As you know, our state is woefully short of the amount it takes to carry out our basic functions, and legislators have been acting like teenagers about it—shrugging their shoulders, rolling their eyes and saying “oh well!”’. Many of the shortfalls will not show up in immediate damage. Inadequately funded schools will result in a poorly prepared workforce, and proration to universities will eventually limit quality to the point our students invest tuition money elsewhere. Loss of support for Medicaid and AllKids could result in poorer child health (and yes, even death from conditions not treated in time), but this could take months to show up.
The delayed nature of these consequences allows legislators to get away with it, for awhile. One program on their hit list, the Department of Mental Health (DMH), could prove the exception to that rule.
Our DMH funds three basic divisions—Developmental Disabilities (formerly called mental retardation), Substance Abuse, and Mental Illness. In the planned budget, mental illnesses will take the entire cut to the department. I am told that this is likely because the opposition to cuts for developmental disabilities would be too heavy, in the form of service mandates, lobbying groups, and potential lawsuits. Addiction treatment is so minimally funded that there is nothing left to cut anyway. So that leaves mental illness.
I would not want to be Zelia Baugh, our state’s mental health commissioner. She has an impossible task. The DMH pays out funds two ways, for operations, including at state owned facilities serving those who are committed by probate courts or criminally committed, and for contracted services by county mental health centers (MHCs). The MHC’s also bring in money from private insurance payments and sliding scale payments by patients, but they are heavily dependent on the DMH money.
Baugh had a choice between cutting payment to the MHCs, already running on less than they need, and cutting payment to the state facilities, also underfunded, or both. If she had cut MHC money, the centers would have had to let large numbers of staff go. Patients would have to wait significantly longer than they already do, and for some of the most fragile patients who had barely been managing in the outpatient setting, the loss of access would have caused rapid increase of hospitalization and civil commitment.
The state facilities probably could not have been funded less and still stayed in operation. So Baugh, under the gun, decided the only option was to close the state facilities almost completely. The patients formerly at Taylor Hardin, for the criminally committed, will move to the new Bryce. Mary Starke Harper in Tuscaloosa, the hospital for geriatric patients, will remain open because it is funded with Medicare money. Everything else will close.
DMH plans to transfer care of committed patients to local facilities, as part of an overall strategy to integrate persons with SMI into their communities. This could be a great plan for many patients, but for some it is unrealistic—I’ll cover the “philosophy” aspect in a later post. So where are these local facilities?
Ah, there’s the rub! There are no such creatures. All over the state, MHC’s are scrambling to figure out what to do. I am the secretary of our Huntsville chapter of NAMI (National Alliance on Mental Illness)—NAMI is an advocacy and support organization for families of persons with SMI. We are not opposed to more community care. We just want to be sure it gets done correctly.
I met with Brian Davis, the director of the Madison County MHC, along with several NAMI members and board members, this past Thursday evening. Brian kindly spent 1.5 hours answering our questions and explaining what our MHC is trying to do. I’ll cover other community services later, but for patients newly committed to hospital care, he has asked for funding to run a 16 bed crisis unit (more than 16 beds would disqualify them from billing Medicaid). If the adjacent counties also get the beds they’ve requested, there will be an equal or greater capacity than we previously had at NARH for our area.
He has submitted a budget request to DMH, but unfortunately he will not have any real idea of the planned funding for several weeks. The state hospital in our area, North Alabama Regional Hospital, is projected to close along with the others at the end of September (because of the fiscal year), and that would be hard enough—but NARH plans to close to new civil commitments as of July 1. That means he must locate a suitable building, renovate it, staff it, and be ready to go in less than 4 months. He can’t start until he knows about the money, so make that less than 3 months.
To compound matters, he expects DMH money to only apply to operations for the crisis unit—it won’t cover capital. So he will have to get a loan for our MHC. He will have to locate a suitable building (not time to actually do new construction), purchase it in the face of the usual NIMBY outcry, and do extensive renovations. Patients aren’t committed here unless they are considered a real threat to themselves or others—that means he will have to replace all the window glass and install “crash bars.” He will have to get safe furnishings. Even details like the showers have to be right—otherwise patients could hang themselves on the shower bars.
Are you getting the picture? Do you think there is any way in heck all these tasks can be completed by July 1, or even September 30? I sure don’t.
I asked Brian what it would take to do this right. He told us he would need twice the expected money and three times the time. If he had that, he said, he could do a GOOD job for us, and the outcome would be improved services for persons with SMI. Money buys time, so that’s our first priority.
Back to the consequences of failing to be ready for this transition. It might help to look at other states that cut services. It is a grim picture. Most mentally ill patients who kill or hurt people target themselves, not others—we can expect an immediate increase in death by suicide. For those who do attack others, it is usually a care-giving family member who gets hurt or killed—the same family members struggling desperately to make up the gap in state services. Speaking as one of these family members, I can tell you I am more afraid of what the state would likely do to my loved one—execution—than I am of dying myself. But given the high frequency of SMI, we should also anticipate the rarer public violence to increase.
We will pay, one way or the other—in money or in death.
I know I’ve asked for a lot of action on your part this year. I hate to constantly have to tell you the sky is about to fall or that the alert level is red! But it’s just that way. You, my friends, are holding up our sky.
Many of our fellow Alabamians with SMI can do well with proper treatment, but their mental health is very, very fragile. A disruption in service can send an apparently stable person over the edge in a matter of days. We will see disaster not in years, as for education, or months, as for Medicaid, but DAYS. I’m not saying we should pass the planned cuts to those other programs—we should not. We should tell our legislators to do their jobs and come up with the money, no matter what campaign pledges they have to break. Otherwise Alabama will go down like the Titanic, with our statehouse playing the no-taxes violin on deck while we prepare to drown.
Your efforts so far have been productive. The sneaky planned privatization of Medicaid, initially termed a “done deal”, has at least for now been slowed down. The attack on women’s health services in the form of SB 12 has been met with such loud public outcry that the bill sponsor is backing down. Keep pressure on—it works! Tell our legislature to give the MHC’s money so they can buy time to do this right. I’ll post a separate list of talking points for my county—please help NAMI Alabama add to it by investigating plans in your area.
Efforts are already in place by NAMI chapters in our state and NAMI Alabama, but family members burdened with providing in-the-trenches care to their loved ones can’t do it alone. We are all affected by the mental health of our state. Get in there and fight with us, shoulder to shoulder!