Mental health funding falls short
December 1, 2013
They're victims of car accidents, they've been shot or they threatened their parents. They have overdosed on cocaine, swallowed too many pills or passed out drunk. On an average Friday or Saturday night, they can make up about half of the sick, injured and wounded crowding the rooms and hallways of the emergency department at Denver Health.
And there's one trait these patients have in common, said Dr. Chris Colwell, director of the department. Had they received needed prior treatment, they might not be there at all.
These ER visitors, for all their outward signs of trauma, suffer foremost from mental illness.
"The emergency room could have been avoided if they had gotten psychiatric care anywhere else," he said.
Colwell thinks uncontrolled behavioral health problems also were at the root of two events that he experienced up close: The mass murders at Columbine High School in 1999 and in Aurora last year. He was a physician on the scene at Columbine and also treated patients from the Aurora shooting.
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"For every one of those that were a big high-profile event that everybody knows about," said Colwell, "there's a hundred that were either near misses … or resulted in violence, just not to the same extent."
As inpatient psychiatric beds have disappeared across the state, he's watched the problem get worse.
"I don't think people understand the crisis that we're in," he said.
An initiative put forward by Gov. John Hickenlooper in December 2012 — after the Aurora shooting in July — and signed into law earlier this year is intended to improve mental health services in the state by putting nearly
$20 million into walk-in crisis centers and a state-wide hotline. Additional state funding also will be put into modernizing treatment at the two public mental health institutes, Fort Logan in Denver and Pueblo, boosting inpatient capacity and other services, resulting in an overall 13.5 percent increase for behavioral health care in fiscal year 2013-2014.
The money is needed, say state officials, health care providers and advocates for the mentally ill, to ease pressure on emergency rooms and jails.
Patrick Fox, an official for the Colorado Department of Human Services who oversees the two state institutes, said that a study of emergency room intakes has indicated that patients often stabilize within 48 hours, and that long-term mental health beds aren't necessarily what's needed most.
"We view the introduction of an expanded crisis stabilization service across the state as being a very important first step to address the most pressing behavioral health needs of Coloradans," Fox said.
But many of the doctors and professionals working on the front lines of the crisis say the money isn't enough to fill a yawning gap in services to prevent and treat mental illness.
A look back across three decades shows that public-sector funding for mental health services in Colorado hasn't kept up with demand.
Per-capita spending on mental health services in the state, when adjusted by the medical rate of inflation, dropped 28 percent from 1981 to 1990, according to data collected by the National State Mental Health Program Directors Research Institute Inc., or NRI.
Federal budget cuts and an economic crisis in Colorado during the '80s conspired to suck funding from state psychiatric hospitals and community mental health centers. And cuts made in that decade never were recovered. In 2010, the state spent the equivalent of 20 percent less per person on mental health services than it did in 1981, according to NRI data.
The persistent funding shortfall long ago made jails and prisons the primary residential treatment centers for the mentally ill in Colorado, clogged emergency rooms, boosted medical expenses across the board and expanded the ranks of the homeless on the streets of Denver and other cities.
Eric Brown, a spokesman for the governor's office, said that the new plan will help people from falling through the cracks.
"There's no way to make up all of the funding deficiencies and implement new programs in a short period," Brown said, adding that it will take time and commitment.
Two national policy shifts and an oil shale bust were behind the drop in funding in the 1980s.
President Ronald Reagan took office at the start of the decade on a pledge to limit government spending. The Omnibus Budget Reconciliation Act of 1981 ranked among his first triumphs, cutting costs in part by transforming funding for mental health services into block grants to the states.
In Colorado, those grants didn't keep up with rising costs.
Less than a year after this national legislation was passed, on May 2, 1982, Exxon pulled out of its oil shale operations in the Western Slope. Known as Black Sunday, the move foretold a massive bust in Colorado's energy sector, triggering a recession and a decline in state tax revenue. Mental health services weren't alone in suffering cutbacks — but the effects were stark.
The state budget crisis took hold just as a broader philosophical shift was transforming the way mental health services were provided across the country.
Legislation signed by President John F. Kennedy in 1963 had called for the funding of community mental health centers, and initiated a broader discussion about the role of large institutions in the treatment of those with mental illness.
Youlon Savage led the movement toward deinstitutionalization in Colorado, and was executive director of the first community mental health center in the state to be funded under Kennedy's initiative. He said the movement into community-based care was intended to help reduce stigma and promote integration.
"Mental illness was no longer manifested by sending people away from home into large institutions," Savage said.
Even the mental health hospital at Fort Logan was conceived as a community center when it opened in the 1960s. Staff didn't wear uniforms, they worked closely in collaboration with patients who lived in a largely open and unlocked campus, and they made home visits to keep people out of the hospital.
But broad slashes to the two state psychiatric hospitals in the 1970s deeply impacted Fort Logan and Pueblo. By 1980, there were 1,103 public psychiatric beds in Colorado, down from 1,609 a decade earlier.
Throughout the next decades, public beds would continue to disappear, and by 2013, the two state hospitals had only 545 beds. It wasn't only the beds but the staffing and services that disappeared — services like home visits, community outreach and vocational training.
"Fort Logan used to do all the things that the community mental health centers are supposed to be doing," said Rebecca Watt, a former nurse at the hospital who thinks that budget cuts have damaged the facility's ability to treat its patients.
The units for the elderly, children and teens at Fort Logan were among the most recent to close, in 2009. Recently, there were 38 people waiting for beds at Fort Logan and Pueblo, according to the Department of Human Services. The average wait time varies between eight and 25 days.
As the money moved out of the state hospitals, community mental health centers said they never got the funding they needed to take up the slack.
Harriet Hall, the chief executive of Jefferson Mental Health Center, said facilities like hers sometimes got a boost from the state when the hospitals' budgets were cut. But often, they got nothing.
"It was never like, we'll just transfer this money to the communities from the hospitals," Hall said.
Hall and others who lead the state's 17 nonprofit community mental health centers say that with adequate funding they can provide much better services than the large institutions ever did — by giving the routine care people need to stay integrated within the community and out of costly hospital stays.
But, they say, there are gaps in the services they can realistically provide, given their tight budgets.
"There's still kind of a dearth of options for folks who have genuinely long-term needs, and (whose illnesses are) a bit more severe than nursing home placement or return to home allows," said Liz Hickman, who heads the Centennial Mental Health Center, which serves rural communities in northeastern Colorado.
What's more, nonprofit community mental health centers say state funding doesn't provide for the treatment of those without some form of public or private insurance or other payment source. Randy Stith, who heads the Aurora Mental Health Center, said that leaves them with no choice but to tell indigent patients to go to the emergency room for care.
"We're referring people to the emergency room off the streets pretty regularly," Stith said. "It's costly but that's what you do."
At Denver Health, Colwell describes having to board psychiatric patients in the emergency room. On a typical night, as many as 10 or 15 beds may be taken up by people who are waiting for psychiatric services, while the psychiatrists on staff at the hospital are overwhelmed with other cases.
Those who pose a risk to themselves or others may be admitted to the psychiatric emergency department.
Dr. Kimberly Nordstrom, the medical director of that department, said more and more of the patients she sees don't have primary care providers. That often means that she can't prescribe medications — with their uncertain side effects and tailored dosing needs — even to those who are very ill.
"I can't start medicine with somebody who's not going to be seen for six months," Nordstrom explains.
Others, Colwell said, are at the brink of posing a risk to the community or themselves — but aren't there yet.
"Once their physical problems are taken care of, we can't keep them," Colwell said.
But that doesn't mean they won't be coming back.
I-News is the public service journalism arm of Rocky Mountain PBS and works in collaboration with news media throughout Colorado. To read more, go to inewsnetwork.org. Contact health reporter Kristin Jones at firstname.lastname@example.org.