All things being equal, Bob Keenan is a man who prefers to have government stay out of the way and let private enterprise tackle the tough societal jobs. As a restaurant owner in Big Fork, Montana, he's always chafed at bureaucratic red tape: He calls federal health inspectors the "food safety gestapo." As a Republican state legislator, he's opposed the Children's Health Insurance Program and crusaded against federal interference with local school policy. He schools his own children at home. "The federal government," he once said, "has no right to be involved with education."
Of all the Montana Senate's 50 members, Keenan might seem the least likely to turn consumer advocate and declare war on an attempt to privatize a major social service. But when the legislature met for its regular session last year, he felt he had no choice. Montana's privatized mental health system, a managed-care scheme inaugurated in 1997 to save money and improve efficiency, had turned into a disaster. The contractor, Magellan Health Services, wasn't paying claims on time, wasn't reimbursing some providers at all and was losing a million dollars a month. It was planning a drastic cutback in patient eligibility. "As a businessman," Keenan says, "I had to look at the way they were managing this."
Many liberal Democrats had complained from the very beginning that privatizing mental health services was a bad idea. But it was Keenan's decision to join them that ultimately did the plan in. Last spring, Keenan cast the deciding Senate vote in favor of canceling the state's five-year, $40 million contract with Magellan. He sponsored a bill creating a Mental Health Advisory Council to figure out how to handle mental health needs, especially for poor people, in the long run. That council is now in the midst of its deliberations--and Keenan is the chairman.
For the moment, there is no crisis. The failed experiment is over, the state Human Services Department is insuring Magellan's previous clients on a traditional fee-for-service basis, and there is enough money in the treasury to pay the bills for the foreseeable future. But few see the current arrangement as more than a stopgap, so it is up to Keenan and his council to decide what comes next. The legislature does not meet in regular session again until 2001, so they have a full year to prepare their recommendations.
One move that will not be made is a return to full-scale managed care. The 1997 effort was the single largest mental health privatization in U.S. history, and there is consensus now that it was simply too massive and sprawling to work effectively. It was also fiscally questionable: The contract provided subsidized coverage to all Montanans earning less than 200 percent of the poverty rate, a threshold that potentially included more than one-third of the population. Many believe a different private vendor with a different contract might have succeeded, but no one seems interested in proving that now. The more likely next step is limited managed-care arrangements for specific areas of treatment, such as substance abuse, but with a carefully monitored fee-for-service operation remaining in place.
Whatever the ultimate choice is, Bob Keenan's political life will never be quite the same. Two years ago, he claimed no particular expertise in mental health; now he is the state's point man on the subject. In fact, he has evolved into something of a crusader, treating the advisory council and its duties as a "passion of mine" and a long-term moral commitment. He has concluded, reluctantly, that whatever the desirability of private solutions may be in theory, mental illness is not a problem that government can simply walk away from.
Some of Keenan's conservative allies worry that he has gone a little soft on social policy; some on the other side, though, seem pleasantly shocked. "I envisioned this bull in a china shop, to the right of Attila the Hun," says veteran Democratic Senator Mignon Waterman. "It didn't work out that way."