The landmark 1999 United States Supreme Court case, Olmstead vs. L.C., established that the Americans with Disabilities Act applies to people with mental illness. In 2011, the United States Department of Justice (DOJ) conducted an in-depth investigation of Mississippi’s mental health system and found that Mississippians with mental illness were not able to live in the community if they wanted to due to a lack of the right kinds of services. This is considered a violation of the Americans with Disabilities Act because it can result in unnecessary segregation in institutions.
The State of Mississippi engaged in negotiations with the DOJ until the negotiations failed and were terminated in 2015. The DOJ sued Mississippi over its mental health system in 2016. The case went to trial in June 2019, and in September 2019, Judge Carlton Reeves ruled that Mississippi’s mental health system discriminates against people with mental illness by unlawfully segregating them in institutions because the right kinds of services to help people live in the community do not exist to the extent needed.
A Special Master with expertise in community-based care, Dr. Michael Hogan, was appointed in February 2020 to help the two sides craft a mutually agreed upon remedy. The parties were unable to reach consensus. Both the United States and the State of Mississippi were then ordered by Judge Reeves to propose remedial plans, and on June 3 Dr. Hogan submitted his recommendations for which plan the Court should adopt.
Dr. Hogan shares in his report that the United States’ and Mississippi’s plans are similar and both are acceptable. He then recommends the State’s plan, other than for supported employment services. He adds public input opportunities, data reporting and independent monitoring as requirements for the State’s plan. Judge Reeves will hold a hearing on the plans on July 12 at 9 AM. The hearing is open to the public. A final ruling will come from Judge Reeves sometime after the hearing.
Why does this matter? All of us likely know or are aware of someone who is affected by serious and persistent mental illness. We may be that person. If this lawsuit remedy is implemented in the way it should be, more people with mental illness will be able to live and work in the community. They will receive intensive services delivered in places convenient to them. Help will be available during crises. Hospitals and community providers will coordinate with each other and with people receiving services. Approaches such as supported employment and supported housing that have been shown to help people live in the community are included in this plan.
In other words, Mississippi’s system will move closer to helping people with mental illness do the same things that all people like to do – work, go to school, be part of the community and have meaningful relationships with friends and family.
In order for Mississippi’s system to be reformed in reality and not just on paper, citizens should expect and demand the same requirements for this remedy and its implementation that Dr. Hogan outlines: public input, data reporting and independent monitoring.
Public Input: There have been very limited opportunities for public input into this lawsuit for the past 10 years. In 2015 the State of Mississippi was required by the DOJ to obtain independent assessments of its mental health system as a condition of not getting sued at that time. The reports, which included feedback about how people actually experience the system, could have been used as settlement terms. Rather than use the reports to avoid being sued or use the feedback to improve Mississippi’s mental health system, the State fought in court for two years to keep the contents of the reports a secret and continued to fight the admission of the reports into evidence at the trial. During the course of his work, Dr. Hogan requested to be able to speak with system providers and organizations that are made up of people receiving services (page 10) , but the State opposed his request. We must demand greater transparency going forward.
It is especially important that people receiving mental health services and their families have opportunities to give input. They know better than anyone what will help them. Only one person who manages a mental illness testified at the trial. At times the defense appeared to try to both patronize and intimidate her, but she remained unflappable as she described the barriers and deficits in the system. Judge Reeves’ ruling begins with her words, and he describes her words as giving him clarity. The system needs that clarity too, and it will not have it until people receiving services and their families are partners at decision-making tables.
Data Reporting: The Department of Mental Health’s Olmstead page lists services that have been added and information about how many people have received housing and become employed. Dr. Hogan’s recommendations include more detailed reporting and holds the Department of Mental Health accountable for ensuring that services occur, that the community mental health centers have the support and training that they need to deliver the services and that care between the hospital system and the community is coordinated.
Although Dr. Hogan’s report does not directly address an accountable framework for Mississippi’s mental health system, his recommendations should help the system move in a more accountable direction. There is not an overarching authority in Mississippi to coordinate the Department of Mental Health, the Division of Medicaid, managed care organizations and community providers.
In other states, the Division of Medicaid and the mental health authority typically answer to the same entity (usually a larger super-agency or the governor), thus increasing the likelihood of coordination. Mississippi is one of only two states in which the Department of Mental Health is a free-standing state agency overseen by a board. The Division of Medicaid reports directly to the governor. Working through the reforms indicated by this remedy may provide a path to better coordination or reveal a more effective model than the current one.
Independent Monitoring: Courts typically appoint independent monitors to oversee lawsuit remedies. The State of Mississippi has repeatedly indicated that it will not submit to independent monitoring and will appeal the verdict if a monitor is assigned to the case. It will be interesting, and possibly speak volumes, if the State continues to take that stance if it is simply required to be monitored as it to implements its own proposed plan.
As noted, this case, and perhaps the mental health system at large, would benefit from greater transparency. Independent monitoring with public reporting would increase transparency and create an environment to better address some of the challenges and potential conflicts of interest underlying Mississippi’s mental health system.
One of the greatest challenges to moving toward a more robust community-based mental health system is that the Department of Mental Health remains the largest state employer and most of its employees work in one of the department’s 12 state-run facilities (people working in community mental health centers are not employed by the Department). Although the department has greatly reduced the number of people it employs, it still has 5000 employees, the same number as the Department of Mental Health in Georgia, a state with over three times the population of Mississippi.
Mississippi’s mental health system stands on the cusp of reform that could make a significant improvement in the lives of many of its citizens with mental illness. We must demand that our state makes the most of this opportunity and be accountable to citizens, especially those with mental illness, as it does so.
Joy Hogge is executive directors of Families as Allies, the only family-run statewide organization for parents and caregivers of children with mental health challenges in Mississippi.