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.
Conclusion
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