1. Can you tell us about your organization and the political landscape that you work in? The Missouri Coalition for Community Behavioral Healthcare has been around for over 40 years and works for access to care for people with mental illness and addiction disorders. It started its mission around the community mental health center movement and the Community Mental Health Act signed by President Kennedy. Missouri was one of the first states to receive a Community Mental Health block grant and one of the last ones, too, to start a center. The Missouri political spectrum has always been fairly conservative. In the beginning, it was more Democrat conservative. But just like other parts of the country, Missouri’s ideology has shifted from a Democratic lean to a Republican lean. There is still a lot that unites the people of Missouri as the political landscape went from blue to purple to red. There are a lot of people that still care about the populations we serve; they understand the issues. There are always partisan issues that you have to navigate. We work continuously with our Republican friends in the legislature and Governor’s office on the common desire to help individuals, families, and communities impacted by mental illnesses and addictions. Medicaid expansion is a hot topic in Missouri. Is it the primary policy that the Coalition is focused on? No, we are also focused on Certified Community Behavioral Healthcare Centers (CCBHCs). We support the expansion of federally designated primary care and behavioral health clinics to enhance services and meet the needs of the community under the CCBHC and Federally Qualified Health Center (FQHC) models. Some conservative legislators believe strongly in access to care but not necessarily through Medicaid expansion; they want to focus on FQHCs and CCBHCs. We have significant allies in law enforcement, veterans’ groups, hospital physicians, and nurses who all believe people who need behavioral health care should not be in jails and should be in the community. They need to be able to access medications, evidence-based therapies, and caseworkers so they can have full lives like anyone else. We try to be nimble and flexible enough to acknowledge that there are different philosophies; these conservative legislators care a lot about the individuals that Missouri elected leaders serve and improving health care access to their constituents. Just because they believe in having a network of providers designated by the federal government as centers of excellence…what makes that any better or worse than just having Medicaid expansion? If Medicaid expansion includes a narrow list of benefits, we could run into real problems; what if there is not a robust addiction or mental health benefit? Does that mean the providers and the individuals we serve will be better off than under a CCBHC model? Maybe not. The devil is always in the details. We need to have honest and frank conversations; legislators are connected to the communities, some have only 30 or 40 thousand constituents. To think that these people don’t know what’s going on, don’t know families, just isn’t true. 2. What is the biggest challenge in working on mental health in a majority red state/blue field? We are always challenged by a culture of cutting taxes. There is a real issue in Missouri around resources. It is tough to run any business at a 1 or 2% growth rate. A 2% growth rate is approximately 180 million of revenue growth in the state’s general revenue budget. A lot of people see that as excessive. Some would like to have slow or no growth. Every year there is a push from some in the party to cut taxes fairly significantly. Some believe the philosophical argument that it will spur growth and generate more revenue; we get in disputes around that. If there is no or slow growth or negative growth in the state’s general revenue budget, money gets taken from higher education, mental health, and corrections. It’s a cut and dry issue for me when I testify on tax bills; these are the big three I mention: your law enforcement communities, your hospital emergency rooms, and your jails…they are all going to be the folks that will deal with the outcomes if you slash the mental health budget. This is the line in the sand that we have to try to balance. I draw the line in the sand there. Being a low tax, low growth state is not necessarily a bad thing at all. 3. Are there other policy examples where you have tried to find common ground? Another example is during the Medicaid expansion debate, we started developing something called the crisis prevention Medicaid waiver. It was designed around the CCBHC model. Outreach workers identified people through emergency departments or referrals from law enforcement – individuals in crisis. Sometimes the family calls and they are threatening the family, or being violent toward the family, or having some sort of crisis in their life. They are probably underinsured or don’t have a job, haven’t gotten a fully disabled determination yet…we serve a lot of those folks. As I recall, about 2/3 of people we engage with in outreach programs are uninsured. We made the argument that the state is paying for them with 100% resources or they aren’t serving them well and they are ending up in the emergency department or jails and taxpayers are paying for them in other ways. So we got a crisis prevention waiver through the budget process and we were in committee, I’ll never forget it, in heated debates about Medicaid expansion writ large. The most conservative guy in the House and Budget Committee said, “Hold on a second,” he was talking to the department that was testifying on the waiver, and he said, “This sounds to me like a mini Medicaid expansion.” Right then, I was in the audience, I thought we were dead, we’re programmed out. He just called it Medicaid expansion; they are going to cut the money, it’s dead. But then he paused and listened to the responses. He said, “I will tell you this though, this Medicaid expansion makes perfect sense to me and I support it.” And so even when lumped into this larger political debate, when you explain things in the right way for the populations we serve, typically even the most conservative members understand that jails and emergency departments are not the most efficient or fiscally smart ways of dealing with the populations we serve and they hear that from law enforcement and their local hospitals. In some ways it is rocket science: some of the evidence-based practices and advances in medicine can be quite remarkable. In general, the concepts aren’t difficult to understand or explain if approached in a reasonable way. 4. Mental health crosses political lines; it’s everyone’s issue. It seems that often the solutions turn automatically to the government’s role. Do your members generally align with this or how do your members try different approaches? Any public/private ventures or anything you have found to be unique in Missouri? We have a few unique features in our system. There are local tax options, where you can have local resources as well as state Medicaid and other resources. In at least a dozen or more counties, we have 115 counties, so in a good 20, there are some local resources for youth mental health needs or adult mental health needs. We had a budget chairman, Rick Stream, a Republican from the St. Louis area, talking to one of my providers. We were explaining how we are funded, that all CCBHCs are not for profit, they are led by boards/community leaders: folks in the banking industry, folks in health care, local government, police chiefs, obviously other community leaders. And there’s lots of local fundraising that is done: Dancing with the Stars, golf tournaments, fishing tournaments. We have all these things that we use to try to raise money and that budget chairman told my CEO, “you guys really are the perfect example of what care should look like…there’s a role for government but there’s a role for the community – the local community and local taxpayers.” To bring that all together – corporate private support and fundraising, partnerships, along with the federal, state, and local government – to serve the community is a really niche approach if you can get all those partners lined up. And that really is the way our system has developed. 5. The more involved communities are, the better: people like to be involved with the people around them, they want to help the people they know. How does this play out in your work? In our space/our world, for so long, we’ve had the stigma surrounding mental health. There’s the example of cancer and breast cancer. They were hush for years, but now they are discussed openly. Mental health isn’t there yet, but we are starting down that path, connecting the mind and body and not separating them. As we do that, community mental health centers (CMHCs) are becoming more a part of the community. We don’t advertise. We’re not like a hospital that puts up a billboard: “Hey come to this emergency department, get the best care in the world.” We’re a hidden secret…but if you are in crisis, somebody in the community or law enforcement or the hospital is going to tell you about us. It’s been a little fun to see that start to change in Missouri. The big thing about CCBHCs is about access, but how do you serve your community if no one knows you are there? This is part of the health care space we’ve not really been engaged in and that’s starting to change now. It will be fascinating to see how that community partnership concept changes with the change in the environment with CCBHC and access-oriented measures. We hope stigma reduces and resources go up. If that does happen across the country, which we hope it does with CCBHCs, maybe we’ll get some real changes. The advertising is [being explored by] one of the agencies that are using CCBHC and the resources for that that can be put into the cost of care and no one has ever thought about how to engage our community. That’s never been part of a budget, so that’s fascinating to see how people use resources to serve their community. It’s a fundamental shift; it will be fascinating to see how that goes. 6. How have you successfully engaged Republicans in mental health issues? In dealing with Republicans it’s a fallacy to believe that they don’t care about individuals’ health or in wellness; they just may have a disagreement in how it can be done. You have to make sure you’re nimble enough to understand that and provide solutions that might be a little different. One important approach in all this is we know that individuals with mental health are much more likely to be victims of crime than perpetrators of crime but it’s also very real that when families are in crisis they often have to call law enforcement. So having that law enforcement perspective on these issues is really important. That’s a huge part of the Republican party; the support of the law enforcement community, making sure they have the resources they need. Another great example: Michael Parson, the Governor of Missouri, is the former Sheriff of Polk County. He was at a meeting with us in St. Joseph, MO. The Buchanan County Sheriff was talking about CCBHCs and said I don’t know what that acronym even means but I know I like it and I sure do wish you’d keep supporting it because ever since that thing came about I now have a mental health professional in my jail. It used to be I’d send someone every day if not twice a day to the local hospital. It would take one or two of my deputies and a jailer to get them there. They’d be tying up the hospital system and then I’d have to get them back to the jail. I bet I don’t send one a month or every three months to the ER that they can’t handle right there. So, it’s saving my deputies time, my jailers time. I don’t have transportation or safety issues with my staff. When you get a Sheriff to talk about it that way, it’s a win. The Governor understood as a former Sheriff; he got that completely. When there are other Republican legislators in the audience that’s a big deal. When you can bring that kind of community-based approach to this, and help them understand in that way, now that’s not a Democrat or a Republican issue, that’s smart health care and safety issue. Also know there are terrible results when folks aren’t trained to deal with individuals with mental health. Look at law enforcement, if they don’t have the training they need and respond to a crisis, don’t know how to de-escalate and misunderstand what’s happening, that can lead to terrible outcomes. We come at it from different ways, but the ends are not mutually exclusive.