Category Archives: Alabama legislative session 2012

Learn Something Every Day—Lessons from Alabama’s 2012 Legislative Session

I’m a big believer in the importance of continuous learning—every day, at least one thing new, and usually several.  During this just-finished Legislative Session, to rephrase Lewis Carroll, I’ve learned far more than 6 impossible things before breakfast!   Those of us who have engaged deeply in following and struggling with the menu of bills have formed new and surprising coalitions, especially among women.  Turns out conservative and progressive women alike don’t cotton to having the government up in our uteri. We managed to make enough noise to hold off a fair amount of damage.  Yay, us!


Advocates protested a deadly plan to close state mental hospitals with no good safety net in place and were at least partly successful.  We may have saved Medicaid (stay tuned), and thus our entire state healthcare system, from collapse.  Not everything went the way we wanted it, but a lot did.  It’s important to take some time to notice that speaking up does make a difference.


I also had a personal lesson or two that forced me to reevaluate my role doing this blog.  When I started it a couple of years ago, my main purpose was (and is) to advocate for single payer, Medicare for All, in our country.  I’ve branched out into other areas that sometimes seem far afield, but they aren’t really—everything winds up connected to the whole of healthcare reform.  We need to understand how reproductive rights work, for instance, and how to protect them, in order to make any national insurance system a good one.  We need to understand how our current Medicaid systems work, and what would happen if they dissolved, to see how intrinsically the healthcare fates of the rich and the poor are intertwined.  And we need to ponder carefully the difference between legislation of insurance coverage (good) and legislation of specific medical protocol (bad), so that we don’t make similar mistakes on a national level.


At the beginning, I did not consider myself a journalist—just an activist blogger.  If you read the comments in the dictionary link I just gave, you will notice a certain contempt towards bloggers from some journalists.  A surprising thing happened this spring that made me wonder what journalism really is.  I ran smack up against a conflict of interest that prevented me from writing about some topics.  My reaction, not necessarily the conflict, was what surprised me—I was unexpectedly distressed, to the point I got a bit of writer’s block.  There were things I wanted so much to say to you, and I could not do it.  I had to shut my trap.


It felt like a betrayal, as if I had abandoned my duty.  I had come to see the blogging as a sort of ministry.   The trigger for my “gag request”—it was a kind request and not an order—was the piece I wrote describing first-hand a meeting with several of our state legislators.  I had never imagined so many people would read and share that post, based on my previous numbers.  Apparently it caused a fair amount of anger, and not just towards me but towards the category of pediatricians in general.  I was told the biggest problem was that the specific individuals I named were not the ones behind the proposed gutting of Medicaid and were actually trying to help us.  I was told by one person that “your name has become synonymous with the negativity about that meeting.” I was asked very nicely by smart people to please hush up on some topics for the rest of the session.  I did, mostly.


Even though I clearly stated in the post that it was my own report and opinion, independent of any organized group or board, some readers took my words to be representative of state pediatricians.  I doubt it would have mattered if I were not a dues-paying member of our state AAP (American Academy of Pediatrics) chapter—the fact remains that I am a pediatrician. It’s such an integral part of my identity that my family has been known to call out “Dr. Abston” in a crowd when I didn’t turn my head to “Mom” or “Pippa”.   I never pretended to be unbiased about that—if I’m a journalist at all, I’m a very amateur citizen journalist in the advocacy journalist genre.  But I had not expected my identity to present such a challenge.


For awhile I wished I had done the blog anonymously.  I use my real name for several reasons, the main one being that it forces me to be fully accountable for what I say.  I even thought about starting a new blog, under an alias, to say the things I can’t say as myself.  But I decided that would be a mistake.  


Professional journalists have specific ethics and employment rules meant to prevent such conflicts of interest.  Here’s a list from the New York Times—scroll down to the part that talks about community involvement.  If I wrote for NYT, I’d have to drop my membership in the AAP, NAMI, PNHP and several other organizations.  Does that work?  Is it really possible to report in a neutral manner?  I suspect not, because humans just aren’t like that.  I’d almost rather our news people go ahead and spit it out—“I’m a Democrat”, “I’m a member of the NRA”, “I donate to Politician X’s campaign”—so we would know where they stand and where they might be inclined to both bias and self-censorship.


So here’s the deal:  I’m biased.  So are you.  I’m part of groups who care about several different things, and sometimes those interests will collide.  I’m not going to go undercover, but sometimes I will have to keep silence even when it makes me feel like I’m going to pop.  I’ll ask advance forgiveness of various affiliations for my loose cannon nature, because I’m sure it’s not the last time I will inadvertently cause trouble.  I’m just like everybody else, a hot mess of a human, and I’m not going to pretend otherwise.  Maybe next year I’ll try parachute journalism.


Filed under Alabama legislative session 2012, citizen responsibility

Seven Days and a Pinch of Hope

As I write this evening, I am keenly aware of the seven legislative days Alabama has left in our regular session.  So much is left to decide, especially about the budget.  I hope you are also alert and continuing to make contact with our state senators, representatives and Governor.  It puts me in mind of watching a storm front approach and expecting a tornado watch—we hope it will dissipate into nothing much, leaving no paths of hurt and hardship across our beautiful state.  What will it be?  Seven days of creation—creation of new revenue and hope for our future?  Or seven days of destruction?


Searching for inspiration, I’ve started to read “The Impossible Will Take A Little While: a Citizen’s Guide to Hope in a Time of Fear” by Paul Loeb.  The title comes from a lyric in a Billie Holiday song.  I’m only at the beginning—I usually plow through a book in no time flat, but I plan to draw this one out.  In the opening, the author recounts how a group of women at a peace gathering in the rain were disappointed at the small turnout, only to learn later that Dr. Benjamin Spock had seen them and was inspired by their determination, their standing in the rain, to speak out himself against the Vietnam War.


Are you a bit weary of fighting or verging on despair at what’s happening in Montgomery?  If so, maybe we can take a moment to encourage each other, at the verge of this somewhat Biblical-feeling seven days.  If you have a small and hopeful story to share, please add it to the comments for this post.


Here’s mine.  Two days ago, my last patient of the afternoon had an eye injury.  It’s the Murphy’s Law of Friday in pediatrics—the child who needs the most urgent evaluation requiring more than just a history and physical always comes last, and we go into mad scramble mode trying to line things up.  I hate to send kids to the ER just because it’s Friday afternoon. 


I examined the child and found a significant looking injury to the central cornea—because of the mechanism, I was really concerned that eye drops and reassurance might not be enough.  I crossed my fingers and phoned the ophthalmologist on call.  Her nurse relayed Q &A back and forth between us—she wanted to know the age of the child, whether he could cooperate with an exam and whether he had any other injuries besides the eye.  Then the nurse said those blessed words every pediatrician longs for—“send him straight over to the office and we’ll take care of it.” I told the nurse to please give her boss a big hug from me and tell her we were grateful for her kindness.


It was only after I had given the mom instructions on how to get to the office and she had left that I realized there was one question the ophthalmologist hadn’t asked.  Do you know?  Try to think before you go down a paragraph, and don’t cheat.


The question she did not ask me was the question consultants ALWAYS ask me, occasionally even before deciding when/ where to see a patient:  “What insurance does he have?”


I asked our staff to fax the insurance referral so the consultant could get paid, and then I sat and smiled for a few minutes before typing his chart note.  She didn’t ask!  At that moment, late on a Friday afternoon when she probably was hoping to go home for dinner with her family, all she wanted to know was whether he could be still for an exam without ER sedation. 


And that is how it should be, isn’t it? No wallet or insurance card biopsy needed.  Just children, parents, and doctors, figuring out how to do the right thing.  


Filed under Alabama legislative session 2012, Children's Issues, Motivation

On the Legislation of Conscience

Among the several bills pending Alabama legislative action this spring, I am sorry to say our state has decided to extend its long arm into the realm of conscience.  There are two bills pending, SB 105 and HB 375, titled Health Care Rights of Conscience.  If you live here, you need to know about them in detail—please read for yourself. 

Conscience is no small matter—without conscience, we become sociopaths.  We’ve learned the hard way in history how blind allegiance to any authority can lead to tragedy.  The exercise of individual conscience through civil disobedience is a vital protection in democracy against a majority gone wrong.  Without bravery like that of Rosa Parks, evil laws can be hard to change by ordinary channels. 

The problem is that consciences differ between persons, sometimes wildly.  If that were not the case, we would have no need of law at all, nor police nor courts.  These are all required to protect us, by mutual consent, from the failure of individual conscience.  If Rosa Parks had done something different—if she had used her personal conscience to rob someone of money she thought they didn’t deserve to have—she would have been rightly arrested and would not have inspired social change.  That is why people who choose to perform civil disobedience must expect arrest—their acts are not meant to ignore the law but to expose it for examination.

 SB 105 and HB 375 seek to override critical citizen protections by allowing individual conscience to run amok, without the restraint of social or professional ethics.

These bills say the State must protect the right of conscience for individuals who provide health care services related to abortion, human cloning, human embryonic stem cell research and sterilization.  They say nothing whatsoever about the State’s obligation to protect patients from medical care below the established standard in our profession or to allow employers the ordinary freedom to hire people who can and will do the work required by a specific job description.

It is odd that basic science research has been mixed with regular patient services in the same bill. I can’t tell you the last time my boss ordered me to go down the hall and clone a human or do something with a stem cell, between treating children for asthma and ear infections.  If he did, I’d have no clue how to proceed.  People don’t accidentally go into training to clone humans or stem cells.  But if these bills pass, a researcher who studies human cloning will have to consider hiring a lab assistant who refuses to do the assigned work on equal footing with one who will do it. 

Under these bills, a healthcare provider is allowed to omit all types of counseling and advice for these particular services.  For cloning and stem cell research, this would imply the researchers no longer have to get consent using the IRB (Institutional Review Board) protocols meant to protect us from unethical research, as long as they say doing so would violate their conscience.  They would be free to collect our cells for these purposes without even asking us.  Bet the bill drafters didn’t realize this!

A doctor could sterilize a man or woman without getting informed consent, because the wording allows any part of a service related to sterilization to be omitted.  That’s as long as it is not because the doctor thinks the patient is less valuable due to being elderly, disabled or terminally ill.  The language leaves it open for docs to practice eugenics by sterilizing a smoker, an obese person or a conservative without consent.

A doctor could perform an abortion on a woman without getting informed consent.  That’s right—bills that were designed to limit access to abortion would allow them to be performed without counseling.  On the bright side, at least the doctor could omit the medically unneeded ultrasound and state-mandated but incorrect written information (except in abortion clinics, to which these bills don’t apply).

A doctor could refuse to tell a man with prostate cancer that removing the testicles is part of treatment in some cases, or a woman with ovarian cancer that she can have her ovaries removed.   A doctor can omit any part of a medical procedure related to abortion or sterilization, as long as it is not an immediately life-threatening situation.  This could include doing procedures like vasectomies or hysterectomies without anesthesia or pain control.  Screaming would be ok, just not dying.  Yes, it is hard to imagine that any doctor would have such a bizarre conscience—it is hard to imagine that a doctor would sexually abuse a patient too, but it happens.  With this law, we’d have no way of removing such a person from medical practice and an employer would have no way to fire him or her.

We could learn from the words of E.H. Chapin, a 19th century Christian preacher:  Let every man be free to act from his own conscience; but let him remember that other people have consciences too; and let not his liberty be so expansive that in its indulgence it jars and crashes against the liberty of others.

By licensing health care providers, the State is assuring its citizens that the license holder meets a certain professional standard of care and ethics.  To this end, Alabama has established various oversight agencies such as the Alabama Board of Medical Examiners and the Board of Nursing, boards with a long history of competent duty.  SB 105 and HB 375 would prevent them from intervening to stop malpractice related to abortion or sterilization if the perpetrator can justify such malpractice on grounds of conscience. 

When a medical provider’s personal ethics conflict with the ethics of his or her profession, the public and the profession itself have a right to be protected from harm.  Please contact your legislator and ask for a “no” vote.



Filed under Alabama legislative session 2012, Politics, women's healthcare

Alabama: a Better Pledge to Sign

Tomorrow, our state House of Representatives will debate a budget worse than the worst one we imagined.  I guess $ 400 million for Medicaid is no more impossible than $ 425 million—we were already at a fat-free budget before these cuts began.


Dr. Don Williamson is being straight with us.  Federal rules prevent us from cutting most parts of the program.   He didn’t pull this out of the air for drama—he is just telling the truth.  We would lose all adult pharmacy.  This would render the salvaging of Mental Health meaningless.  What good is it to let people with schizophrenia see the doctor but not give them medicine?  It would also mean pregnant women, who only get Medicaid for the brief duration of pregnancy, would not be able to get medicine for things like pregnancy-induced hypertension and gestational diabetes, thus putting their lives and their babies’ lives at risk.


We would lose hospice.  This would, ironically, increase the cost of dying.  People who had wanted to die at home with their families would not be able to get the pain medication and medical support needed.  They would go to the hospital instead.  And most dramatically, we would be forced to stop dialysis.  As Dr. Williamson said, dialysis patients would die within two weeks. Do we really want our children to see us behave so?


Even after all that, we would still have to cut payments to doctors dramatically.  We would still lose pediatricians who could no longer pay for rent, staff and supplies. 


Dr. Bentley, our Governor, said the proposed budget was irresponsible.  I agree.  What is he willing to do to prevent it?  His initial budget required money to be taken from education, also already underfunded, and made cuts to the Department of Mental Health.  This weekend I read an interview in which he once again implied he might want the legislature to override his veto of any new tax.   He explained it by saying the voters of Alabama no longer trust the government when it says we need more money and that we, the voters, believed it was important to re-examine our funding priorities periodically.  He said if we weren’t willing to cut now, we never would be, as if we need to prove that to ourselves.  He sounded (my friends tell me I’m being overly optimistic) like he was saying he wanted US to “get it”—to send our state lawmakers a clear message—clear enough to make them override his veto—that we have changed our minds and are no longer willing to drown our children and mentally ill in the bathtub along with the government.


In a way, he is right.  Unless we Alabamians, as a people, unite in deciding we value our children and truly understand that the fates of the children of the poor and the children of the rich are intertwined, this kind of budget slashing will be up anew every year and could get worse with every election cycle.  I saw in a recent poll that most of us think the state could cut spending without a bad outcome.  That means we have work to do in our communities, talking to each other, not just calling Montgomery.


On the one hand, I want to believe Governor Bentley is correct—that if we do the right thing now, we will own this budget.  That it could change us at a deep enough level to last at least a few years. 


On the other hand, I do not agree it is safe to risk the lives of our children in a game of chicken.  I set up a Facebook Group last week to get the word out—I made a rule that we would all belong to the “Children’s Party” and avoid partisan criticisms.  You would think everyone could join the Children’s Party.  Indeed, I still believe most of us in this state and enough of our lawmakers can, not just for brownie points but because at their core, they know it is right.  But even a Children’s Party is not without enemies.  It is far too dangerous to let the bodies of our children dangle in their hands.


Our Governor and several legislators have signed a no new tax pledge.  I don’t know if they all realized what that would require of them.  If they are going to do the right thing for children, they must agree to be adults themselves.  Being adults means sometimes they have to admit they have been wrong.  If they are not just adults but also leaders, it means sometimes they have to be the ones to stand up and show us the right path.  Even when it is hard, even when it gives them heartburn, even when they fear for their jobs.  If our leaders can’t do that for us, they have no business in Montgomery.


Fellow Alabamians, we also have work to do.  This problem is too big for one party to solve.  I’m going to pick on the progressives first, since I’m one.  Part of the reason we have lost strength is that we haven’t been willing to see the importance of some conservative values.  We can’t be a state for children without valuing reasonable security and safety from crime.  We can’t go into debt they will have to pay later, without a very good reason. We don’t raise our children by giving them everything they ask for, like sugary cereal for breakfast—we have to understand that in the same way, safety nets can go too far and enable folks to hurt themselves.  We have to stop punishing the children of conservatives for their parents’ decisions, such as by dropping opposition to homeschoolers playing public school sports and looking for other ways to protect our school funding.


Most importantly, if our current leaders make an attempt to go in the right direction, don’t beat them down with snarky comments and say they don’t mean it.  Give them a chance to be good.  When adults go after each other, children are the ones who suffer.


Conservatives, we need you and your children too.  We need you to add a measure of care to your values of fairness, justice, liberty and personal responsibility.  You are the ballast that keeps liberals from overdoing it, but that ballast will fail without the strength of compassion.  Wherever the actions of adults make you justifiably angry, remember that their children are not to blame and do not deserve to be punished.  Remember to do as much for living children as you do to defend the unborn. We need you to understand that you can’t pull the rug out from under those you see as irresponsible without hurting yourselves as well.


Let us ask each other to take a minute this morning to read and sign the Children’s Promise


“I, (your name here), promise to support policies that promote the healthy development of Alabama children into responsible, educated adults.  I will consider the needs of a child in poverty as carefully as the needs of a child in wealth. I will set an example of civilized behavior, and I will not treat any individual or group in a way I would be ashamed to have to explain to a child.  As an adult, I will sacrifice my own self-interest when necessary, for the sake of our children, our future.”


When you have signed it, pass it on.  Ask your friends and neighbors to sign.  And call your legislators and the Governor today.  It’s time to speak plainly, Governor Bentley.  Tell us you know what is right. Renounce your Norquist Pledge, and sign the Children’s Promise.


Filed under Alabama legislative session 2012, Children's Issues

Alabama: No State for Children?

Yesterday, I made the six hour round trip to Alabama’s state capitol, Montgomery, to attend Pediatric Legislative day.  I’ve been many times—it was the largest turnout of docs I’ve seen yet.  This is my personal report, not in my capacity as a state AAP (American Academy of Pediatrics) board member.  In keeping with the several references to Titanic I heard, I am sorry to tell you that we have already hit the iceberg and our ship is in process of sinking.  I do not know if there are enough lifeboats.  Our legislators and Governor are tossing children overboard first.


Those of us who arrived early chatted while drinking coffee, before all the optimism got sucked out of us.  Last month, we got notice that Medicaid provider payments due March 16 were to be delayed and that “a payment date has not been established.”  Many friends in private practice, especially in rural areas where the great majority of their patients have Medicaid, have already forgone their own paychecks.  Many have had to let staff go (one lost 40% of her staff this week) AND take out emergency loans.  Some of the younger docs are already talking about leaving Alabama completely.


A friend in Mobile reported that because of these payment delays, not a single ENT (Ear-Nose-and Throat surgeon) in her county would accept a new child patient with Medicaid.  In Mobile, one of the largest cities in our state, doctors will have to send children out of town for care. Still, while we drank our coffee, we were smiling, hopeful that when our lawmakers heard about this, they would do something.


Once the speakers arrived, the news got worse.  First we heard from some of my personal heroes, those in our Medicaid agency.  These are the people who work day and night to find ways to stretch a dollar for the sake of children.  We heard that there was still no provider payment date set, and that Medicaid was waiting for the Finance office to release funds.  They are anticipating it may be a recurrent problem and are already making contingency plans for a rotating payment schedule.  Some doctors will get paid one month, some the next, etc.  We heard these grim words:  “You are going to see things you’ve never seen before.”


The Alabama House Budget is due in committee today.  We heard there is talk that the Medicaid Budget will be as low as 425 million.  I was told this is far less than the amount that even the corporate Third Party people would consider taking as a managed care contract.  That this would not fund adequate care for children.  That adult pharmacy benefits (serving the disabled poor, including those with serious mental illness like schizophrenia) would have to end.  There will most likely be a significant payment cut to All-Kids doctors (Alabama’s SCHIP program, for children in working families just above the poverty cutoff for Medicaid).


It was hard to watch my heroes try to smile and come up with something hopeful to say.  They looked so tired.


Next came the legislators.  They had big smiles!  Many of them said they personally “got it” and put the blame on Governor Bentley for his signed no new tax pledge, a bizarre Medes and Persians type oath that apparently means more than his oath of office to do his best for our state.  Senator Orr said the idea of having to override Bentley’s promised veto for a tax increase “gives us heartburn.” But the way they were smiling, I have my doubts about the “got it” part.  I sure didn’t see anything that made me want to dig in my purse for an antacid to share.


Speaker Mike Hubbard came in last, also smiling, at first.  He said his philosophy was “never let a good crisis go to waste” and that this was our chance to make Alabama’s government “leaner.”  He said “Medicaid is a black hole”.  I have added and deleted a sentence ten times about why he might have chosen those exact words, because I’m trying to be objective—you decide.  Don’t believe him, by the way—here’s a more accurate description of state spending.


The first question from the floor came from Dr. Marsha Raulerson, a nationally respected pediatrician who has served her poor rural community for decades—a woman who brings her beeper even on vacation and has somehow also managed to perform tremendous leadership and advocacy work.  She asked if Mr. Hubbard realized she was having to let staff go already and if he would consider a tobacco user fee, a $1 a pack fee on cigarettes that would bring us close to the average of other states, improve child health, and raise an estimated 200 million for the General Fund.  He gave the same heartburn sob story.


Around the room, other pediatricians spoke up.  We are usually a polite crowd, and we still were.  There was no name calling or personal criticism, but there was both passion and anguish.  I heard voices with barely held-back tears.  One friend told Hubbard he needed to understand children would die.  He listened to a few of these comments with visibly rising irritation and then said, curtly, “We appreciate your time”, turned on his heel, and walked out.  Dr. Raulerson tried to hand him an information sheet as he left, and he refused to take it.  It was a level of rudeness I have never encountered at our state house.


As we sat in shock, a legislator I didn’t recognize, stuffing his mouth with the lunch sponsored by Children’s Hospital of Alabama, said he had heard doctors were stealing from Medicaid left and right.  He also left.


I looked around the room and saw pediatricians in all stages of grief except denial.  We can no longer deny that this is happening—that our state legislators and Governor will let this ship sink. If the budget is as bad as we are anticipating, we will not be able to fund care at the level required by federal rules.  I didn’t hear anyone mention it, but I was reminded of reports in the media in 2010 that Alabama might drop Medicaid entirely.  After seeing these people smile in the face of child death, I would not be surprised.  The story would be that Alabama tried but just couldn’t comply with “unfunded mandates”.


If nothing is done—and I mean immediately, not just for FY 2013—we will lose pediatricians very quickly.  No matter how much we love our patients, we will not be able to run offices without rent money, staffing or supplies.  Rural areas will go first.  Pediatric residents graduating in June will decide to take jobs elsewhere.  When they leave, they won’t come back.  We will lose the pediatric specialists who can’t pay staff and rent without Medicaid funding.   We will lose our Children’s Hospitals.  There won’t be special hospitals left for children of privately insured parents.  There will be nothing.  It will be like a bad movie called “Alabama: No State for Children.”


What is to be done?  I don’t know what to tell you.  It’s worth a try to make noise now, but it would take real noise, not just a friendly email or phone call.  Dr. Raulerson calls her legislators every day.  If you are a parent or a business owner who employs parents, and you don’t make or hear an uproar, I would be remiss if I didn’t advise you to start making evacuation plans soon.


Filed under Alabama legislative session 2012, Children's Issues

Letter from Bazelon: Alabama’s Mental Health Funding Crisis

Interesting letter to Governor Bentley from the Bazelon people.  This is the law firm involved in the Wyatt vs. Stickney case– if you don’t know about that, there is some good background on it by Dr. Fuller Torrey’s group.  It is the lawsuit that resulted in the tragic consequences of deinstitutionalization in prior decades– the burgeoning population of homeless mentally ill, the dumping of sick people into prisons, and the loss of sick persons to suicide.  It was intended by some involved to force hospitals into better standards of treatment, not to abandon patients entirely– but the consequences were disastrous.

The letter is a clear threat that if Alabama doesn’t fund our mental health, we are about to get sued– again.  Bazelon says Bentley should apply all the funds initially intended for Bryce to use for transitional planning and they seem to think this will be enough.  I am uncertain of that– we need not only funds for transition, including capital costs and training of new personnel, but also for the ongoing expenses of our current and future services.  Using one-time funds may not cut it– we won’t know until DMH releases a clear plan and estimated expense.

Bazelon’s insistance on closing all the hospitals may be misguided– the Olmstead decision says that we should place people in the least restrictive setting possible, and to integrate them into the community if it can be done.  Some people are too sick to make it in the community, no matter how hard we try, until we have a real cure.  More will be intermittently very sick, since relapses happen even while on previously effective medicine, and they must have a secure, safe place to get treatment.  It is possible we could replace the hospital with local crisis stabilization units– we should be open-minded– but they would have to have capacity to keep people until they are REALLY ready for a lower level of care.  Here’s a brief breakdown of what Olmstead requires and does not require, from Iowa– note that it does NOT require all hospitals to be closed!  It just says that people can’t be kept in the hospital longer than they need to be there, if it is possible to serve them in a community setting.  The pitfalls of over-reliance on community settings are severe.  Bazelon is hurting us by over-interpreting Olmstead.

Bazelon has an ulterior motive that conflicts with reality.  They do not believe in commitment, even to outpatient care– they think all patients with mental illness should be left to their own devices unless they are right about to kill someone.  The reality this conflicts with?  There is a well-studied phenomenon in serious mental illness called anosognosia.  People who have this are incapable of understanding that they are sick or need treatment, the same way as some people after a stroke will not be able to believe they have a left arm.  It is part of the illness itself.  Real advocates for loved ones with mental illness have a more realistic approach.  We are definitely not in favor of restrictive setttings when they are unneeded, and we fight for the inclusion of patients in making their treatment decisions whenever possible.  We want our loved ones to be as independent as they can be and to have fulfilling lives.  None of that is possible if they die from suicide or undergo permanent brain damage as a result of inadequately treated illness.

Torrey’s site has a good explanation of why we need approximately 50 hospital beds for each 100,000 population (same as my prior estimate of 140 beds needed for Madison County alone) and a list of capacities per state– notice Alabama is far short.

Bentley and Baugh have promised that they will not close the hospitals until local infrastructure is ready.  If they keep that promise, the transition could go well.  The reason many of us are not reassured by their words is many-fold.  There have been multiple and rapidly changing plans issued from DMH since February, so we are uncertain anything they say is going to remain in place.  They have not yet told us how they will pay for it or how they will apply the 2012 proration to DMH without hurting outpatient services.  At our regional meeting last week, we were told that DMH couldn’t guarantee a timeline because it depended on funding– which is in direct conflict with saying the timeline depends on having infrastructure prepared.

The threat of lawsuit may be the only thing that saves our mental health system.  Will Bazelon be just as ready to sue on behalf of those who become homeless or commit suicide because they have inadequate care as they are to sue for what they consider excessively restrictive care?  Don’t hold your breath.

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Filed under Alabama legislative session 2012, mental health, Uncategorized

Notes from Region I DMH Meeting

Notes from Region I DMH meeting, March 23, 2012, Huntsville Main Public Library, 10 am to 1 pm

 (This may be of interest to those of you who are preparing for mental health cuts, but I am mainly posting it here so local Alabama advocates can review.  DMH= Alabama Department of Mental Health, NARH is North Alabama Regional Hospital.  As I’ve posted previously, the state is preparing to close all the large regional psychiatric hospitals except for criminally committed and geriatric, and move care into the communities.  However, the communities are not ready.   This was the last in a series of regional meetings around the state between DMH representatives and what they call “stakeholders”– family members, consumers, service providers, law enforcement, etc.  It was a LONG meeting).

My general impression/opinion:  DMH came planning to reassure us and give some broad platitudes.  Long on “philosophy” and short on facts.  Peacock told the press she expected us to leave feeling “more open-minded”.  We quickly uncovered that they have NO IDEA what they are going to do—not reassuring at all.  They do not even have an estimated cost analysis or desired timeline.  They are saying that the regional facilities won’t close until local capacity is in place, but in the next breath, they can’t give a timeline because it depends on proration.  So the truth is, they don’t even know if they will be ready before they are forced to close the hospitals because they can’t pay to run them.


Lots of use of “I agree” and “I feel your frustration” but the group was not taken in by these therapy tactics.  I suspected the questioners were more well-informed than they expected.


I do not think it is DMH’s fault that the legislature is not funding adequately, but I am very frustrated that they are not following the example of other state agencies and being clear that they can’t cover services without $.  They owe us the duty of presenting a clear budget need to the Legislature and a clear time-frame for transition, whether the government provides that needed money or not.  They need to be clear in saying what the consequences of inadequate funding will be. It is unacceptable for them to be so passive in this circumstance.


Fortunately, the press did read the release and talking points I sent in advance and were quite pointed in their reporting—they could definitely tell that DMH was not providing the answers we requested.  We also did a 1 hr sign protest in the pouring rain beforehand—made for some great TV footage.



Dr. Tammy Peacock began with introductory remarks/ background.  Said Commissioner Zelia Baugh had planned to come but was in a finance meeting discussing plans to deal with proration.  They do not know how they are going to deal with the 10.6 proration (21.2% cut in next 6 months). Discussed anticipated 29 million dollar cut in DMH budget for 2013.  Said hospital budgets had already been cut as far as possible and that even closing only 2 of them would not be enough to cover a 29 million $ gap.  Said other reason to close hospitals is that the Department of Justice is enforcing Olmstead ruling, which says that individuals with mental illness have the right to live in the most integrated setting they are capable of.


Peacock said no one had been comfortable with the October 1 timeline.  They are still not certain of where funding to create the new community infrastructure will come from.  They plan to overlay mobile crisis teams onto local MHC services, work toward tele-psychiatry 24-7, and leverage more federal dollars.  They are not sure of plans for long term care of the most seriously mentally ill.  They are currently talking to other states and federal agencies to get ideas.  It is “not our intention to shift the financial responsibility to the local level.”


Peacock said the timeline is extended but they don’t know by how much.   She then opened the floor to questions.


Questions/ Comments from floor (my occasionally snarky editorial comments in italics, and interchanges that seemed particularly significant to me in bold– I may have missed some, was writing furiously—please fill in if you notice a gap):



Q:  If consumers were required to clean their facilities themselves, how much money would that save?  (Really, someone said this—I almost fell out of my chair. Fortunately, it got better)

A:  Consumers would need to be compensated fairly for any work they did


Q: Isn’t it a short-term solution to become dependent on federal $?  And the questioner can’t tell when her relative with SMI is stopping meds—he would be capable of killing somebody if off them.

A: Most consumers would be able to live in their homes but some could go to supported housing.  They have been in meetings with HUD.  They will need ACT teams and PACT teams (a larger team) for the most seriously ill.  (Did not answer the question about federal $).


F/U Q: But if my relative refuses treatment the PACT team can’t force him, right?

A: No, they can’t


Comment: HUD housing is in bad neighborhoods where people prey on mentally ill.

A: This is not about us saving money—reality is that we have 29 million less to spend. (not an answer)


Comment:  Concern that outpatient commitment law has no teeth and needs to be revamped. 

A: There will be inpatient care through “different means”.  Alabama just hasn’t been sued “yet” because of restrictive care. (doesn’t seem like an answer)


Q: Is the state prepared to help local hospitals become designated facilities?

A: Contact your local MHC


Comment (mine):  I disagree that we have too many people in restrictive care and are at risk under Olmstead.  For Madison County alone, if 1.1% of adults over 18 have schizophrenia, national statistics say 5% should be in the hospital at a given time.  That would be 140 at NARH for our county alone, just for schizophrenia.  We have fewer served by the hospital and group homes than should be there, not more—what we need is MORE community services in addition to crisis and group home services.  Told briefly about son’s experience with commitments and difficulty getting community services.  Said that without adequate services at every level, people would cycle through repeatedly and each time they had a bad relapse, they could suffer permanent damage.

Answer:  I agree but we don’t have the money  (that was all she said.  To me, that says she knows good and well that this Olmstead bit is blowing smoke.)


Q: Can you elaborate on the timeline for hospital closings?

A:  The Commissioner is working with the Governor and hopes to announce next week.  We are not going to close the hospitals until communities have identified local beds.  Says there has never been a July deadline at NARH (for stopping new civil commitment admissions) and doesn’t know where we heard that.


Comment:  A son has been committed 4x for mania but in between is fine.  Risk of being hurt/ arrested when manic.  Takes 3 to 4 weeks before safe out of a confined place.


Comment: Our Place (drop in center in Huntsville) needs more $ for peer-led services


Q: If Judge says a person is committed to the hospital, where will they go if no hospital?

A: No closings until we have local beds

Q: Where is the funding for new facilities coming from?

A: We aren’t going to put the bulk of our money into bricks and mortar.  There will be “repurposing” of existing structures.  We can’t do it without bridge $. (basically, they don’t know)


Comment:  The cost of renovation is high—must do expensive items like replacing window glass, etc, not cheap

A: I agree


Comment:  “It sounds like you’ve decided to sell us out”

A: That’s not my perspective


Comment:  We need more research and funding to find early treatment for SMI


Comment:  Concern about consumers who will be discharged too soon because they have learned what to say—doesn’t think ACT/ PACT teams maintain outpatient control without offending constitutional rights


Comment:  the community is uneasy because of how the information was released.  People don’t have enough info, being given conflicting information, changing info–  DMH should have given better/ more complete info

A: I agree.  Hard to be definitive when we don’t know


Q: Why didn’t DMH prepare for this earlier—they knew the budget situation was coming long before now

A: “It isn’t cost-cutting—nobody has $” (how is this an answer?)


Comment from consumer:  NARH helped me tremendously

A: Closure is on hold until access at community level


Q: What is the probable time of hospital closure?

A: We don’t know—it depends on proration and funding.   MHC’s have been asked to give a plan for what they need.  There is a philosophical change to move to community care. (Philosophy, Shmilosophy… give us some facts)


Q (me): How much time and money do you actually NEED to do this right?

A: Can’t answer—“we can’t control the process”  “we don’t make a wish budget”


Q: Is there a 5 year plan for how to evaluate/ monitor this transition?

A:  Didn’t answer.  Just said they would get feedback from MHC’s.


Q: Is there a plan to meet individually with MHC’s?

A: We have been meeting collectively, and some individual meetings are in process


Q: Can local hospitals serve as crisis stabilization and will $ be available to them?

A: talk to your MHC


Comment:  Georgia did a similar transition to community care, and it was fine until patients decompensated and they did not have enough places to send them.  Became a revolving door system.

A: Isn’t it already a revolving door system? (Wow—she really said that.  How is that a helpful answer?)


Q: Have you pressured the fed govt for $?

A: Commissioner hasn’t asked yet, doesn’t know how many housing vouchers needed, “a lot of data hasn’t been gathered”


Comment: Real stakeholders have not been brought into this process.  Crisis houses have failed in other states

A: They have applied for housing grants (first, doesn’t answer the question—second, seems to conflict with answer above but I may be misunderstanding)


Comment:  Illinois closed a hospital in one area to rely on community services, then closed community services, and now churches are doing a rotation to care for the mentally ill (I have not seen this in print)


Q: Have you coordinated with the Sherrif’s Depts, State Police to find out needs?

A: Not sure.  Did meet with Probate Court committee


Q: What about Deaf?  Are interpreters in plan?  Commenter noted that her local hospital was often not staffed to assist her 24-7.

A:   Possible regional capacity. Haven’t figured it out (Note—there was a Sign interpreter present)


Q:  The responsibilities of the Community Mental Health centers are increasing—how will we fund all this?

A: Never underestimate the power of your vote.  (By this point, I think she realized we were serious)


Q: How will the MHC’s handle the 10.6% proration and handle new administrative responsibilities to develop these plans? 

A: “No one has told the MHC’s they will have a 10.6% cut”.  (umm… you said earlier that the hospitals could not be cut further at 25% cut—this will be a 21.6% cut over the rest of the fiscal year—how could it NOT come down on the MHC’s? Is there some secret department we don’t know about?)


Comment:  You can’t answer our questions and can’t give us a plan.  You haven’t done a cost-benefit analysis.

A: I understand your frustration


Comment:  State has been trying to get out of hospital business for years.  ECM (Eliza Coffee Memorial) hospital is limited to short term only.  Communities have trouble keeping psychiatrists to staff local hospitals.  How many on the planning committee are probate judges, family and consumers? 90% of commitments are recycled. (I didn’t hear the answer, sorry)


Comment: People get bumped from group homes to communities and then their families bear the burden.


Comment:  It doesn’t just take resources to begin this project but resources to sustain it.


We broke into groups and discussed our needs, then reported back.  I could not see the written lists of the other groups, but the verbal reports were very general—just basically needing peer support, law enforcement training/ support, more community capacity.


Madison County MHC group requested a long list of items by process of brainstorming, which I have because I was in that group.  Note that Brian Davis, who has spoken to us about his own perspective previously, gave us a chance to tell HIM what we think we need.  Thanks, Brian!  I don’t know if the other groups did it that way.


1) 60 additional group home beds in addition to present capacity

2) 100 more supervised apartments and $ for setup/ furniture, etc

3) Ability to use larger than 3 bed homes if necessary for economy of scale

4) Private rooms in the group homes, for consumers who relapse from stress of no privacy

5) A mobile psychiatrist available 24-7

6) More peer support, another drop-in center

7) Young adult Peer Support and transitional support

8) Maintain current services at Huntsville Hospital

9) Consumer classes for communication skills/ assertiveness

10) A crisis stabilization unit ready before NARH closes

11) More timely access to appointments at MHC

12) Recruit/ hire more psychiatrists

13) Try to get some of the oil money for infrastructure

14) Respite beds for short term care, if family needs to be out of town or are ill

15) Flexibility in policies about who needs therapy and med monitoring

16) Mixed opinions on tele-psychiatry—some in favor, some worried about pinning too many hopes on it

17) More services for autism/ Asperger’s

18) DMH needs to tell the Governor and Legislature how much $ they NEED and not just take what they get

19) Transportation for consumers

20) More family members involved at DMH level in planning

21) More local planning sessions/ communication.  Don’t call the meetings “stakeholder” meetings—should be town hall/ forums and should be well-publicized.  The whole community is affected

22) More commitment from local government to be involved

23) Increase the skill level of MHC therapists

24) Some remaining capacity in the state for long-term hospitalization


Filed under Alabama legislative session 2012, mental health