States’ Budget Crises Cut Deeply Into Financing for Mental Health Programs

By MARC LACEY, KEVIN SACK and A. G. SULZBERGER
Published: January 20, 2011

TUCSON — Unlike many of her fellow governors, Jan Brewer of Arizona knows well the inner workings of her state’s mental health system: her son has schizophrenia and was committed to a state hospital more than 20 years ago after being found not guilty by reason of insanity of sexual assault and kidnapping.

Although she rarely speaks of her son’s crisis, Ms. Brewer has long been an advocate for the mental health system, pushing for state money for drugs and community programs.

But with Arizona and other states across the country facing huge budget holes, Ms. Brewer and many of her fellow governors in both parties are presiding over what is being described as a dismantling of the safety net for the mentally ill.

The cuts, denounced by activists, are gaining fresh scrutiny after a troubled young man’s shooting rampage here on Jan. 8 left 6 people dead and 13 wounded, although nobody is suggesting that budget cuts, past or present, had any connection. The man accused, Jared L. Loughner, 22, exhibited signs of bizarre behavior in the years leading up to the shootings, according to people around him, but was not known to have received a diagnosis of a mental illness, or any treatment.

“After what happened in Tucson, we need to realize that we need these programs,” said Linda Lopez, a Democratic state senator in Arizona who works in community outreach at a Tucson mental health facility.

Until recently, Arizona had one of the most generous benefits packages for mental health treatment, largely as a result of the settlement of a 1989 class-action lawsuit and a state law guaranteeing assistance to the mentally ill. But last year, the program began to shrink. The state cut counseling, case management, voluntary hospitalization, brand-name medication and numerous other services for non-Medicaid patients.

Ms. Brewer, a Republican, is also proposing cuts in eligibility for Medicaid, which is the largest insurer of public mental health services.

“I’ve been close to her for years, and she has been a help,” said Charles L. Arnold, a mental health lawyer in Phoenix who once sued the state to force it to provide better services. “But she’s thrown the human service community under the bus.”

Not everyone blames Ms. Brewer. “Since she has become governor she has tried very hard to shelter the system to the best of her ability, and that’s despite a lot of pressure from her own party,” said Daniel J. Ranieri, president and chief executive of La Frontera Center, a mental health clinic in Tucson.

Ms. Brewer and other governors say dire fiscal realities are forcing them to propose cost-saving measures that carry profound consequences. This year’s cuts are expected to be substantial, but they are just the latest round in the recessionary demolition of a public mental health system that has long been underfinanced and politically vulnerable.

The National Association of State Mental Health Program Directors estimates that at least $2.1 billion has been cut from state mental health budgets in the last three fiscal years.

Adult day treatment centers have been shuttered; subsidies for outpatient counseling, medications and family support services have dried up; case managers have been laid off; and more than 4,000 beds in psychiatric hospitals have closed, according to Michael J. Fitzpatrick, executive director of the National Alliance on Mental Illness. The fiscal squeeze has highlighted the inadequacy of community services to accommodate deinstitutionalization, and waiting lists have grown steadily in many states.

In Washington State, Gov. Christine Gregoire, a Democrat, imposed nearly $19 million in midyear cuts to community treatment programs last fall, said David A. Dickinson, director of the state’s Division of Behavioral Health and Recovery. The cuts led to the immediate closing of a 16-bed evaluation and treatment center and a 30-bed ward at a state hospital.

The state had previously reduced Medicaid payment rates to mental health providers, and the governor has proposed additional cuts of $17.4 million over the next two years. As Ms. Gregoire presented the plan last month, she conceded that “this budget does not represent my values, and I don’t think it represents the values of this state.”

In Kansas, the new governor, Sam Brownback, a Republican, has asked the Legislature to eliminate $10.2 million from the state’s community mental health centers and $5 million from therapeutic services for children with severe disorders.

In Mississippi, Gov. Haley Barbour, a Republican, has proposed spending 13 percent less on mental health than his own division director said would be needed to provide the same level of services as this year. His state has already cut spending on group homes, subsidized medications, case management, halfway houses and crisis intervention. It has also eliminated $7 million in grants to community agencies and closed more than 200 beds at a state hospital and a dorm at an adolescent treatment center.

In Iowa on Wednesday, the new governor, Terry Branstad, rejected a proposal by his predecessor, Chet Culver, to eliminate 129 beds and 136 workers to help close a midyear gap. The state’s human services director said savings would have to be found elsewhere.

Here in Arizona, where the governor delayed announcing her budget to mourn the victims of the Tucson shooting, Ms. Brewer is proposing to help close a $1 billion budget hole by seeking federal approval to significantly scale back the state’s Medicaid program. To reduce the blow on 5,200 mentally ill people who would lose their health coverage, she proposes spending $10 million to keep vulnerable people on medication.

While no one suggests that such budget cuts had anything to do with the Tucson shootings, advocates point out that slashing mental health programs does have consequences, including potential human costs.

“We know that incidents of violence with people with severe mental illness are only slightly higher than with the average person,” said Sita M. Diehl, director of state policy and advocacy for the National Alliance on Mental Illness. “But when you get untreated mental illness and substance abuse combined, you do get some pretty bizarre and alarming things sometimes.”

Patients, who know the system best, lament how the shrinking of services can throw their fragile lives into turmoil.

Not long after Arizona’s cuts went into effect last year, Jo Evelyn Ivey, 32, whose bipolar disorder forced her to end her career as a lawyer, had the worst episode of her life. But having lost access to a case manager, she spent four days trying unsuccessfully to reach a doctor. On the fifth day, she tried to commit suicide by overdosing on medicine.

When she instead became very ill, she called the police and was taken to the hospital in restraints. She was kept in intensive care for four days, then spent a week in a mental hospital, she said.

“The harder you make it for people with mental illness to access their medicine, their doctor or their services, the more situations you’re going to have like me in restraints,” she said.

Gary D. Alexander was Gov-elec Corbett's choice for secretary of the Department of Public Welfare

Alexander, most recently served as Rhode Island's Secretary of Health and Human Services, where, according to the transition team, he was "the governor’s chief adviser on all health care, social services and rehabilitative policies, overseeing more than 3,000 employees and a combined budget of more than $2.5 billion."

The Rhode Island state government website press release section credits Alexander with "crafting and designing the landmark and first in the nation Global Consumer Choice Medicaid Waiver (unique in the nation) transforming the Rhode Island Medicaid program into a value-oriented and performance-driven healthcare system focused on the needs of the consumer."

We have reached out to NAMI Rhode Island asking for their assessment of Alexander's tenure as Secretary and to also assess their working relationship over the years. More to come after NAMI Rhode Island responds.

In previous public service, Alexander has served as policy director for Rhode Island's Lt. Governor and as a healthcare budget analyst for the Massachusetts Senate Committee on Ways and Means.

Alexander earned his Juris Doctor at Suffolk University Law School in 2002. He graduated Magna Cum Laude from Northeastern University in Boston with a Bachelor of Arts in Political Science.

The appointment of Alexander requires Senate confirmation.

We will provide updates on the transition as merited along with useful tips for outreach to the incoming Administration.

The Arizona Tragedy and Mental Health Care

Statement by

Michael J. Fitzpatrick, Executive Director,

National Alliance on Mental Illness (NAMI)


NAMI is an organization of individuals and families whose lives have been deeply affected by mental illness.


We share the sadness of other Americans over the Tucson, Arizona tragedy and extend our sympathy to the families of the six individuals who died. We pray for the recovery of U.S. Representative Gabrielle Giffords and the 13 other persons who were wounded.


Representative Giffords is a NAMI friend who has served as co-chair of the NAMIWalk in Southeast Arizona and has supported our missions of education, support and advocacy.


When tragedies involving mental illness occur, it is essential to understand the nature of mental illness—and to find out what went wrong.


The U.S. Surgeon General has reported that the likelihood of violence from people with mental illness is low. In fact, “the overall contribution of mental disorders to the total level of violence in society is exceptionally small.” Acts of violence are exceptional. They are a sign that something has gone terribly wrong, usually in the mental health care system.


Nationwide, the mental health care system is broken. Arizona, like other states, has deeply cut mental health services. Arizona has a broad civil commitment law to require treatment if it is needed; however, the law cannot work if an evaluation is never conducted or mental health services are not available.


In specific cases such as this, authorities and the news media should seek to objectively determine every factor that may have contributed to the tragedy—so that we can act on lessons learned.

* Was there a diagnosis?
* What is the full medical history?
* When were symptoms first noticed?

* Did family members receive education about mental illness and support?
* Did the person or family ever seek treatment—only to have it delayed or denied?
* Was the person seen by mental health professionals? By whom? How often?
* Was treatment coordinated among different professionals?
* Was the person prescribed medication? Was it being taken? If not, why not?
* Was substance abuse involved?
* What may have triggered the psychiatric crisis?





About NAMI



NAMI is the nation's largest grassroots mental health organization dedicated to improving the lives of individuals and families affected by mental illness. NAMI has over 1,100 state and local affiliates that engage in research, education, support and advocacy.