer had service. He said it’s less of a problem in health care, because, “Nobody’s more than 20 minutes from a hospital in the state of Connecticut,” and there are clinics and other facilities that can provide many of the services hospital emergency rooms do.
“If there isn’t enough critical mass for a hospital in some part of Connecticut…why should the other citizens of Connecticut subsidize them and their health care?” Foley said. “You choose to live where you live. If you want to live closer to a hospital, move closer to a hospital.”
“I don’t think it’s the government’s role to make sure everybody is within X miles of a hospital, because that’s personal choice,” he said.
Assisted Suicide: Cautious
National and local groups are pushing for Connecticut to allow terminally ill patients to get prescriptions for lethal doses of medication from their doctors. Foley isn’t outright opposed to the idea, but he said he’s concerned about it being misused, such as if people make a decision against a patient’s wishes.
“There’s just so many opportunities for that to get corrupted,” he said. “People have a personal interest in, maybe, how long their parents live.”
Foley thinks it’s possible to design a system with appropriate safeguards, but said he hasn’t yet heard a proposal that he’d be comfortable with.
“I think it’s like capital punishment,” he said. “I’m not opposed to capital punishment, but you’d better be right every time. So how do you have a system that you can be confident you’re right every time? And I would feel the same way about this.”
Health insurance: Skeptical of benefit mandates
Legislators have passed many mandates requiring insurers to cover certain services or conditions. Lawmakers who support them describe them as important to ensuring that people get the prevention or care they need.
But if Foley wins the election, they’ll face a skeptical governor. While a small number of benefit mandates are probably good, Foley said he thinks most are politically motivated.
The problem, he says, is that mandates increase insurance premiums, but consumers usually don’t hear about the trade-off or get to choose between the added coverage or lower prices.
So what would his criteria be for evaluating any new benefit mandates that pass?
“They better make sense and they better have a nice, crispy 3-page memo associated with them, if they don’t want me to veto it, explaining why it’s in the interest of Connecticut citizens and not just political grandstanding or wanting to deliver support back to their friends and insiders,” Foley said.
Social Services: Private or Public, Lower The Costs
Connecticut has a hybrid social service system, with some services provided by state employees in state facilities and others handled by nonprofits that contract with the state. Most nonprofits cost less, in part because they pay workers significantly less and don’t offer benefits comparable with those given to state employees.
Foley said he’s not biased in favor of private or state providers, but believes they should be measured on their performance and costs, and the business should be moved to those offering the best value.
“I’d like to leverage the competitive environment to get the cost of providing services by the government down, but let the government keep doing it,” he said.
Larry Dorman, a spokesman for Council 4 of the American Federation of State, County and Municipal Employees, isn’t convinced. He thinks Foley’s ideas boil down to “selling off” government work to the private sector.
“I think all of the rhetoric is actually a recipe for economic disaster because you’re talking about making workers poorer and not having any guarantees of service quality,” Dorman said.
Closing Southbury Training School
The state-run Southbury Training School, an institution for people with developmental disabilities, operates in something of a transitional state. It’s not accepting new residents and the campus is being consolidated as the number of residents declines.
The state Department of Developmental Services, in accordance with a federal court settlement, presents options for living elsewhere to residents and their families. But those who prefer to stay at Southbury can. Currently, there are 329 residents. Their average age is 65. Some family members are concerned about their loved ones leaving. Some have been there most or all of their lives.
Caring for a person at Southbury costs more than at a private-sector facility providing the same level of care – in 2013, Southbury cost $976 per day for one person, compared to $452 in the private sector.
And the budget for developmental services has faced significant cutbacks in recent years, making it harder for many people with developmental disabilities to receive residential services, even in less costly settings. Some have suggested that the money spent keeping Southbury open could be better used serving more people in the community.
Foley believes the state should close Southbury Training School and find other services for the people who live there.
“It’s hard for me to believe that they’re able to provide the quality of care and the environment there that the state of Connecticut’s resources in today’s world can and should provide,” he said, calling the facility “pretty bleak.”
Foley said he’s sympathetic to families of people who spent most of their lives there. “It’s going to be a real traumatic transition to something else, I can see the reasons for doing what they’re doing,” he said.
But, he added, “I’ve got to believe there’s a better form of care for the people… than that place.”
This story originally appeared in the Connecticut Mirror.