GAO

United States General Accounting Office

Report to the Committee on Finance,

U.S. Senate

December 2000 MENTAL HEALTH

Community-Based

Care Increases for

People With Serious

Mental Illness

GAO-01-224

Page 1 GAO-01-224 Mental Health

Contents

Letter 3

Appendixes Appendix I: Scope and Methodology 22

Appendix II: Involuntary Outpatient Commitment 23

Appendix III: Selected SAMHSA Efforts to Help the Implementation

of Community-Based Programs 24

Appendix IV: Selected Community-Based Approaches to Treating

People With Serious Mental Illness 25

Appendix V: Selected HUD Programs That Can Assist Homeless

People Who Have SMI 29

Appendix VI: Comments From the Substance Abuse and Mental

Health Services Administration 30

Appendix VII: Comments From the Health Care Financing

Administration 32

Appendix VIII:GAO Contact and Staff Acknowledgments 35

Table Table 1: Community Mental Health Services Designed to Address

Needs of Adults With SMI 13

Figure Figure 1: Percentage of Total Mental Health Expenditures by

Funding Source, 1987 and 1997 10
Contents

Page 2 GAO-01-224 Mental Health

Abbreviations

ACT assertive community treatment

APA American Psychiatric Association

BBA Balanced Budget Act of 1997

CMHC community mental health center

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

HUD Department of Housing and Urban Development

IPS Individual Placement and Support

NASMHPD National Association of State Mental Health Program Directors

NIMH National Institute of Mental Health

SAMHSA Substance Abuse and Mental Health Services Administration

SMHA state mental health agency

SMI serious mental illness
Page 3 GAO-01-224 Mental Health

United States General Accounting Office

Washington, D.C. 20548 Letr

December 19, 2000

The Honorable William V. Roth, Jr.

Chairman

The Honorable Daniel Patrick Moynihan

Ranking Minority Member

Committee on Finance

United States Senate

Mental disorders take an enormous toll on the nation’s families and

finances. The indirect costs of mental illness, such as for lost productivity,

were estimated at $78.6 billion in 1990. In 1997, $73 billion was spent on

mental health services. The Surgeon General has estimated that about 20

percent of the U.S. population is affected by a mental disorder in a given

year.1 About 5 percent of the population are considered to have a serious

mental illness (SMI). SMI, which includes, among other diseases,

schizophrenia, bipolar disorder, and major depression, is a chronic

condition that can substantially limit a person’s ability to function in many

areas of life such as employment, self-care, and interpersonal relationships.

Effective treatment can reduce the severity of these problems for the

majority of people with SMI. Much of this treatment can now be provided

in the community rather than in institutions.

Because of your long-standing concern with the availability and financing

of mental health services, you asked us to review mental health services for

people with SMI. Specifically, you asked us to (1) provide information on

mental health spending and how it has changed since the 1980s; (2) identify

the types of community-based services that are provided to adults with

SMI, including people who are homeless, and difficulties in providing these

services; and (3) determine how the Health Care Financing Administration

(HCFA), which administers the Medicaid program, supports the provision

of community-based services for adults with SMI who are eligible for

Medicaid.

To answer these questions, we interviewed and obtained documents from

officials at the Department of Health and Human Services’ (HHS)

Substance Abuse and Mental Health Services Administration (SAMHSA),

HCFA, and the National Institute of Mental Health (NIMH). We also visited

1

Mental Health: A Report of the Surgeon General (Rockville, Md.: U.S. Department of Health

and Human Services, 1999).
Page 4 GAO-01-224 Mental Health

state mental health and Medicaid officials and service providers in

Michigan and New Hampshire, states that have been identified as operating

exemplary community-based programs. In addition, we reviewed

documents from the National Association of State Mental Health Program

Directors (NASMHPD). Finally, we interviewed officials from several

organizations concerned with mental health issues as well as individual

experts on mental health. (For additional information on our methodology,

see app. I.) We conducted our work between May and November 2000 in

accordance with generally accepted government auditing standards.

Results in Brief Between 1987 and 1997, the growth in mental health spending in the United

States roughly paralleled the growth in overall health care spending. After

adjusting for overall inflation, spending on mental health services grew by 4

percent a year, on average, compared with 5 percent a year for spending on

all health care. However, federal mental health spending grew at more than

twice the rate of state and local spending. This led to the federal

government’s share surpassing that of state and local governments, while

the share attributable to private sources declined slightly. Increasing

Medicaid and Medicare expenditures accounted for the larger federal

share, with combined federal and state Medicaid expenditures accounting

for 20 percent of all mental health spending in 1997.

The focus of care for adults with SMI has continued to shift from providing

services in psychiatric hospitals to providing services in the community.

The ability to care for more people in the community has been facilitated

by the continued development of new medications that produce fewer side

effects and are more effective in helping people manage their illness.

Furthermore, treatment approaches such as assertive community

treatment (ACT), supported employment, and supportive housing have

been developed to provide the multiple forms of ongoing assistance that

adults with SMI often need if they are to function in the community. These

approaches can also help homeless people with SMI, whose treatment

needs are additionally complex, partly because many of them also suffer

from a substance abuse disorder. Coordinating and integrating services can

be effective in treating people with multiple needs, and organizing care in

this way is especially important for people making the transition from

institutions to the community.

Medicaid is a major source of support for people with SMI. HCFA has

encouraged the use of community-based services for Medicaid

beneficiaries with SMI by disseminating information on the use of new
Page 5 GAO-01-224 Mental Health

medications and treatment models, which can help people function better

in the community. HCFA has also supported states’ use of Medicaid

managed care waivers to provide a wider array of community-based mental

health services. However, incentives associated with capitated payment

can lead to reduced service utilization. Recognizing the risks for people

with special health care needs, such as serious mental illness, the Congress

required HCFA to take steps to ensure that beneficiaries enrolled in

managed care receive appropriate care. HCFA is developing a set of

safeguards for such people enrolled in Medicaid managed care. The

safeguards provide measures that states can take to better ensure that

beneficiaries can obtain the services and supports they need to function.

HCFA has indicated that it will devise a plan to implement these

safeguards, such as through legislative or regulatory action or making

changes in Medicaid administrative policies. Effective oversight to ensure

that adequate safeguards are implemented will be essential to provide

meaningful protection to this vulnerable population. SAMHSA and HCFA

commented on a draft of this report and generally agreed with our findings.

Background Historically, people with SMI were cared for primarily in hospitals. States

developed a system of public mental hospitals, but by the 1960s they were

viewed as ineffective and inadequate because of overcrowding, staff

shortages, and poor facilities. Advocates and reformers contended that

long-term institutional care in the hospitals had been characterized by

patient neglect and ineffective treatment. Improved medications that

reduced some of the symptoms of mental illness allowed more people to

live in the community with support.

Certain legislative and judicial actions contributed to a changed focus of

providing community-based rather than institutional care. In 1963, the

Community Mental Health Centers Act authorized the development of a

nationwide network of community mental health centers (CMHC) to

replace state institutions as the main source of treatment for people with

SMI and to decrease the incidence of mental illness in the broader

population.2 The act and amendments created federal grants for states to

build the CMHCs and staff them for 8 years. Funds were intended to

supplement existing state and local revenues to help communities develop

the new services necessary for adequate community mental health care.

2

Pub. L. No. 88-164, title II, 77 Stat. 290.
Page 6 GAO-01-224 Mental Health

States and communities were expected to develop alternative funding

sources to eventually replace the federal funds. CMHCs were required to

provide a number of services, including inpatient, outpatient, emergency,

and day care services; follow-up care for people released from mental

health facilities; and transitional living facilities. CMHCs were also required

to coordinate service delivery with other mental health and social service

providers in the community.

The vision of a national network of community mental health centers was

not fulfilled. Many communities were unable to find the funds to match

federal dollars to build the CMHCs or to provide all the required services;

others were unable to find qualified professionals to staff the centers.3 As

of 1980, only 768 of the projected 2,000 CMHCs had been funded. Moreover,

implementation of the CMHC act did not adequately address the needs of

people with SMI who were released from institutions. The CMHC

program’s regulations emphasized the prevention and treatment of mental

disorders in the broader population, and CMHCs did not provide the

intensive, more comprehensive services people with SMI required, such as

housing, support services, and vocational opportunities in addition to

treatment. Medication was the only service provided to many patients.

Further, the extent to which CMHCs coordinated with mental hospitals

concerning the release of patients to their communities varied. Section 901

of the Omnibus Budget Reconciliation Act of 1981 ended federal funding to

states specifically for community mental health centers and replaced it

with block grants to the states to support services for people with SMI.4

A series of court decisions in the 1970s establishing that institutionalization

is a deprivation of liberty also played a role in moving people with SMI

away from institutions into the community. States had previously exercised

broad latitude in allowing an individual with mental illness to be

involuntarily confined, but court rulings recognizing individuals’ right to

refuse treatment made it difficult to commit people to a psychiatric

hospital without their consent. In 1975, the Supreme Court held that

mentally ill individuals could not be committed involuntarily unless they

were found to be dangerous to themselves or others.5 This led to a reform

3

Later amendments set out more specific requirements for CMHCs. Community Mental

Health Centers Amendments of 1975, Pub. L. No. 94-63, title III, 89 Stat. 304, 308.

4

Pub. L. No. 97-35, 95 Stat. 543.

5

O’Connor v. Donaldson, 422 U.S. 563 (1975).
Page 7 GAO-01-224 Mental Health

of state laws, which now generally allow involuntary inpatient commitment

only if persons present a clear danger or threat of substantial harm to

themselves or others. Some state laws specify that inpatient commitment is

appropriate only after full consideration of less restrictive alternatives,

such as involuntary outpatient commitment. (See app. II for a discussion of

involuntary outpatient commitment.) A recent Supreme Court opinion has

brought additional pressure on states to offer community-based treatment

to people with mental illness when such treatment is appropriate, the

individuals do not oppose such treatment, and the placement can be

reasonably accommodated, taking into account the state’s resources.6

The public mental hospital population declined. Many people with SMI

returned to communities without adequate mental health services and

some of these people became homeless. Other major factors contributing

to homelessness were unemployment, a decline in the supply of lowincome housing, and alcohol and drug abuse.

The State and Federal Roles

in Supporting Mental Health

Services

State mental health agencies (SMHA) have primary responsibility for

administering the public mental health system, through their role as a

purchaser, regulator, manager, and, at times, provider of mental health

care. The public mental health system serves as a safety net for people who

are poor or uninsured or whose private insurance benefits run out in the

course of their serious mental illness. Many people with SMI are

unemployed, and they are often poor and financially dependent on

government support. SMHAs arrange for the delivery of services to more

than 2 million people each year, most of whom suffer from a serious mental

illness. Services are delivered by state-operated or county-operated

facilities, nonprofit organizations, and other private providers. The sources

and amounts of public funds SMHAs administer vary from state to state but

usually include state general revenues and federal funds.

The federal funds that SMHAs administer generally include Medicaid and

Medicare payments for services provided in state-owned or state-operated

facilities and other Medicaid payments when the state Medicaid agency has

authorized the SMHA to control all Medicaid expenditures for mental

health services. HCFA’s Medicaid and Medicare programs pay for certain

mental health services for eligible beneficiaries. States operate their own

Medicaid programs within broad federal requirements. Medicaid pays for

6

Olmstead v. L.C., 527 U.S. 581 (1999).
Page 8 GAO-01-224 Mental Health

mandatory services, such as physician services, and optional benefits that

states may choose to provide, such as rehabilitation and targeted case

management. Since Medicaid is an entitlement program, states and the

federal government are obligated to pay for all covered services that are

provided to an eligible individual.7 Each state program’s federal and state

funding share is determined through a statutory matching formula, with the

federal share ranging from 50 to 80 percent.8

In the 1990s, state Medicaid programs increasingly turned to capitated

managed care plans to provide medical and behavioral health services as a

way to control costs and improve services. Twenty-two states have “carved

out,” or separated, mental health services from physical health services in

contracting with managed care plans, placing them under separate

financing and administrative arrangements. Some states create separate

capitated arrangements and others use fee-for-service arrangements.9

Medicare covers elderly persons and persons who receive Social Security

Disability Insurance, and it pays for a range of inpatient and outpatient

mental health services.10 The Medicare statute requires a 50-percent copayment from beneficiaries for outpatient care of mental disorders,

compared with 20 percent for other medical outpatient treatment.11

Furthermore, the Medicare statute limits treatment in a freestanding

psychiatric hospital to a total of 190 days in a patient’s lifetime.12

7

For adults aged 22 to 64, Medicaid does not cover most services provided in institutions for

mental disease, which are hospitals, nursing facilities, or other institutions of more than 16

beds primarily engaged in caring for people with mental illness. In addition, some states

restrict the number of mental health services a person can receive in a year, require prior

authorization for certain services, or both.

8

In 1995, the average size of the federal match was 57 percent.

9

States may require people eligible for Medicaid to enroll in a managed care plan if the state

receives a waiver from HCFA under section 1115 or 1915(b) of the Social Security Act (42

U.S.C. 1315 and 1396n(b)). In addition, section 4701 of the Balanced Budget Act of 1997

(BBA) amended the Social Security Act to authorize states to establish Medicaid managed

care programs simply by amending their state Medicaid plans. Pub. L. No. 105-33, 111 Stat.

251, 489 (classified at 42 U.S.C. 1396u-2).

10After receiving Social Security Disability Insurance benefits for 24 months, a person

becomes eligible for Medicare.

1142 U.S.C. 1395l(c).

1242 U.S.C. 1395(d)(3).
Page 9 GAO-01-224 Mental Health

SMHAs also administer the funds they receive from SAMHSA’s Community

Mental Health Services Block Grant program. Block grants are allocated to

states according to a statutory formula that takes into account each state’s

taxable resources, personal income, population, and service costs. The

grants give states and territories a flexible funding source for providing a

broad spectrum of community mental health services to adults with SMI

and children with a serious emotional disturbance. Funding for the block

grant program totaled $356 million in fiscal year 2000; SAMHSA used about

$18 million for state systems development, including technical assistance,

data collection, and evaluation. The remainder was awarded to the states

and territories, with an average award of about $5.7 million. (See app. III

for other SAMHSA programs that help implement community-based mental

health services.)

Federal Mental Health

Spending Grew Faster

Than State and Local

Spending, and the Role

of Medicaid and

Medicare Increased

In 1997, the nation spent about $73 billion for the treatment of all mental

illness, up from $37 billion in 1987.13 Mental health spending grew at about

the same rate as overall health spending during this period. After adjusting

for overall inflation, spending for all health care grew by 5 percent a year,

on average, compared with 4 percent for spending on mental health

services.14 In 1997, the public sector (that is, federal, state, and local

governments) provided 55 percent of mental health spending, in contrast to

providing less than half (about 46 percent) of overall health care spending.

From 1987 to 1997, adjusted annual federal spending for mental health

grew, on average, more than twice as fast as state and local mental health

spending (6.3 percent versus 2.4 percent). This led to the federal

government’s share of total mental health expenditures increasing from 22

to 28 percent during the period, while state and local governments’ share of

spending declined from 31 to 27 percent.15 The proportion from private

spending sources also declined slightly from 46 to 45 percent (see fig. 1).

13National information is not collected specifically on the amount of money spent to treat

serious mental illness. HCFA, SAMHSA, and others collect information only on overall

mental health spending.

14Growth rates are based on data in National Expenditures for Mental Health and Substance

Abuse Treatment 1997 (Rockville, Md.: U.S. Department of Health and Human Services,

2000). The gross domestic product deflator was used to adjust for inflation.

15Federal expenditures included Medicaid’s contribution, Medicare payments, and other

federal expenditures, such as those from the Community Mental Health Services Block

Grant and the departments of Defense and Veterans Affairs.
Page 10 GAO-01-224 Mental Health

Figure 1: Percentage of Total Mental Health Expenditures by Funding Source, 1987 and 1997

Note: Percentages may not total 100 because of rounding.

Source: National Expenditures for Mental Health and Substance Abuse Treatment 1997 (Rockville,

Md.: U.S. Department of Health and Human Services, 2000).

Medicaid and Medicare played increasingly important roles in funding

mental health services between 1987 and 1997. Medicaid’s proportion of

mental health spending (federal and state) rose from slightly more than 15

percent ($5.7 billion) to about 20 percent ($14.4 billion). Medicare’s share

rose from 8 percent to slightly more than 12 percent, with expenditures

increasing from about $3 billion to $9 billion. HCFA and SAMHSA officials

have suggested several reasons for Medicaid’s increase. These include the

trend toward Medicaid beneficiaries receiving their inpatient care in

psychiatric units of general hospitals, where services are covered by

Medicaid, rather than in psychiatric hospitals, where services are not

covered; increased costs for psychiatric medications; and states’ increased

use of Medicaid to pay for community-based mental health services. The

increase in Medicare spending may be associated in part with a 1990

Private

Insurance

23.0%

Out-of-Pocket

19.8%

Other

Private

3.6%

Other State

and Local

24.4%

State

Medicaid

6.9%

Federal

Medicaid

8.5%

Other

Federal

5.9%

Private: 46.4%

State and

Local:

31.3%

Medicare

8.0%

Total Expenditures = $37.1 billion

Federal: 22.3%

1987 1997

Private

Insurance

24.4%

Out-of-Pocket

17.8%

Other

Private

2.6% Other State

and Local

19.2%

State

Medicaid

7.9%

Federal

Medicaid

11.8%

Other

Federal

3.9%

Private: 44.8%

State and

Local:

27.1%

Medicare

12.4%

Total Expenditures = $73.4 billion

Federal: 28.1%
Page 11 GAO-01-224 Mental Health

statutory change that expanded coverage to nonphysician professionals

providing mental health services, such as psychologists, clinical social

workers, and nurse practitioners.16

Community-Based

Services Are Designed

to Address the

Complex Needs of

Adults With Serious

Mental Illness

Over the past 20 years, states have largely shifted the care of people with

SMI from institutions to the community. The continued development of

psychotropic medications that both are more effective and produce fewer

side effects has facilitated the ability to care for more people with SMI in

the community. Furthermore, treatment approaches such as ACT,

supported employment, and supportive housing can provide the multiple

forms of ongoing assistance that adults with SMI often need to function.

These approaches can also help homeless people with SMI, who have

particularly complex treatment needs and who often have difficulty gaining

access to the multiple services they need. Integration and coordination of

services have been found to be effective in treating people with multiple

needs.

Care Emphasis Continues to

Shift From Institutions to

Community Services

The focus of mental health services for people with SMI has continued to

shift from providing care in psychiatric hospitals to providing communitybased care. From 1980 to 1998, the number of patients institutionalized in

state and county mental hospitals decreased by almost 60 percentby the

end of 1998, about 57,000 people were in state or county psychiatric

hospitals.17 Although nationwide expenditure data are not available, data

from 33 states show that state mental health agencies’ expenditures for

psychiatric hospitals dropped from 52 percent to 35 percent of total

expenditures between 1987 and 1997, while community-based spending

rose from 45 percent to 63 percent.18

The continued development of new antidepressant and antipsychotic

medications has helped make it possible to care for more people with SMI

16Before 1990, generally only mental health services delivered by physicians were covered

under Medicare.

17Additions and Resident Patients at End of Year, State and County Mental Hospitals by Age

and Diagnosis by State, United States 1998 (Rockville, Md.: SAMHSA, Center for Mental

Health Services, 2000).

18Expenditure data were reported to NASMHPD by the 33 states, representing 74 percent of

the U.S. population in 1997, in state fiscal years 1987 and 1997.
Page 12 GAO-01-224 Mental Health

in the community. The newer medications further improve the ability of

people with SMI to live in the community, receive care at a general hospital

or in other clinical settings, and manage symptoms of their illness. The

Surgeon General recently reported, for example, that the newer

antipsychotic medications show promise for treating people with

schizophrenia for whom older medications are ineffective, by reducing

symptoms such as delusions, hallucinations, disorganized speech and

thinking, and catatonic behaviors.19 Further, the Surgeon General reported

that some of the newer drugs carry fewer and less severe side effects,

generally resulting in better compliance with medication regimens, and

that they may improve a person’s quality of life and responsiveness to other

treatment interventions. Patients using certain medications, however,

require careful monitoring to ensure that they are receiving the appropriate

dose and to minimize side effects. For example, in about 1 percent of

patients, clozapine causes agranulocytosis, a potentially fatal loss of white

blood cells that fight infection. Because this condition is reversible if

detected early, weekly blood monitoring is critical.

States have supported an array of community-based services that are

designed to enable people with SMI to remain in their communities and live

independently. States frequently provide services directly or contract with

county or community mental health organizations to offer services.

Although most care is provided on an outpatient basis, people with SMI

sometimes experience periods when they are unable to care for themselves

and need short-term hospitalization. Table 1 describes types of mental

health services for adults with SMI provided in the community.

19Mental Health: A Report of the Surgeon General.
Page 13 GAO-01-224 Mental Health

Table 1: Community Mental Health Services Designed to Address Needs of Adults

With SMI

Many people with SMI need a range of services to help them function in the

community. Several approaches to providing ongoing assistance and

coordinated services have been developed to meet the varying needs of this

population, such as ACT, supported employment, and supportive housing.

ACT is a model of providing intensive care to people with the most severe

and persistent mental illness. It is generally targeted toward people who

have recently left institutions, typically do not schedule or keep

appointments, or do not do well without extensive support. Under the ACT

model, multidisciplinary teams are to be available to provide services

around the clock in community settings, such as at the person’s home.

Services can include administering medications, interpersonal skills

training, providing crisis intervention, and providing employment

assistance and are intended to be available as long as the person needs

them. Supported employment programs assist people who have SMI to

work in competitive jobs. Some supported employment programs

emphasize quick placement into regular jobs, rather than training people

before job placement, and then help enable individuals with SMI to perform

acceptably in their jobs. Supportive housing programs attempt to address

the needs of people with SMI who have been homeless or who are at risk of

Service Description

Ambulatory Services provided in an outpatient setting that may include the following:

Counselingindividual, family, or group therapy that can be provided in an

office or community setting, such as the person’s home or employment

site;

Medication dispensing and monitoringdirectly administering

medications to an individual and observing the individual to identify both

beneficial and inadvertent or undesirable side effects;

Case managementhelping clients obtain financial, housing, medical,

employment, social, transportation, and other community resources;

Crisis interventionscreening, psychiatric evaluation, emergency

intervention, and stabilization; and

Day treatment/psychosocial rehabilitationstructured program activities

including services such as social support, vocational training, and

independent living skills

Residential Services provided in group homes, independent or shared apartments,

and single-room occupancies that may include training, support,

medications, and supervision of routine activities, including community

orientation, meal preparation, financial management, and transportation

Inpatient Services provided in facilities such as a general hospital or inpatient unit

of a community mental health clinic, including diagnosis and treatment

services
Page 14 GAO-01-224 Mental Health

becoming homeless by combining housing with other needed services,

such as case management and substance abuse treatment. (For more

detailed information on ACT, supported employment, and supportive

housing, see app. IV.)

Homelessness Complicates

the Treatment of Adults

With Serious Mental Illness

Approximately 1 in 20 adults with SMI are homeless; they account for an

estimated one-third of the approximately 600,000 homeless adults in the

United States. At least half of homeless people with SMI also have

substance abuse disorders. Mental illness in combination with substance

abuse may predispose individuals to homelessness, as their conditions

often lead to disruptive behavior, loss of social supports, financial

problems, and an inability to maintain stable housing. Homelessness adds

to the complexity of treatment needs for people with SMI; beyond mental

health services, they need a range of physical health, housing, and social

services. Compared with other homeless people, those with SMI are

generally in poorer physical health, are homeless for longer periods of time,

and often reside on the streets.

Homeless people with SMI have difficulty gaining access to the full range of

health care, housing, and support services they need. Typically, they lack

the income verification documentation necessary to enroll in entitlement

programs, such as Medicaid; they have problems maintaining schedules;

and they lack transportation. The Department of Housing and Urban

Development (HUD) funds programs, including rental assistance and

housing development grants, that have been used to help homeless people

with SMI obtain housing. (See app. V.) Researchers and experts widely

agree that the demand for low-income housing and housing subsidies far

exceeds the supply. According to the National Coalition for the Homeless,

many traditional mental health providers are neither equipped to handle

the complex social and health conditions of homeless people nor typically

linked to the range of services needed for their recovery and residential

stability. Traditionally, separate systems have provided these

servicessuch as the mental health, substance abuse, public housing, and

social welfare systemseach of which has its own eligibility and program

requirements. It is particularly difficult for people with SMI to negotiate

systems in which services are separate and uncoordinated.
Page 15 GAO-01-224 Mental Health

Research indicates that coordinated service delivery is important for

meeting the numerous and complex needs of homeless people with SMI.20

One study found that homeless people with SMI who participated in

programs using an integrated treatment approach—in which multiple

services were provided through a single entity—spent more days in stable

housing (such as an apartment or group home) and reduced their alcohol

use more than those receiving services through multiple agencies.21

SAMHSA’s Access to Community Care and Effective Services and Supports

programan interdepartmental demonstration program integrating

housing, mental health, substance abuse, employment, and social support

servicesfound that service system integration was associated with

improved access to housing services and better housing outcomes for

homeless people with mental illness.22

Efforts are under way to coordinate services to reduce the number of

homeless people with SMI who become incarcerated.23 SAMHSA is funding

a study of programs for diverting adults with mental illness and substance

abuse problems from the criminal justice system to community-based

treatment. According to SAMHSA, diversion programs are often the most

effective way to integrate an array of mental health, substance abuse, and

other support services to help people break the cycle of repeated

incarceration. In some communities, mental health courts are designed to

hear the cases of people with mental illness who are arrested for

misdemeanors such as loitering or creating a public nuisance. In these

20We discuss the issues of coordination and integration of services for homeless people in

more detail in Homelessness: Coordination and Evaluation of Programs Are Essential

(GAO/RCED-99-49, Feb. 26, 1999) and Homelessness: State and Local Efforts to Integrate

and Evaluate Homeless Assistance Programs (GAO/RCED-99-178, June 29, 1999).

21Robert E. Drake and others, “Integrated Treatment for Dually Diagnosed Homeless

Adults,” The Journal of Nervous and Mental Disease, Vol. 185, No. 5 (1997), pp. 298-305.

22The departments of Agriculture, Education, Housing and Urban Development, Labor, and

Veterans Affairs were also involved in this program.

23In 1999, the Department of Justice reported that 60 percent of inmates with mental illness

were under the influence of alcohol or drugs at the time of their offense and that 20 percent

of those with mental illness had been homeless at some time during the 12 months before

they were arrested.
Page 16 GAO-01-224 Mental Health

programs, people with mental illness can have their case heard by the

mental health court and can agree to follow a plan of mental health

treatment and services instead of going to jail.24

HCFA Is Supportive of

New CommunityBased Services and Is

Developing Safeguards

for the Use of Managed

Care

HCFA has disseminated information to states about the more effective

medications and treatments for adults with SMI and has supported states’

use of Medicaid managed mental health care to provide a wider array of

services not covered by traditional fee-for-service Medicaid. HCFA is

developing safeguards to help ensure that states that use managed care

arrangements furnish appropriate services to people with special health

care needs, including people with SMI.

HCFA Has Encouraged

States to Provide Advanced

Treatments

HCFA has taken steps to encourage states to use new modes of care for

adults with SMI. In June 1999, HCFA issued a letter to state Medicaid

directors noting that research had demonstrated that ACT is an effective

strategy for treating persons with SMI. The letter stated that states should

consider these positive findings in their plans for comprehensive

approaches to community-based mental health services.25

HCFA has also encouraged the use of newer medications. In a letter to state

Medicaid programs in 1998, it provided information on the effectiveness of

new antipsychotic medications in treating schizophrenia. HCFA noted that

24A federal demonstration program to promote mental health courts has been authorized for

fiscal years 2001 through 2004. Under the America’s Law Enforcement and Mental Health

Project, in consultation with the Secretary of HHS, the Attorney General is to make

matching grants to states and municipalities to establish up to 100 such courts throughout

the nation. These courts will hear cases involving individuals with SMI charged with

misdemeanors or nonviolent offenses, with the purpose of diverting many of them into

appropriate mental health treatment. Among other things, grant funds will also be used to

provide specialized training of law enforcement and judicial personnel. Pub. L. No. 106-515,

114 Stat. 2399 (2000) (to be classified at 42 U.S.C. 3796ii et seq.).

25HCFA is also jointly sponsoring a contract with SAMHSA to examine the factors that

contribute to the successful implementation of ACT programs at the state level. HCFA states

that this contract will also review how states are using Medicaid and other resources to

support ACT programs, how programs are designed to meet the needs of people with

serious and persistent mental illness, and the outcomes of services.
Page 17 GAO-01-224 Mental Health

some states and managed care organizations with formularies have already

adjusted them to recognize these new medications.26 HCFA suggested that

all states consider the medications’ advantages in reducing side effects,

increasing patient compliance with treatment regimens, and possibly

reducing psychiatric hospital readmissions.

HCFA has used its waiver authorities to support some states’ initiatives to

use Medicaid managed care carveout programs to enhance their provision

of mental health services. With a waiver, states may gain the opportunity to

provide some community-based mental health services that are not usually

covered by fee-for-service Medicaid, provided they do not increase overall

spending. For example, while many ACT program services can be

reimbursed under existing Medicaid policies, some services, such as family

counseling and respite care, are typically not reimbursable through

Medicaid’s traditional fee-for-service program. A survey of states with

mental health carveout waivers found that some states did use the waiver

to add coverage for services not previously included in their Medicaid

plans, most frequently psychiatric rehabilitation and case management.27

Safeguards Are Important to

Ensure Access to Care for

Medicaid Beneficiaries in

Managed Care

As HCFA has noted in a draft report on strengthening Medicaid managed

care, managed care organizations are often not accustomed to serving

people with special health needs, such as adults with SMI, and may lack the

expertise and provider networks required for treating them appropriately.28

Moreover, while managed care arrangements can provide greater flexibility

in the design and development of individualized services, capitated

payment arrangements create incentives to limit access and underserve

enrollees.

In a previous study of Medicaid managed mental health care, we found that

HCFA had provided limited oversight of mental health managed care

26A formulary is a list of drugs or classes of drugs a health care system or other organization

has identified as appropriate for treating patients.

27Chris Koyanagi and Jennifer Stevenson, Assessing Approaches to Medicaid Managed

Behavioral Health Care, prepared by the Bazelon Center for Mental Health Law

(Washington, D.C.: Kaiser Commission on the Future of Medicaid, July 1997).

28This draft report was prepared for the Congress in response to the BBA requirement that

HCFA develop a set of safeguards for individuals with special health needs who are enrolled

in Medicaid managed care, including persons with SMI. Pub. L. No. 105-33, sec. 4705(c)(2),

111 Stat. 251, 500.
Page 18 GAO-01-224 Mental Health

carveouts.29 Most monitoring occurred when the waiver application was

made or renewed, and it varied in content and intensity across HCFA’s

regional offices. This stemmed in large part from a lack of central office

guidance on the type of program monitoring and oversight that HCFA staff

should perform. HCFA officials told us that the agency has recently revised

the monitoring guide that regional offices use when conducting site visits

of managed care programs, including those that provide services to people

with SMI.30 In addition, SAMHSA now reviews all waiver applications to

help HCFA ensure that waiver applications appropriately address issues

such as the capacity of the proposed delivery system, the array of benefits

covered, and quality of care.

Recognizing the risks for vulnerable individuals with special health care

needs, the Congress in the BBA required HCFA to determine what

safeguards may be necessary to ensure that the needs of these individuals

who are enrolled in Medicaid managed care organizations are adequately

met. HCFA’s draft report in response to its BBA mandate contains a series

of recommendations for HCFA, states, and managed care organizations

regarding safeguards to help ensure that adults with SMI obtain needed

services. HCFA recommends, for example, that states take steps to ensure

that necessary services and supports are reasonably available to

beneficiaries whose ability to function depends on receiving them. For

example, HCFA suggests that states require in their contracts that managed

care organizations’ medical necessity decisions not always require

improvement or restoration of functioning but may also provide for

services needed to maintain functioning or compensate for loss of

functioning. The draft indicates that HCFA intends to develop plans to

implement its recommended safeguards, such as through legislative or

regulatory action or changes in Medicaid administrative policies. HCFA has

taken comparable action to protect children with special needs, another

vulnerable population, when they are enrolled in state Medicaid managed

care programs. HCFA developed interim review criteria with mandatory

safeguards, which the agency plans to use to review state waiver

applications that include these children in managed care.

29Medicaid Managed Care: Four States’ Experiences With Mental Health Carveout Programs

(GAO/HEHS-99-118, Sept. 17, 1999).

30Although the guide is in draft, it was distributed to HCFA regional offices in August 2000.
Page 19 GAO-01-224 Mental Health

Concluding

Observations

As people with SMI increasingly receive their care in the community, it is

important that they have access to the variety of mental health and other

services they need. Because of the nature of SMI, people with this

condition are often poor and must rely on the public mental health system

for their care. Recently, states have stepped up their efforts to provide

community-based services that give ongoing support to adults with SMI.

These services are especially critical for people making the transition from

institutions to the community, to help prevent their becoming homeless or

returning to institutions. Homeless people with SMI especially need to

receive a range of mental health, substance abuse, social support, and

housing services to function in the community, and it is important for

providers to link these services effectively.

The use of managed mental health care by some state Medicaid programs

has resulted in the flexibility to provide a wider array of services. However,

given the potential for managed care providers reducing access to needed

services, it is important for HCFA and state Medicaid programs to ensure

that beneficiaries enrolled in managed care receive appropriate care.

HCFA’s current effort to identify safeguards recognizes the importance of

people with SMI receiving the necessary services and continuity of care

that are fundamental to their well-being. The agency has indicated that it

will devise a set of actions to implement these recommended safeguards.

Identifying the appropriate actions and effectively implementing them will

be essential if the safeguards are to provide meaningful protection to this

vulnerable population.

Agency and Other

Comments

We provided a draft of this report to SAMHSA and HCFA for comment.

SAMHSA generally agreed with the report’s information on communitybased mental health services for people with SMI. SAMHSA noted two

developments that it considers importantan increase in the number of

people with SMI who are treated in the criminal justice system because of

inadequate resources for community mental health supports and states’

support of consumer-run services and increasing solicitation of consumers’

views on the delivery of community-based services. We did not evaluate the

link between the number of people with SMI treated in the criminal justice

system and the adequacy of community mental health resources or assess

the participation of people with SMI in the operation of community-based

services. In its technical comments, SAMHSA highlighted several efforts on

which SAMHSA and HCFA work collaboratively. For example, SAMHSA

staff have accompanied HCFA staff on site visits to monitor various states’
Page 20 GAO-01-224 Mental Health

waiver programs, and a joint workgroup is developing indicators that states

can use to predict problems or ensure success in their managed care

programs.

In its comments on the draft report, HCFA summarized additional efforts

by the Medicaid and Medicare programs to serve the needs of people with

SMI. For example, HCFA has made grant money available for states to test

demonstration projects that focus on removing barriers to employment for

people with disabilities, including people with SMI. SAMHSA and HCFA

provided technical comments, which we incorporated where appropriate.

(SAMHSA’s and HCFA’s comments are in apps. VI and VII.)

We are sending copies of this report to the Honorable Donna E. Shalala,

Secretary of HHS; the Honorable Joseph Autry, Acting Administrator of

SAMHSA; the Honorable Robert A. Berenson, Acting Administrator of

HCFA; officials of the state mental health and Medicaid agencies we visited;

appropriate congressional committees; and others who are interested. We

will also make copies available to others on request.

If you or your staffs have any questions, please contact me at (202) 512-

7119. An additional GAO contact and the names of other staff who made

major contributions to this report are listed in appendix VIII.

Janet Heinrich, Director

Health CarePublic Health Issues
Page 21 GAO-01-224 Mental Health
Page 22 GAO-01-224 Mental Health

Appendix I

Scope and Methodology ApApenednxidexiIs

To do our work, we interviewed officials at the Health Care Financing

Administration (HCFA), the Substance Abuse and Mental Health Services

Administration (SAMHSA), the National Institute of Mental Health (NIMH),

and the National Association of State Mental Health Program Directors

(NASMHPD), and we reviewed documents such as SAMHSA’s National

Expenditures for Mental Health and Substance Abuse Treatment 1997,

SAMHSA’s Center for Mental Health Services 1998 Survey of Mental Health

Organizations and General Hospitals with Separate Psychiatric Services,

and NASMHPD reports and data regarding the funding sources and

expenditures of state mental health agencies. Although other federal

agencies, such as the Department of Defense and the Veterans

Administration, provide services to people with mental illness, we

generally restricted our scope at the federal level to the Department of

Health and Human Services (HHS) because HHS programs account for

most federal mental health spending.

We conducted site visits to Michigan and New Hampshire, where we

interviewed state mental health and Medicaid officials and administrators

of selected treatment programs. We selected these states for site visits

because experts identified them as implementing exemplary programs. We

also reviewed several states’ Center for Mental Health Services monitoring

reports, annual implementation reports, and Community Mental Health

Services Block Grant applications.

We also reviewed relevant literature and obtained information from

individual experts as well as a number of organizations interested in mental

health issues such as the American Psychiatric Association (APA), the

American Psychological Association, the Bazelon Center for Mental Health

Law, the International Association of Psychosocial Rehabilitation Services,

the National Alliance for the Mentally Ill, the National Mental Health

Association, and the Treatment Advocacy Center.

We conducted our work between May and November 2000 in accordance

with generally accepted government auditing standards.
Page 23 GAO-01-224 Mental Health

Appendix II

Involuntary Outpatient Commitment ApendxiI

Most states have laws authorizing involuntary outpatient commitment, also

referred to as mandatory or assisted outpatient treatment. APA defines

mandatory outpatient treatment as court-ordered outpatient treatment for

patients who suffer from severe mental illness (SMI) and who are unlikely

to comply with such treatment without a court order.1 APA considers this a

preventive treatment for people who do not meet criteria for inpatient

commitment and who need treatment in order to prevent relapse or

deterioration that would predictably lead to their meeting inpatient

commitment criteria in the foreseeable future. Some states have adopted

standards for involuntary outpatient commitment that reflect this

approach, but most have adopted the criterion of individuals presenting

danger to themselves or others, the same standard they use for involuntary

inpatient commitment. Mandatory outpatient treatment may also be used

as part of a discharge plan for persons leaving inpatient facilities or as an

alternative to hospitalization.

Although 41 states and the District of Columbia have adopted involuntary

outpatient commitment laws, they are rarely used in many of these states.

The approach of using involuntary outpatient commitment has generated

some controversy.2 People who support it believe that it helps ensure

treatment for people who need services but whose very illness prevents

them from recognizing their need, thus enabling them to remain in the

community instead of deteriorating in ways that could result in their being

institutionalized. Those who oppose it are concerned that it threatens civil

liberties, diverts scarce resources, and undermines the relationship

between people with mental illness and service providers. Some states

have preferred to take other approaches, such as the use of advance

directives. These legal documents allow individuals to express their

choices about mental health treatment or appoint someone to make mental

health care decisions for them in case they become incapable of making

their own decisions.

1

APA, Mandatory Outpatient Treatment: A Resource Document of the American Psychiatric

Association (Washington, D.C.: 1999).

2

See also National Health Policy Forum, “Outpatient Commitment in Mental Health: Is

Coercion the Price of Community Services?” Issue Brief 757 (Washington, D.C.: 2000).
Page 24 GAO-01-224 Mental Health

Appendix III

Selected SAMHSA Efforts to Help the

Implementation of Community-Based

Programs ApendxiI

Program Description Funding

Community Action Grants for

Services Systems Change

Awards community groups grants of less than $150,000 to sponsor a best

practice targeted toward adults with SMI or adolescents and children with serious

emotional disorders.

$18.9 million over

fiscal years 1997-

2001

Employment Intervention

Demonstration Program

An eight-site demonstration program to learn about the most effective approaches

for helping adults with SMI find and maintain competitive employment.

$15.5 million over

fiscal years 1997-

2001

Knowledge Exchange Network Uses various media to provide information about mental health to users of mental

health services, their families, the general public, policymakers, providers, and

researchers.

$9.3 million over

fiscal years 1997-

2001

National GAINS Center for

People with Co-Occurring

Disorders in the Justice

System

A partnership with the National Institute of Corrections, the Office of Justice

Programs, and the Office of Juvenile Justice and Delinquency Prevention, this

program collects information about effective mental health and substance abuse

services for people with co-occurring disorders who come in contact with the

justice system and disseminates it to states, localities, and criminal justice and

provider organizations. Its goals include assessing which services work for which

people, interpreting information, putting it into a useful form, and stimulating the

use and application of information.

$4.7 million,

including $200,000

from the

Department of

Justice, over fiscal

years 1995-2000

Center for Mental Health

Services’ Jail Diversion

Program

A nine-site program to examine the relative effectiveness of pre- and post-booking

diversion to community-based services for people with mental illness and

substance abuse disorders in the justice system.

$11 million over

fiscal years 1998-

2001

Access to Community Care

and Effective Services and

Support Program

A demonstration program that is testing the hypothesis that integrating

fragmented service systems will substantially help end homelessness among

people with SMI.

$93 million over

fiscal years 1994-

2000

Projects for Assistance in

Transition From Homelessness

Annual formula grant that provides states and territories with a flexible funding

source specifically to serve homeless individuals with SMI, including those with

substance abuse problems. The program is designed to provide services that will

enable homeless people with a mental disorder to find appropriate housing and

mental health treatment.

$31 million in fiscal

year 2000

Consumer-Operated Services

Program

Eight-site program to evaluate the extent to which services operated by people

with SMI are effective in improving outcomes of adults with SMI when used as an

adjunct to traditional mental health services.

$19.6 million over

fiscal years 1998-

2001
Page 25 GAO-01-224 Mental Health

Appendix IV

Selected Community-Based Approaches to

Treating People With Serious Mental Illness ApendxiIV

The development of varied community-based treatment models has

increased the ability to meet the complex needs of adults with SMI.

Following are descriptions of several approaches and examples of how

they are implemented in New Hampshire and Michigan.

Assertive Community

Treatment

Assertive community treatment (ACT) is designed to provide

comprehensive community-based services to people with SMI. ACT is

intended for people with the most severe and persistent illnesses, including

schizophrenia and bipolar disorders. It is also appropriate for persons who

are significantly disabled by other disorders and have not been helped by

traditional mental health services. Experts report that ACT is a good

approach for people with SMI who have recently left institutions, typically

do not schedule or keep appointments, or do not do well without a lot of

support. ACT programs use a variety of treatment and rehabilitation

practices, including medications; behaviorally oriented skill teaching; crisis

intervention; support, education, and skill teaching for family members;

supportive therapy; cognitive-behavioral therapy; group treatment; and

supported employment.

Under the ACT model, services are delivered by a mobile, multidisciplinary

treatment team. Unlike traditional case management, in which the case

manager often brokers services that others provide, the ACT staff are to

work as a team to provide services directly. These services are to be

available 24 hours a day, 365 days a year. The majority of ACT services are

to be provided in the community, including the person’s home, employment

site, or places of recreation rather than in an office setting. The treatment

team is to adapt and individually tailor interventions to meet the specific

needs of the person with SMI rather than requiring the person to adapt to

the team or the rules of a treatment program. Under the ACT model,

services are to be designed to continue indefinitely, as needed.

In order to provide the type and intensity of services required, ACT, as a

program model, has a number of staffing requirements. First, the ACT team

typically includes 10 to 12 mental health professionals, depending on the

number needed to be able to provide services around the clock. All teams

have a full-time leader or supervisor, a psychiatrist, a peer specialist, and a

program assistant. ACT programs are designed to have a ratio of no more

than 10 clients for each staff person, not counting the psychiatrist and

program assistant. As a result, the typical maximum caseload is 120 for

urban teams and 80 for rural teams.
Appendix IV

Selected Community-Based Approaches to

Treating People With Serious Mental Illness

Page 26 GAO-01-224 Mental Health

A provider we visited in New Hampshire operates three types of ACT

teams. Two of these teams, one of which works exclusively with people

who have both mental illness and a substance abuse disorder, are designed

for people with SMI who generally reject treatment and need care available

to them around the clock. These teams do not routinely operate in the

evenings or on weekends, but staff are on call at all times. People are

moved from these programs as their need for intensive services decreases,

partly because the programs are very expensive to operate. The third team

operates during normal business hours and is designed for individuals who

have been institutionalized but accept treatment and do not require 24-hour

care.

Michigan offers ACT services statewide. Its program delivers a

comprehensive set of treatment, rehabilitation, and support services to

persons with SMI through a team-based outreach approach. A provider we

visited in Michigan offers ACT services to persons who have been

repeatedly hospitalized and who have failed to become stabilized on their

medications. The provider generally does not offer ACT services until less

intensive services have been tried and have failed. After 15 years of

operation, about 65 to 70 percent of the original participants continue to

receive ACT services.

Studies have found that ACT may be associated with reduced hospital

admissions, shorter hospital stays, better social functioning, greater

housing stability, fewer days homeless, and fewer symptoms of thought

disorder and unusual activity.1 Studies have also found that ACT services

1

Anthony F. Lehman and others, “Cost Effectiveness of Assertive Community Treatment for

Homeless Persons With Severe Mental Illness,” British Journal of Psychiatry, Vol. 174 (1999),

pp. 346-52. Anthony F. Lehman and others, “A Randomized Trial of Assertive Community

Treatment for Homeless Persons with Severe Mental Illness,” presentation at the Annual

Meeting of the American Psychiatric Association (Miami, Fla.: May 1995). Gary Morse and

others, “An Experimental Comparison of Three Types of Case Management for Homeless

Mentally Ill Persons,” Psychiatric Services, Vol. 48, No. 4 (1997), pp. 497-503. Jerry Dincin

and others, “Impact of Assertive Community Treatment on the Use of State Hospital

Inpatient Bed-Days,” Hospital and Community Psychiatry, Vol. 44, No. 9 (1993), pp. 833-38.

Gary R. Bond and others, “Assertive Community Treatment for Frequent Users of

Psychiatric Hospitals in a Large City: A Controlled Study,” American Journal of Community

Psychology, Vol. 18, No. 6 (1990), pp. 865-87.
Appendix IV

Selected Community-Based Approaches to

Treating People With Serious Mental Illness

Page 27 GAO-01-224 Mental Health

cost less than other services, especially inpatient and emergency room

care.2

Supported

Employment

Supported employment is an approach to help people with SMI succeed in

regular work settings by providing them ongoing training and support as

needed. In supported employment, participants generally earn money for

their work (usually at the prevailing wage) and work as regular employees

alongside nondisabled employees (not segregated with other employees

with disabilities, either mental or physical).

Individual Placement and Support (IPS), the most studied supported

employment approach, focuses on finding adults paid work in regular work

settings and providing them training and support as long as necessary after

placement, in contrast to more traditional approaches that provide testing,

counseling, training, and trial work experiences before they seek

competitive employment. IPS focuses on integrating clinical and vocational

services, performing minimal preliminary assessments, conducting rapid

job searches, matching people with jobs of their choice, and providing

ongoing supports, such as helping with transportation or finding a

substitute for the position if the person is having trouble with illness

symptoms. Studies have found that participants in IPS programs have had

higher employment rates than people involved in traditional programs. For

example, an early study of IPS found that 56 percent of IPS participants had

competitive jobs during their first year in the program, compared with 9

percent of those who stayed in a day treatment program that emphasized

skills training groups, socialization groups, and sheltered work within the

mental health center.3

The provider we visited in New Hampshire began offering IPS in 1995

because staff found it was effective at getting persons with SMI back to

work. Further, they had earlier found that participants were not able to

apply the skills learned in the provider’s prior sheltered vocational training

program to jobs outside that sheltered environment. The provider serves

2

Anthony F. Lehman and others, “Cost Effectiveness of Assertive Community Treatment for

Homeless Persons With Severe Mental Illness.” Daniel Chandler and others, “Cost

Effectiveness of a Capitated Assertive Community Treatment Program,” Psychiatric

Rehabilitation Journal, Vol. 22, No. 4 (1999), pp. 327-36.

3

Robert E. Drake and others, “Rehabilitative Day Treatment vs. Supported Employment: I.

Vocational Outcomes,” Community Mental Health Journal, Vol. 30, No. 5 (1994), pp. 519-32.
Appendix IV

Selected Community-Based Approaches to

Treating People With Serious Mental Illness

Page 28 GAO-01-224 Mental Health

225 people at a time in its IPS program and told us that about half of those

have jobs at any given time.

Supportive Housing Supportive housing addresses the needs of people with SMI who are

homeless or at risk of becoming homeless. This approach combines

housing with access to services and supports, such as case management

services, substance abuse treatment, employment assistance, and daily

living supports. Supportive housing refers to a range of housing

interventions that can be transitional or permanent. Transitional housing is

typically group housing, where the person can live for a predetermined

period of time, with services and supports provided on-site. Permanent

supportive housing, which includes single room occupancy hotels and

apartments, has no predetermined time limits and generally includes

access to services in the community. There appears to be no single housing

model that is most effective for people with SMI. Experts have stated that

linking housing and supportive services is crucial for helping people with

SMI live independently and that, because of the varying needs of people

with SMI who are homeless, a range of housing and service options is

necessary.
Page 29 GAO-01-224 Mental Health

Appendix V

Selected HUD Programs That Can Assist

Homeless People Who Have SMI ApendxiV

a

Safe havens are designed to provide safe residences for homeless people with SMI who are

living on the street and unwilling or unable to participate in mental health or substance

abuse treatment programs or to receive support services. Safe havens are intended to reach

homeless people who are suspicious or afraid of more structured supportive housing.

Program Description Funding

Section 8 Rental Certificate and

Voucher Program

Provides rental assistance to very low-income families,

elderly persons, and disabled persons for decent, safe, and

sanitary housing in the private market.

$10 billion in fiscal year 1999

Single Room Occupancy Program Provides rental assistance to homeless individuals to obtain

permanent housing in single-room occupancy units.

$17 million in fiscal year 1999

Shelter Plus Care Provides rental assistance, together with supportive services

funded from other federal, state, local, and private sources,

to homeless people with disabilities. Program grants provide

rental assistance payments through (1) tenant-based rental

assistance, (2) sponsor-based rental assistance, (3) building

owner-based rental assistance, or (4) single room occupancy

assistance.

$152 million in fiscal year 1999

Supportive Housing Program Provides grants to states, local governmental entities, private

nonprofit organizations, and community mental health

associations to develop supportive housing and supportive

services to assist homeless persons in the transition from

homelessness and to enable them to live as independently

as possible. Program funds may provide (1) transitional

housing, (2) permanent housing for homeless persons with

disabilities, (3) supportive services for homeless persons not

living in supportive housing, (4) housing that is, or is a part of,

an innovative development of alternative methods designed

to meet the long-term needs of homeless persons, and (5)

safe havens.a

$581 million in fiscal year 1999
Page 30 GAO-01-224 Mental Health

Appendix VI

Comments From the Substance Abuse and

Mental Health Services Administration ApendxiVI
Appendix VI

Comments From the Substance Abuse and

Mental Health Services Administration

Page 31 GAO-01-224 Mental Health
Page 32 GAO-01-224 Mental Health

Appendix VII

Comments From the Health Care Financing

Administration ApendxiVI
Appendix VII

Comments From the Health Care Financing

Administration

Page 33 GAO-01-224 Mental Health
Appendix VII

Comments From the Health Care Financing

Administration

Page 34 GAO-01-224 Mental Health
Page 35 GAO-01-224 Mental Health

Appendix VIII

GAO Contact and Staff Acknowledgments ApendxiVI

GAO Contact Helene F. Toiv, (202) 512-7162

Staff

Acknowledgments

Other major contributors to this report were Renalyn Cuadro, Nila GarcesOsorio, Brenda R. James, Janina R. Johnson, Carolyn Feis Korman, and

Craig Winslow.

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