DRI was asked to provide testimony to the Idaho Advisory Committee of the U.S. Commission on Civil Rights concerning Idaho's mental health system and compliance with the U.S. Supreme Court Decision in Olmstead v. L.C. This is what I submitted.
Testimony of DisAbility Rights Idaho.
Idaho’s mental health services system is broken. Mental health crisis calls are stretching our law enforcement and emergency responders to the breaking point. Admissions to the state psychiatric hospitals are increasing and the prisons and jails have more inmates with serious mental illness than our hospitals do. Last but not least untreated or inadequately treated mental illness is causing enormous human suffering for people with mental illness and their families. Part of this crisis is the result of a lack of public funding for services, made worse by the significant cuts to state funded services and Medicaid since 2007. Part of the cause is a fragmented and disorganized collection of programs with conflicting priorities and inefficient parallel administrative structures. All of this was well documented in a 2008 study of Idaho’s mental health system commissioned by the legislature. The full text of that report is available on line, http://www.legislature.idaho.gov/sessioninfo/2008/interim/mentalhealth_WICHE.pdf (WICHE Report).
The WICHE report recommended that Idaho pool its resources for mental health and substance abuse treatment from all of its sources (Medicaid, Health and Welfare, Department of Corrections, federal block grants, counties, schools and private) and create regional mental health authorities, with the power and authority to allocate the combined resources to meet local needs. The state mental health authority (Idaho Department of Health and Welfare, IDHW) would be the guarantor of services with the responsibility to insure that local agencies meet minimum standards and comply with state and federal requirements.
The report also condemned Idaho’s system for forcing people to reach some sort of crisis to get access to services. Access to mental health treatment for people who do not have Medicaid is available only to people who are involuntarily committed or who come into the system through the criminal courts, or who are at risk of harm to self or others. Since 2008, this situation has gotten much worse. A 40% cut to state funded services from 2007 to 2011 almost eliminated services for the 55% of Idahoans with serious and persistent mental illness who do not have Medicaid (unless their treatment is court ordered, or they pose a danger to themselves or others). Since 2008, some state level structural changes have been made. One Mental Health Crisis Center has been opened and one more approved. There has been a reduction in access to community services and Medicaid coverage of psychiatric rehabilitation services has been severely decreased.
Idaho’s History with Olmstead v. L.C. and Integrated Community Services
When the U.S. Supreme Court decided Olmstead v. L.C. 527 U.S. 581 (1999) (hereafter, Olmstead), it was concerned that, states with non-compliant systems would be swamped with individual suits and that litigious plaintiffs would move to the front of the waiting lists for services. The Court granted states protection from individual litigation if they developed a reasonable plan for compliance (Olmstead plan), and made consistent progress implementing it. Based on an Idaho Attorney General opinion, Idaho declared that the state was in full compliance with Olmstead, and that no plan was necessary. However, noting that there was widespread disagreement with this position, the Governor created a “Community Integration Committee” (CIC) to explore barriers to integrated services for people with disabilities, and to make non-binding recommendations to the state. The Committee consulted reports, evaluations, people with disabilities, and advocates. The Committee’s last report was submitted in 2004 (attached). Idaho’s mental health system has deteriorated considerably since then.
Applying the ADA’s “Integration Mandate” to the State Mental Health System
Avoiding unnecessary institutional segregation requires a robust and flexible system of community services. The system must include access to mental health treatments like psychiatrists, medication management, psychotherapy, and counseling. For people at risk of institutionalization, it must also include rehabilitative services like psychoeducation, independent living skills, peer supports, and vocational services. Finally, the system must provide access to community supports such as affordable housing, medical care, case management and social services. Failure in any one of these areas can result in decompensation, relapse, re-hospitalization, arrest and incarceration, or suicide. The Olmstead decision, mandated the state system to be redesigned and even to include optional services like Home and Community Based Services (HCBS) waivers, in order to remove the institutional bias of the state’s Medicaid system. However, since the ADA applies to all state services, Idaho must remove institutional bias from the entire state operated mental health system. In other words, Idaho has an obligation to ensure that people with mental disabilities can get adequate mental health treatment and community supports without resorting to state hospitalization. Preventive treatment and supportive services are the key to avoiding unnecessary institutionalization, and segregation. While Olmstead addressed the needs of plaintiffs who were in the state hospital trying to get out, the principle also applies to people seeking mental health services to avoid institutional segregation. In this respect, Idaho’s mental health system falls short.
Idaho’s Department of Health and Welfare (IDHW) has two separate and very different systems which provide adult mental health services. Using national statistics, an estimated 75,000 Idahoans experience a serious mental illness each year.
41,000 of these have a serious and persistent serious mental illness (SPMI) that impairs their ability to function in society. About 19,000 of these Idahoans receive treatment through the Department of Health and Welfare for these illnesses each year. Only about 9,000 of them are covered by Medicaid; about 10,000 are not. Of the 21,000 people with SPMI who do not receive treatment from IDHW, some may be being treated privately, some are in jails or prisons, some get services from county indigent programs, some are receiving no treatment or services, some are homeless. We have no Idaho specific data on these subgroups.
The Division of Medicaid offers coverage for mental health services to people who qualify for Medicaid due to extremely low income combined with severe disability. Medicaid mental health services are covered under a managed care contract with Optum Health, Inc. People who have coverage from both Medicaid and Medicare also have the option of choosing a managed care plan offered by Blue Cross (True Blue).In the last three years, Optum has systematically reduced authorization for Community Based Rehabilitation Services (CBRS is the psychiatric rehabilitation service covered by the plan). They have increased authorization for clinical services like psychotherapy. However, community supports are often more important to preventing hospitalization than additional psychotherapy. For three years the amount of community based rehabilitation services authorized has declined significantly. Medicaid does not cover hospitalization for adults in psychiatric hospitals. So the financial burden of failed community supports is passed on to the Division of Behavioral health.
We do not have enough experience with the Blue Cross plan to know how they will deal with rehabilitation services
The Division of Behavioral Health (DBH) provides services to people with serious mental illness who do not qualify for Medicaid coverage or other insurance. Generally speaking, about 55% (about 9,000 per year) of the people receiving mental health services from IDHW receive only DBH services. DBH operates the two state psychiatric hospitals and provides some community services, such as therapy and Assertive Community Treatment (ACT) teams. Community services are mostly provided when ordered by a court for a criminal defendant, or when people are in crisis and pose a serious risk of harm to self or others.
Community Based Mental Health Services have declined and hospital admissions have increased since 2007.
In 2007, Idaho was spending just under $44 million on community Mental Health Services including ACT teams, and regional mental health centers. From SFY 2008 through SFY 2011 drastic cuts in state Community Mental Health (CMH) services were made. ACT teams were reduced and hundreds of people with severe and persistent mental illness lost ACT team support. IDHW closed many community mental health centers and cut services across the state. IDHW started this process before the recession and before the state legislature reduced budgets. The “budget cuts” (i.e. reduced appropriations) followed the service cuts and have never dropped as low as the state’s actual expenditures. Each year IDHW provided fewer services and requested less funding from the legislature. In 2011CMH expenditures had plummeted to just under $27 million, a 40% reduction from 2007. In 2014 it had rebounded slightly to about $30 million. During that time spending on state hospitals climbed from $27.8 million to $31.7 million.
Idaho Community Mental Health Funding 2007-2014
Source: Idaho Legislative Fiscal Reports
Source: Idaho Legislative Fiscal Reports
It is noteworthy that, starting in SFY2008, IDHW significantly cut services and expenditures well below the amounts appropriated by the legislature and continues to significantly underspend the appropriated amounts. During this time, many adults and children with mental illness have sought CMH services and been turned away by the Department. By 2010, the amount spent on community services was less than the amount spent on state hospitals and remains so to this day. However, the amount Idaho spends on services is not the ultimate issue in looking at Olmstead compliance. It is only relevant if the cuts in community services result in higher levels of institutional placements. Since 2007, state hospital admissions have steadily increased as the availability of community supports and services have declined.
Idaho State Hospital Admissions 2007-20014
Source: IDHW “Facts Figures and Trends” 2007-2014. Note: During 2008, SHS was required by the Joint Commission and the Centers for Medicaid and Medicare Services to reduce admissions due to a shortage of psychiatrists at the hospital.
CMH Expenditures vs. State Hospital Admissions
Source: IDHW “Facts Figures and Trends” 2007-2014
When we map CMH expenditures over state hospital admission for the same time period we see a strong inverse correlation between CMH expenditures and state hospital admissions.
Another measure of the level of segregation of people with mental illness is the median length of stay (MLOS) at the state hospitals. Idaho’s MLOS statistics are not exceptional compared to other state hospitals and the yearly MLOS fluctuates without showing an overall trend since 2011.
These CMH figures apply only to the Division of Behavioral Health. We have no data which would tell us how many hospital admissions are DBH clients and how many are Medicaid patients. Although Optum has recently reduced access to Community Based Rehabilitation Services (CBRS), Medicaid patients in Idaho, generally have much better access to mental health treatment and community supports than DBH clients. People who have been diverted from the criminal justice system through a state mental health court, and receive services pursuant to the court’s order, may be exceptions to this rule.
Idaho is now dead last among all of the states in per capita expenditures on mental health services, http://kff.org/other/state-indicator/smha-expenditures-per-capita . Idaho is consistently in the top seven states for per capita suicide rates and the top five for juvenile suicide, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6345a10.htm . In 2007, Idaho was investing in preventive and supportive community services at a much higher rate. For some reason, in SFY 2008, the Idaho Department of Health and Welfare decided to drastically reduce its commitment to community based services and began to rely increasingly on hospitalization for delivery of mental health services. Although there are no statewide data, many local hospitals and law enforcement agencies report increased utilization of county programs, law enforcement, jails and hospital emergency departments in handling mental health crises. 2014 and 2015 appropriations show an incremental reversal of this trend, but there is ample evidence of a continuing institutional bias in Idaho’s Mental health system. This raises legitimate questions about Idaho’s compliance with Olmstead’s “integration mandate”.
Submitted by: James R. Baugh, Executive Director, DisAbility Rights, Idaho