Underfunded, understaffed and riddled with gaps, Iowa’s mental health system is broken. Such is the dismal assessment of advocates, state and county officials and families who have sought care.
Counties and state institutions have faced limited funding for years, and legislators are now beginning to draft plans to overhaul the system.
Like policymakers across the nation, Iowa struggles to distribute limited revenue without jeopardizing care for the 34,985 residents who rely on the state’s system, according to an IowaWatch study that was part of a national examination by the Center for Public Integrity.
“Our people with mental illnesses are in worse shape today, than when I started 30 years ago,” said June Judge, a family education teacher with National Alliance on Mental Illness of Johnson County.
Unlike many other states, Iowa’s mental health system places a large financial burden on counties. Only Ohio and Wisconsin require local governments to foot a larger portion of the bill. Revenue shapes the services a county can provide, creating drastic inequality across the state.
In 2009, Shelby County spent an average of
$81.12 on mental health for each resident, while Muscatine County spent just $3.33. Average county spending was $36.35.
“What services you get, is basically dependent on where you live,” said Roger
Munns, Department of Human Services spokesman.
Iowa also faces a widely-acknowledged shortage of mental health physicians, and the state ranks near the bottom of the nation in psychiatric beds per capita.
This leaves some families unable to get the care they need.
Becker case: A “vivid example of how the system is not working”
In 2009, the fatal shooting of football coach Ed Thomas raised questions about a system that failed to protect and care for the community.
On June 24 that year, Mark Becker stole a .22-caliber pistol from his father’s gun cabinet, drove 10 miles to his old high school’s weight room and repeatedly shot Thomas in front of 22 Applington-Parkersburg High School students.
As Thomas lay on the ground, Becker stomped and cursed him before instructing the students present to “be free.”
The incident may have been prevented had Becker, a diagnosed paranoid schizophrenic, received proper care, said Joan Becker, his mother. Her account of the months leading up to the shooting is the story of a system that failed her son at every turn, and left her family in danger.
“There was no accountability in my son’s case,” she said in a recent interview. “We felt like no one cared.”
On June 23, Becker was released from a three-day stay in the psychiatric ward of a Waterloo Hospital - the ninth institution he visited in less than a year. The next day, he shot Thomas.
Becker had just a day’s worth of medication in him at the time of the shooting, and, though he had been diagnosed in April, he was still weeks away from receiving his prescription, his mother said.
Schizophrenia requires long-term treatment, according to fact sheets from the College of Psychiatric and Neurologic Pharmacists. Once in jail, Becker received steady treatment, and his mother said it took three to six months for his hallucinations to subside.
Emily Piper, lobbyist for the Iowa Psychiatric Society, called the case a “vivid example of how the system is not working” that underscores Iowa’s need for long-term care. She added, however, there was no proof such sub-acute care could have prevented Thomas’ death.
A lack of long-term care is one of many issues that plague the system.
“We do not have enough psychiatrists – that’s a very big problem,” said Deb Niehof, executive director, National Alliance on Mental Illness of Central Iowa.
Iowa ranks 47th nationally in psychiatrists per capita, according to the most recent review from the Health Resources and Services Administration and is short 157 mental health physicians. The worst shortages are in rural communities, which make up nearly half the state’s population and 89 of its 99 counties.
Due to state belt-tightening and limited county funds, even residents of urban, physician-filled counties may face service cuts.
Cash-strapped counties bear large burden
Counties rely on property taxes to finance mental health care programs, but an unchanged 1996 law froze those levees, essentially capping how much money counties could raise. As a result, counties became increasingly dependent upon state funding to serve the mentally ill.
Making matters worse, state funding for mental health has decreased since 2008, a trend officials expect to continue through 2012. In recent years some counties used federal stimulus funds to plug that gap, but that money has since dried up.
Over the past year, shrinking budgets have led seven counties to adopt waiting lists for mental health services. If the state does not increase funding, more counties will likely follow suit.
Johnson County, which includes Iowa City, may be among them, said Kristen Artley, director of its Mental Health and Disability Services.
The county recently held an emergency meeting of its mental health and disabilities planning council to discuss how to handle an unprecedented $2.5 million shortfall for 2011.
Along with instituting waiting lists, Johnson County may also make cuts to several non-mandated services, Artley said at the meeting.
Cuts to one of those services listed, a home care program, could prove devastating for Carol Spaziani and her son - a 49-year old diagnosed schizophrenic, who has relied on the program for 31 years.
“He would not make it on his own if it weren’t for that kind of service. He would be under the bridges or in jail some place,” she told the planning council.
Johnson County officials hope to avoid that scenario, but unless they receive more state or federal money, the county will have to reduce services.
“I don’t think anyone wants to make cuts,” said County Supervisor Janelle Rettig. “We want more money in the system, but we’re not allowed to spend another dollar.”
Directly north of Johnson, Linn County, which includes Cedar Rapids, faces similar decisions. Though it will likely end 2011 with a $1.8 million surplus for mental health services, officials predict a $5 million deficit in 2012, said Craig Wood, central point coordination administrator for the county.
Tight state budgets
Counties are not the only ones struggling to maintain services. The state's four mental institutions have grappled with tight budgets for years and recently found themselves endangered. Outgoing Gov. Chet Culver had proposed to eliminate 129 beds and 136 workers as part of the $84 million in cuts the Legislature required last spring.
One of the four institutes, the Clarinda Treatment Complex, considered eliminating all 30 beds for elderly psychiatric patients or all 20 acute beds, said Mark Lund, superintendent for the complex.
“Both Plan A and Plan B were pretty drastic,” Lund said. “People would just no longer be able to get that care.”
Terry Branstad’s Jan. 27 budget rejected those cuts. But the institutes remain under a hiring freeze and the number of beds is capped — reducing Clarinda’s acute care unit to 11 beds out of the normal 15 to 20.
Clarinda will also lose nine of its beds for the elderly, and the substance abuse treatment unit of the Mount Pleasant Mental Health Institute will cut 25 of its 45 beds, according to a letter from Chuck Palmer, Department of Human Services director.
These reductions diminish an already limited service. In a national ranking from 2001, Iowa had 13.8 beds per 100,000 people, and ranked 31 in the nation. By 2005, Iowa fell to 8.1 beds and ranked 47. As of 2007, beds dropped even further, to 5.8, although there were no national rankings that year.
Between 2009 and 2010, the number of people served by the four institutes dropped 8.4 percent, to 2,017.
A Legislature searching for remedies
Although both county-run and state-run programs face challenges, there is a movement in the Legislature to consolidate services under a state-controlled system.
A provision in the House version of the Taxpayer’s First Act, an omnibus spending bill, would have mandated construction of a new system in which the state would bear more responsibility for services and funding. Policymakers are uncertain how that system might look.
“The Republicans and Democrats have two different visions of how to replace it (the county system). Those discussions are just beginning,” said Sen. Jack Hatch, D- Des Moines. One early idea involves adopting a 10-region system that would deliver services locally.
The House bill would have also appropriated $25 million to help reduce the number of people on county waiting lists.
But the version of the bill recently passed in the Senate made no mention to mental health reform.
The Senate opted to address those issues, including the funding to alleviate waiting lists, in separate legislation, said Sen. Bob Dvorsky, D-Coralville, at the Johnson County mental health meeting.
“More than any year in the past several years, you’re going to see a lot more negotiation in Des Moines, because it is divided government,” he said. “Frankly, you’ll probably see a lot of things you don’t like coming out of Des Moines.”
State officials have voiced general support of efforts to consolidate what Branstad described in his recent budget brief as Iowa’s “99 different mental health systems.”
Others, however, are leery of such a shift.
Wood, the Linn County administrator, said he worries about the consequences of giving the state more control.
“In my experience, the mental health and disability services are always the first thing to go when a state has a budget problem.” he said.
Linda Hinton, government relations manager for the Iowa State Association of Counties, feels similarly.
“With a state system, people will fall through the cracks,” she said. “It is a one-size-fits-all system.”
Although recent discussions of reform have sparked hope among some advocates, Margaret Stout, executive director of Iowa’s chapter of National Alliance on Mental Health, remains skeptical.
“I’ve been director for NAMI for 20 years, and I don’t know how many documents I have – accumulating in my drawers and shelves – that have proposed solutions to our broken system that have not been funded,” she said.
Iowa’s mental health woes are hardly unique. Officials across the country are worried about how shrinking revenues might affect service for the mentally ill, according to a new report from the Center for Public Integrity.
Among the report’s findings:
- States have cut $2.2 billion from their mental health budgets over the last three fiscal years, and more slashing is expected in coming weeks as they finalize spending plans for 2012;
- More than a dozen states and the District of Columbia have cut their mental health budgets by more than 10 percent between 2009 and 2011;
- The nation’s mental health infrastructure may further erode, as the federal stimulus money that had been keeping it afloat officially dries up this summer;
This all comes as the nation's demand for services has increased.
Read reports from other regional partners in the project: