As we reflect on 2022, we have many legislative accomplishments to celebrate and significant momentum to carry forward into 2023. Thank you to all our advocacy partners – these successes would not have been possible without your help!

We are celebrating key wins that reduced barriers to timely treatment. Treatment Advocacy Center helped pass bills that made significant improvements to civil commitment law in seven states! We engaged in the regulatory process in Maryland to establish the first-ever legal definition of “danger” for the purposes of involuntary commitment. Treatment Advocacy Center’s research was also used to inform ambitious programs in California and New York City to help those with untreated severe mental illness get treatment.  

We made progress against the discriminatory federal Medicaid Institutions for Mental Disease exclusion. A federal waiver for SMI was approved in Maryland, and steps have been taken towards securing waivers in California, Missouri and New York. Treatment Advocacy Center also supported two federal bills to repeal the IMD once and for all, and we look forward to continuing this fight in 2023. 

We advocated for critical mental health provisions in the federal budget, including the reauthorization and expansion of the assisted outpatient treatment grant program and requiring the Department of Health and Human Services to conduct a study on the cost of serious mental illness (including the costs to family members and caregivers and SMI’s effects on employment). We also made sure SMI was included in congressional discussions around priorities for the new federal agency, Advanced Research Projects Agency for Health, and will continue to do so moving forward. 

Thank you to each person who supported us in these efforts by participating in one of our advocacy campaigns. We distributed 12 action alerts, and you sent 1119 messages directly to decision makers in 2022!  

State updates

Key civil commitment bills enacted

Treatment Advocacy Center staff and our grassroots partners actively engaged in passing the following seven laws to improve civil commitment statutes and reduce barriers to treatment. 

• Alabama - HB 70 improved continuity of care in Alabama. The new law finally provided a definition for what "real and present threat of substantial harm to self or others" means, taking Alabama off the short list of states with no definition in law. HB 70 made step-down AOT more accessible to ensure robust support for those being discharged from inpatient treatment back into the community. It also included several recommended changes to both the emergency and inpatient criteria, so timely care is easier to achieve. Thank you to NAMI Alabama for collaborating with us on this effort.
• Georgia - HB 1013, a sweeping mental health reform bill, included a substantial section on civil commitment to establish a three-year AOT grant program for five sites, improve the AOT criteria by replacing the requirement that a person be determined to imminently need inpatient treatment without AOT to instead determining if outpatient treatment is needed to prevent deterioration, provide a pathway for law enforcement to detain an individual for evaluation without witnessing a crime and require important data collection.
• Kentucky - HB 127 improved Tim's Law (AOT) by broadening how a person's history of nonadherence with mental health treatment is considered, removing the requirement that a person be determined to have anosognosia, and correcting language ambiguities regarding clinical evaluations and timeframes. Thank you to Judge Stephanie Burke of Louisville for her leadership in crafting and advancing this bill that responds to specific barriers identified in AOT implementation.
• Louisiana - HB 335 added the risk of psychiatric deterioration as grounds for emergency evaluation and civil commitment. HB 335 defined "psychiatric deterioration" as a "decline in mental functioning, which diminishes the person's capacity to reason, exercise judgment, or control his behavior" and added "significant risk of psychiatric deterioration" to the definition of "gravely disabled." Thank you to Janet Hays and Healing Minds NOLA for their tireless advocacy to advance this bill.
• Maine - LD 1994 removed a unique barrier to accessing progressive treatment program, Maine's court-ordered outpatient treatment. In Maine, private hospitals, intensive case managers, ACT teams or county sheriffs must pay the legal fees to initiate a PTP petition for an individual being discharged by a private hospital. This new law created a non-lapsing fund to reimburse legal fees to initiate PTP petitions. Thank you to the National Shattering Silence Coalition for partnering with us.
• Virginia - HB 633 reorganized the mandatory outpatient treatment statute which has proven difficult for programs to implement. Treatment Advocacy Center staff have participated in an MOT stakeholder group over several years that resulted in significant substantive changes in 2021. HB 633 clarifies those changes in the statute and makes it easier to follow.
• Washington - HB 1773 simplified and improved Washington's AOT law. It extended the maximum duration of an AOT court order from 90 days to 18 months, allowed petitioning from a broader range of professionals, allowed for voluntary admissions (previously excluded) to be counted as qualifying prior hospitalizations for eligibility, and clarified procedures and uses for both AOT and "less restrictive alternative" (LRA), another form of outpatient civil commitment. Thank you to our local partners, NAMI Washington and Jerri Clark with Mothers of the Mentally Ill.

Regulatory wins: IMD waivers and defining danger 

As we continue to advocate for the federal repeal of the discriminatory IMD exclusion, Treatment Advocacy Center is working with our grassroots partners to secure state Medicaid waivers. We made progress in four states this year. 

• California - The California Department of Health Care Services released a concept paper in November detailing its intention to apply for an IMD waiver for SMI. While Treatment Advocacy Center supports California’s intention to apply, the current plan to require counties to opt in to the waiver is yet another discriminatory approach to the IMD exclusion that will select winners and losers based on their county of residence. We have sent comments to DHCS expressing this concern. If you are a California citizen, we invite you to use our form to submit your comments today!
• Maryland (2) - Treatment Advocacy Center partnered with our board member Evelyn Burton and Schizophrenia and Psychosis Action Alliance to see Maryland become the eighth state to be granted a Medicaid waiver of the discriminatory IMD exclusion in January! We will continue to engage with the Maryland Department of Health to ensure it is properly implemented. Treatment Advocacy Center also engaged with MDH’s proposed regulations to define “danger” for the purposes of involuntary commitment. Thank you to the advocates in Maryland who responded to our call to action to provide recommendations to improve the proposed definition to better serve Maryland residents with untreated SMI.
• Missouri -  The Missouri General Assembly included a provision to require MO HealthNet (Missouri's Medicaid program) to apply for the federal IMD exclusion waiver within the Department of Social Services appropriations bill (HB 3011). Treatment Advocacy Center has seen this approach successfully result in acquiring a waiver in other states, and we look forward to supporting this application.
• New York - The New York State Department of Health released a draft application for the federal IMD exclusion waiver for SMI. The state took comments in October and November and will release a final draft soon.

New initiatives to address untreated SMI

• California - SB 1338 enacted Gov. Gavin Newsom's CARE Court proposal. The program will connect a person who has a diagnosis of schizophrenia or other psychotic disorders with a court-ordered CARE plan to include comprehensive treatment, housing and supportive services for up to 12 months. Treatment Advocacy Center applauds the legislature for passing this ambitious bill to bring desperately needed treatment and services to Californians with schizophrenia and other psychotic disorders, a population that is all too often forgotten. We are thrilled that the final version of the law includes the following elements that the Treatment Advocacy Center supported as essential ingredients for the success of the program: (1) prioritizing individuals with schizophrenia and other psychotic disorders, (2) holding counties accountable and (3) giving families and loved ones access to petition courts for treatment. Read Treatment Advocacy Center's full statement on the passage of the bill for more details. Several other important bills reforming the Lanterman-Petris-Short Act and Laura's Law were also enacted in 2022. Find details in our Fall 2022 issue of SMI Advocate. 
• New York - New York City Mayor Eric Adams, in November, announced a plan to provide care for people with untreated SMI. The plan includes a legislative agenda that has been presented to the legislature. The agenda “takes aim at 11 legal barriers to psychiatric crisis care and crisis avoidance: five that prevent the timely and effective provision of hospital care, five that prevent the use of AOT with individuals stuck in the mental health system’s revolving door, and one that prevents coordination of care between inpatient and outpatient providers when patients shuttle between hospitals and the community.” Treatment Advocacy Center looks forward to working with the New York State Assembly next year as it considers solutions to barriers in civil commitment law.

Federal updates 

Federal budget: Reauthorizing the AOT grant program, ARPA-H, and an SMI cost study 

The federal budget for fiscal year 2023 was enacted on Dec. 29, 2022. The budget includes multiple Treatment Advocacy Center priorities, including reauthorizing and expanding the assisted outpatient treatment grant program and studying the cost of serious mental illness. Funding levels for the AOT grants were increased to $22 million for fiscal years 2023-2027, up from $18 million for FY 2022. The budget also requires the Department of Health and Human Services to conduct a study on the cost of serious mental illness and report the findings to Congress no later than two years after enactment. The study is to estimate the costs to both government and nongovernment across seven broad areas: the health care system, homelessness, structured residential facilities and other supportive housing, law enforcement and criminal justice system encounters, employment, family members and caregivers and other government programs and services. The study will also estimate the total number of people with serious mental illness in the U.S. and provide breakdowns of costs by types of serious mental illness, as well as certain chronic medical conditions, demographics, and type of entity (nongovernmental, Federal Government, and State, local, and Tribal governments). 

Repealing the federal IMD exclusion 

The Treatment Advocacy Center is engaging with congressional staff to further awareness around the need for a federal repeal of the IMD exclusion. Two bills were introduced in the 117th Congress, Rep. Carolyn Maloney’s (D-New York) Michelle Alyssa Go Act (HR 7803) and Rep. Grace Napolitano’s (D-California) Increasing Behavioral Health Treatment Act (HR 2611). "This discriminatory federal law denies coverage to people with severe mental illness while allowing federal Medicaid dollars to be spent on the treatment of other health conditions," said Executive Director Lisa Dailey in Congresswoman Maloney's press release.  We look forward to working with Congresswoman Napolitano and other members during the 118th Congress towards the repeal of this discriminatory law. 

Advanced Research Projects Agency for Health  

The Advanced Research Projects Agency for Health is a new agency within the U.S. Department of Health and Human Services that will "support transformative high-risk, high-reward research to drive biomedical and health breakthroughs--ranging from molecular to societal--that would provide transformative solutions for all patients." 

Within the 2023 budget legislation, Congress expressed intent for ARPA-H to invest in, "mental health research, including diagnosis and treatment of SMI to address widespread behavioral health issues to spur industry developments and new academic partnerships."

Treatment Advocacy Center successfully advocated to ensure the severe mental illness community is not left out. In an opinion piece, "ARPA-H is our moonshot for schizophrenia," Executive Director Lisa Dailey writes, "We must not accept this status quo as an inevitability: The next breakthrough in schizophrenia research is waiting for us to decide that we must find it. This is our chance."