Mental health costs outstrip state funding

Teton County Sheriff Jim Whalen had two people in his jail in February he didn’t think should be there. “Both of them were exhibiting signs of mental illness,” Whalen said. One man attacked a guard.

Both men needed to go to the state mental hospital in Evanston, but there were no beds available. The two man languished in Whalen’s jail, their mental state vulnerable to further deterioration without sufficient treatment. One prisoner waited at least four months for a treatment, the other a month.

It took a sharp intervention from Whalen to set off court hearings and get the men out of his lockup. He finally told the state hospital, “either you come deal with them or I’m bringing them to you,” he said.

“Something is the matter in the State of Wyoming when we have people in need of mental health care and jail is the only place to put them,” he said.

There are few empty beds at the State Hospital because the number of people involuntarily hospitalized for mental illness has been steadily increasing. Hospitalization of the mentally ill takes place under a system called Title 25, and the number of people in that system has increased 36 percent from 261 to 357 in the last six years.

As the 64th Legislature got under way, Gov. Matt Mead and Tom Forslund, director of the Wyoming Department of Health, asked for $21 million in contingency funding to help pay for Title 25’s skyrocketing costs. If they don’t get it, Forslund will have to find money for the program internally, though his budget was already cut by $141 million for the current biennium.

The request is sure to raise eyebrows as the Legislature stares down the twin barrels of a deficit in education funding and dwindling revenue from the energy industry. Whether the request is granted, and whether the Legislature advances Wyoming’s treatment of the mentally ill, remains to be seen.

Title 25 as a catch-all

One of the men in the Teton County Jail had been stable for 30 years before he slipped, according to the Jackson Hole News&Guide, which published several articles about the state’s mental health woes. Diagnosed with bipolar disorder and allegedly off his medication, he had unsettled a store employee by unsheathing a knife from a display, pointing it at her and making comments.

That story could be what Forslund was thinking of eleven months later. Days before the legislative session opened, he described what happens when Wyoming residents with mental illnesses fall and no one is there to catch them.

“Let’s start at the beginning when somebody goes into crisis,” Forslund said. “What happens generally speaking is they start to act out and somebody responds. As an example, a 911 call comes in to dispatch and they say ‘there’s a crazy person in my store. Come and get them.’”

The way law enforcement officers are trained to interact with suspects is often the worst way to approach a person in the midst of a mental health crisis, Forslund said. The officers shout, and seek to take control of a situation aggressively.

“So then the individual is taken into custody, he or she is in the backseat of a police car… then what?” Forslund asked. “In many cases the officer just wants them out of the backseat, so [he or she] takes them to the local hospital. In some cases it’s jail. But most of the case anymore it’s the local hospital,” he said.

In the case of Whalen’s prisoner it was jail, and a felony charge of aggravated assault, according to the News&Guide. But the end result was basically the same. “They end up in the system,” Forslund said. That means court hearings, and if warranted, hospitalization under Title 25.

Because of the assault charge the man was not considered a Title 25 case, as that statute is used to take people into custody who may not have committed a crime but are a threat to themselves or others. Whalen also said private hospitals wouldn’t take a patient with pending criminal charges, and so there was no option but to keep him in jail until a bed in Evanston opened.

But when the court orders involuntary hospitalization under Title 25, and “there’s no room at the inn,” as Forslund puts it, the person is sent to private psychiatric facilities — on the Department of Health’s dime.

The reasons Title 25 numbers have gone up are still unclear. However, Forslund said he believes it’s at least partially indicative of a larger problem in Wyoming’s system for treating mental illness.

“In many respects the Title 25 process is to catch [people] after the system has failed,” he said. As the program was used to catch more and more people, the state hospital filled up and people were diverted to private facilities. That drove up the program’s costs for the state.

Forslund’s dilemna

Since 2013, the amount of money the Department of Health spends on Title 25 each year has increased from more than $4 million to $10.3 million. Meanwhile the amount of money the Legislature budgets the department for Title 25 has stayed the same, at $4 million.

In 2015, Forslund asked the Legislature to grant him additional funds to pay for the program. The Legislature declined. In the budget session of 2016 he asked again, and the Legislature again refused.

The Legislature did, however, grant him flexibility to move money around within his budget to cover Title 25. Forslund said he was able to do so even when the cost overruns of Title 25 last biennium meant finding $18 million elsewhere. “A chunk of change to say the least, but luckily we were able to do it,” he said.

No more, he says now. Not after the Legislature cut $10 million from his department in March, and the governor cut $90 million in June. That amounted to 9 percent of his budget and was followed by an additional $40.9 million lost in matching federal funds. Before the session started, Forslund told lawmakers he would not be able to absorb Title 25 overruns again without hurting healthcare.

Forslund asked for an additional appropriation to his budget of $21 million. On the governor’s recommendation, however, he is now asking for that sum to be contingency funding — withdrawn from the state’s “rainy-day fund” and returned if it is not used. Gov. Mead asked the Legislature to grant that request during the Joint Appropriations Committee meetings, and again during his State of the State speech.

For the Department of Health, the dilemma is relatively simple. Not paying for  involuntary hospitalizations as it is required to by courts is not an option. The agency would be in contempt of court, Forslund said.

If the Legislature doesn’t come through, Forslund will have to go back to a budget that has been cut by $141 million and see what programs can best withstand another round.

“Of course we can have more cuts. It just means we slice and dice more organizations,” he said. “So I pay less to nursing homes, or I give less money to senior centers. Or to the community health providers.”

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The governor’s cuts already hit mental health, suicide-prevention and substance-abuse programs. After reductions to matching federal funds were included, almost $3 million was erased from Public Health Division prevention programs, and more than $16.5 million from related treatment programs under the Behavioral Health Division.

But some believe cutting services could increase Title 25 costs. “The more of those cuts you have at a local level, the more you’re going to see those Title 25 patients showing up at the emergency rooms,” said Linda Burt, a former director of the ACLU and attorney in Laramie county who is often involved in Title 25 cases.

The contingency money Forslund and Gov. Mead asked for is a stop-gap measure. An upswing in Title 25 costs are a sign of a larger question of how the state will approach the seriously mentally ill, one that Forslund said he believes lawmakers are aware of.  “I think everyone recognizes it’s a problem,” he said. “The question is how to pay for it.”

Baby steps

In an aspirational opening speech, House Minority Floor Leader Rep. Cathy Connolly (D, HD-13, Laramie) asked lawmakers to recognize the value of investments today that “will pay off for generations to come.” One she mentioned was in mental health.

“Imagine our neighbors, who are suicidal or with mental illness or substance abuse problems getting help before being placed in hospitals,” she said.

Connolly said she is worried her counterparts in the Legislature won’t recognize the value of such an investment and could reject the request for contingency funding. She cited an entrenched “distrust” of spending on social services and mental health, and said a belief exists among Republican lawmakers “that there’s got to be another way.”

Rep. Eric Barlow (R, HD-03, Gillette) seems interested in looking at the mental health system in its entirety, Forslund said. Barlow will offer a bill calling for a longterm study of the state’s mental health programs, the lawmaker told WyoFile. He has also introduced a bill to create more treatment options before hospitalization.

Two other pieces of legislation that approach some aspect of the Title 25 problem were introduced by committees. One, SF-66, passed committee and will next be debated on the Senate floor. That bill ordered hospitals to spend six months seeking payment from federal agencies like the Veterans’ Affairs office, Indian Health Services and the U.S. Department of Health and Human Services, before turning to the state.

After hospital lobbyists testified that medical centers can’t wait six months to be paid, the language was amended to four months. The hope is that this would shift some of the burden of paying for health costs to the federal government.

“For those that aren’t aware, or have been living under a rock for a long time, Title 25 is in desperate need of repair,” Sen. Fred Baldwin (R, SD-14, Kemmerer) said before the vote, calling this bill just one small step.

The other small step already under consideration is HB-17, which allows the courts to extend the period an adult could be put under protective custody in his or her own home. If the courts find someone who generates a call to emergency services — for instance a mentally ill adult — is incapable of taking care of themselves, or is being abused, then that person can be placed under protective custody of the state in their own house. Today, that protective custody can only last 72 hours. The new bill would extend that up to 30 days. That would create another option judges could use before they reach for Title 25.

That bill awaits a final vote in the House before moving on to the Senate.

An unlikely advocate?

If the state’s mental health system needs real reform, Burt is worried that Sen. Charles Scott (R, SD-30, Casper) might be a roadblock. Senate chairman of the Labor, Health and Social Service Committee, he opposed Medicare expansion to the exasperation of many in the state. “I don’t understand his theory about health care,” Burt said, “but he’s really blocked any kind of progressive health reform in Wyoming for years and years and years.”

However, Scott appears dedicated to creating a more workable Title 25 program. He told WyoFile he is working on a bill that would give the Health Department the power to add incentives to grants made to community health centers. The idea is “to make sure that the community mental health centers do everything they can to take care of these people,” before they reach the hospital, Scott said.

Scott’s bill seeks to address the idea expressed by Forslund — that hospitalization catches people who could not have their illnesses treated before becoming a crisis. The better people are cared for at the outset, the less chance of them falling into Title 25.

Rep. Barlow has expressed the same desire — to fix the system upstream of the state hospital and prevent more patients from showing up at its overcrowded door. It’s finding out how to best approach that upstream side, which many say is nearly as complicated as mental illness itself, that Barlow thinks could be the work of an interim committee.

Scott’s bill would direct some of the money that Forslund and Gov. Mead have asked for to community mental health centers, according to Erin Johnson, director of the Wyoming Association of Mental Health and Substance Abuse Centers.

An earlier plan pushed by Forslund would have focused treatment paid for by the state on the most severe mental health cases. That would have redirected millions of dollars put into mental health and substance abuse programs, the second biggest area in the Department of Health’s budget. The idea was that by addressing the most severe need, Title 25 numbers would go down as the patients most likely to reach a crisis and require hospitalization received more attention.

Community mental health centers lobbied against that idea, worried that in an effort to solve the Title 25 problem, the Department of Health would redirect funding from a significant piece of their business — mental health care for low-income patients that is subsidized by the state.

Cutting those services could move more struggling and impoverished individuals down the road to crisis, Johnson said.

Her group would support Scott’s plan, if it came with additional funding from the rainy day fund. Community mental health organizations around the state are interested in increasing services to people on the edge of mental health crises anyway, she said. They just don’t want to cannibalize other services and already strained budgets to do so.

“If there’s new money we’re on board,” Johnson said.

“This feels like a solution, or at least we are stepping toward a solution,” she said. If, that is, the Legislature agrees to the $21 million request.

Read about  Wyoming’s fraying social safety net

Forslund has bemoaned that his department is on the receiving end of the Title 25 costs — and the lawmakers’ attention when those cuts skyrocket — but has no direct authority over how many people are entered into the program. “It’s not under our control in the Department of Health,” he said. “We can influence and talk about it and recommend and such, but at the end of the day there’s lots of players in this,” he said. Most particularly, he noted, his department has no control over the courts.

“The court’s are just reacting to cases brought to them by the county attorneys. And the county attorneys are just dealing with the cases that are in the local hospital or jail,” Forslund said.

For sheriff Whalen, what is needed is a firmer solution for mental illness on all levels.  “I don’t believe this problem has been a priority for our Legislature,” he said. “And I get it. It’s a lot of money to deal with these folks, but it just didn’t seem like we’re treating them to the extent that we should.”