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.