The New Hampshire government subsidizes mental health care by funding some outpatient and inpatient mental health services.
The state recently increased that funding thanks to a 2014 lawsuit, which found that New Hampshire needed to do more to keep mental health patients out of hospitals, instead treating them within a community care setting.
Outpatient Care in NH
Community mental health centers
New Hampshire provides funding for ten not-for-profit community mental health centers. This funding allows the centers to take on any patient in their area who needs help, regardless of his or her ability to pay.
The centers will bill patients who have insurance coverage, whether through a private insurer, Medicaid, or Medicare, but can use a sliding fee scale for uninsured or underinsured patients.
Even when these centers can bill an insurer, the rates at which they’re reimbursed for these services don’t completely cover costs. The funding the state provides—using a combination of state money and federal grants—is what enables them to keep their doors open.
Legal troubles and impact on funding
A large part of New Hampshire’s outpatient mental health funding is dictated by the terms of a 2014 settlement agreement. That lawsuit argued that New Hampshire violated federal laws – particularly the Americans with Disabilities Act – by failing to provide adequate mental health services in a community setting and instead relying too much on housing citizens with mental illness in hospitals.
Under the terms of the 2014 lawsuit settlement, New Hampshire had to provide funding to expand community mental health treatment as follows:
- Develop Assertive Community Treatment (ACT) – teams that can provide regular services out in the community – to serve up to 1,500 individuals with mental illness
- Develop mobile crisis services – teams that can visit a patient in crisis and provide services – in Concord, Manchester, and Nashua
- Expand supported employment opportunities, which help individuals with mental illness find and keep employment
- Expand supported housing, such as group homes and rental subsidies
- Develop transition plans for residents of Glencliff Home and New Hampshire Hospital to move to community settings
As of the end of the 2017 fiscal year, an independent evaluator concluded that New Hampshire was meeting most of these requirements. However, the evaluator noted that ACT teams were understaffed according to the terms of the agreement. The state Department of Health and Human Services disagrees with that claim.
In addition to outpatient, community-based mental health treatment, the state provides inpatient treatment for individuals with severe mental illness at New Hampshire Hospital. There are also some patients living long-term at Glencliff Home, although the state is working to move those individuals back into the community.
A long waitlist at New Hampshire Hospital was one reason for the 2014 lawsuit against New Hampshire – but so far increasing community-based treatment has not decreased demand for inpatient services.
At the time of the lawsuit settlement in 2014, on any given day an average of 24 adults were waiting in hospital hallways and emergency rooms for a bed at New Hampshire Hospital. In 2016 the average was over 30. On August 21, 2017 there were a record 72 people waiting for beds at the state hospital.
Some of this increase is due to private hospitals around the state closing their inpatient mental health facilities. The opioid addiction crisis has also placed more strain on the health care system overall.
Recent state budgets have attemped to address the waitlist issue by funding more mental health beds at hospitals. The state is also moving kids out of New Hampshire Hospital to a new facility, repurposing that space to accomodate more adult patients.
Patients in prison?
New Hampshire Hospital has also faced criticism for its lack of a secure psychiatric unit. In New Hampshire, an individual with mental illness who “present[s] a serious likelihood of danger to himself or to others” may be committed to the Secure Psychiatric Unit in the state prison without committing a crime.
New Hampshire is starting work on a new 25-bed secure forensic hospital in 2020. Patients currently housed in the SPU will be moved to this new facility as soon as it is operational.
Insurance coverage for mental health treatment
A state law passed in 1994 requires insurers in New Hampshire to cover mental health treatment. The federal Affordable Care Act also requires any insurer offering a plan on the health insurance exchange to cover mental health services.
Furthermore, state and federal laws require any insurer that covers mental health services to cover those services and other physical health services in about the same way. For example, insurers cannot require a much higher copay for a visit to a psychologist than for a visit to a primary care physician.
However, New Hampshire has not increased its Medicaid reimbursement rate for mental health services since 2006. Many insurers also offer mental health providers low reimbursement rates. These low reimbursement rates are a financial challenge for mental health professionals, and contribute to a shortage of mental health professionals in the Granite State. According to the U.S. Department of Health and Human Services, there are shortages of mental health care professionals in every New Hampshire county except Cheshire. New Hampshire lawmakers responded to this problem in 2019 by adding an 8% increase in Medicaid rates for mental health and substance abuse services to the 2020-2021 budget. Those rates will take effect in January 2020.
“New Hampshire should increase funding for mental health.”
- According to the Treatment Advocacy Center, states should provide a minimum of 50 hospital beds per 100,000 people for patients with severe mental illness. New Hampshire only provides 12 beds per 100,000 people. The state needs to dramatically increase the number of inpatient beds to meet minimum standards for Granite Staters in crisis.
- The number of individuals waiting for a bed at New Hampshire Hospital has more than doubled in just a few years. This rapid increase indicates a failure to meet the needs of citizens with mental illness before they reach a crisis point.
- According to the latest data from Mental Health America, roughly 1 out of 5 adults with mental illness in New Hampshire report they are not able to get the treatment they need. This lack of treatment is due to high costs for treatment as well as a lack of available treatment providers. While other states have even worse access to mental health treatment, it is still unacceptable to leave one-fifth of residents without treatment.
- According to the Centers for Disease Control and Prevention, New Hampshire has the highest suicide rate in New England, and the 18th highest rate in the United States.
- New Hampshire’s practice of housing some patients in the Secure Psychiatric Unit of the state prison is unethical and potentially violates federal laws. New Hampshire needs to fund a Secure Psychiatric Unit at the state hospital or contract with an appropriate mental health facility out-of-state.
“New Hampshire should not increase funding for mental health.”
- New Hampshire is on track to meet every requirement of the 2014 lawsuit settlement, and the 2018-2019 state budget actually adds mental health treatment services above and beyond what the settlement requires.
- While Mental Health America reports that roughly 1 out of 5 adults with mental illness in New Hampshire are not able to get the treatment they need, this statistic may not be as bad as it seems. According to the same report, in 2014 New Hampshire ranked sixth in the nation for access to mental health treatment. That ranking included nine measures of access, from the percentage of adults with mental illness receiving treatment to the size of the mental health workforce.
- According to the Henry J. Kaiser Foundation, in fiscal year 2013 – before the lawsuit required New Hampshire to increase spending on community mental health treatment – New Hampshire ranked 16th among states for per capita spending on mental health services, well above average. Since then New Hampshire has more than doubled state funding for community mental health services.
- Additional state spending on mental health services will not address the shortage of mental health professionals in the state. If the state wants to strengthen its mental health care workforce, it should instead invest in programs that encourage university students to prepare for careers in mental health.