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132 let the People speak a carved-out mental health care system in the first place? Like so many things, this began as good public policy designed to accomplish something important, yet brought with it unintended negative consequences. When the Kennedy administration launched their CMHC initiative in the 1960s, it correctly recognized that the centers needed to be funded as stand-alone organizations. Why? Because otherwise funding intended for mental health services would easily migrate back into the general health care system. If community mental health services had been provided through general health clinics and hospitals in the 1960s, the effort would probably have failed because funds would inevitably end up being drawn into the organizations’ primary mission—health care. Thus the mental health care system was “carved out” as a stand-alone so that it could survive in an environment that focused on and prized general health care. The CMHCs were required by law to be separate so that they could accomplish their work and, hopefully, flourish. Unfortunately, it took decades for the centers’ planned expansion to be adequately funded so that a center would be conveniently available for every community. Even now that is not fully the case, although the vast majority of counties nationwide do have a CMHC. Yet, thankfully, the basic purpose of a carved-out mental health system was accomplished, since a separate system of mental health services is now in place. Although the current system is broken and in need of transformation, at least it exists. The carve-out worked in that it allowed for something new to become well established. Now, however, the limits of a stand-alone mental health system are showing. It is very hard to coordinate care for a person’s mental health and substance use needs with care for his or her medical needs. Yet the two are often closely related, as stated above by the Institute of Medicine. Also, it is still hard to overcome the barriers to treatment resulting from stigma that are inherent in a carve-out. Consider the case of Ed. “Ed” Ed was a young professional in the Los Angeles area who had survived a close call with pancreatic cancer three years ago. He worked for the aerospace industry and had excellent private health insurance from his employer, so when he went in for his annual physical he always got good service. This year, though, he brought a new issue to his family doctor—he seemed to be suffering from some sort of panic attacks. During the physical he told the doctor let the People speak 133 that he had had several times when his heart raced and he thought he was going to die, often had trouble sleeping, and felt generally on his guard at all times. Did this mean he had a mental disorder, or could it be something physiological? Could this perhaps be some sort of delayed reaction to the chemotherapy treatment he had endured? Ed had read something to that effect but did not know what to believe. The doctor was attentive but had little expertise in mental illness. So he recommended that they add a few more blood tests to the usual array required for annual physicals, then talk again. A week later the nurse called Ed to tell him his blood work all looked good, so the doctor recommended that he see a mental health professional. Ed asked for a specific referral but was told that he needed to contact his insurer’s vendor who handled mental health services, a different organization altogether. Ed already had mixed feelings about acknowledging that he was struggling with panic attacks, and it had taken a lot of effort just to bring it up to the doctor. Reluctantly he called the mental health vendor and scheduled an appointment. But when he drove up and found that the office was located on an out-parcel at a psychiatric hospital, he changed his mind. He turned around, went back home, and gave up on getting help. Instead, he decided to “tough it out,” which meant that he endured his panic attacks for another six months until he finally found an outpatient clinic that specialized in anxiety disorders. Had he been treated earlier, he probably would have recovered within six weeks. Instead, he endured a heavy burden that was costly on him, his family, and his co-workers. What would help? Suppose that Ed’s doctor had a mental health professional who worked with him...

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