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The Fraying of the Mental-Health Social Safety Net: Possible Costs and Consequences

This week has brought several excellent pieces in the papers and on the radio about mental illness and community services in a time of fiscal austerity. Here’s a browse through it, and some context.

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Occupy Wall Street and Occupy Together, surmising from various data points, seems to have a substantial focus on the fraying social safety net for the middle class, or what’s left of it; among the main concerns is access to health care. The fact that it much of its focus has been on income brackets above the poverty level has come in for some criticism, notably from my former colleague Steve Bogira at the Reader. I have mixed feelings about it—making the perfect the enemy of the good vs. overshadowing the problems of the very poor once again—but as #OWS draws attention to the expense of health care for those who are in the ballpark of being able to afford it, it’s worth giving a thought to the segment of our health care system that serves those who can’t. Especially this week, as there have been a few notable developments in Chicago and Illinois:

* Many aspects of Rahm Emanuel’s new budget have gotten lots of attention, even on the editorial page of the New York Times, from parking fees to water-rate hikes to increased sticker charges on heavy vehicles. One that hasn’t: public health. According to the Chicago Reporter’s Megan Cottrell, community services will be cut by nearly a fifth, more than any other segment of the budget:

During the first six months of next year, the department will close all of its health clinics and “transition the patients of its seven primary health care clinics to community-based federally qualified health clinics.” Mental health clinics won’t be shut down completely but will be reduced by half–from 12 to six.

* In the Tribune today, John Keilman reports on a “political battle royal over the closing of three state mental hospitals,” focusing state care on the incarcerated:

State officials say they are legally bound to care for those who have been found unfit to stand trial or not guilty by reason of insanity, and with a $58 million funding gap in the hospitals’ budgets, they must cut back elsewhere. They also contend that many people would be better served outside of a hospital.

* And it’s not just direct cuts—it’s also the backdoor cuts that come from late payments, as Sophia Tareen reports in the Sun-Times today, which fall heavily on community services:

llinois ranks first nationwide when it comes to nonprofit groups reporting late payments from the government, according to a survey last year by the nonpartisan Urban Institute. More than 80 percent of Illinois groups say their money doesn’t come on time.

* That survey has some sobering numbers across the board:

Human service nonprofits have been hit hard by the recession. Revenues from major sources such as government and donations have declined, and about 42 percent of human service nonprofits faced a budget deficit in 2009. Half of all organizations froze or reduced employee salaries, and almost 40 percent drew on reserves or reduced staff size.

* And to add insult to injury, the (infelicitous) name of DCFS’s recently departed director, Erwin McEwen, turned up in a state ethics violation report.

* In the midst of this, WBEZ has a well-timed series called “Out of the Shadows,” about mental illness among Illinois youth. I’d start with Alison Cuddy’s interview with Barbara Shaw and Mark Heyrman.

You may be thinking, “I’m not mentally ill and have health insurance, what’s in it for me?” A couple things. Well, there’s substantial evidence that taxpayers are going to have to pay to treat these mental illnesses one way or another, and it’s better for obvious reasons to do it before incarceration necessitates it (see Keilman’s article above). As E. Fuller Torrey writes in Out of the Shadows: Confronting America’s Mental Illness Crisis, excerpted as a companion to the excellent Frontline documentary “The New Asylums”:

Observations by psychiatrists and by corrections officials also support a causal relationship between deinstitutionalization and the increasing number of former patients in jails and prisons. California was the first state to aggressively undertake deinstitutionalization, implementing the Lanterman-Petris-Short (LPS) Act in 1969, which made it much more difficult to involuntarily hospitalize, or keep in the hospital, persons who are mentally ill. In 1972, Marc Abramson, a psychiatrist in San Mateo County, published data showing that the number of mentally ill persons entering the criminal justice system doubled in the first year after the Lanterman-Petris-Short Act went into effect. Abramson said, “As a result of LPS, mentally disordered persons are being increasingly subjected to arrest and criminal prosecution."46 Abramson also coined the term “criminalization of mentally disordered behavior” and in a remarkably prophetic statement said, “If the mental health system is forced to release mentally disordered persons into the community prematurely, there will be an increase in pressure for use of the criminal justice system to reinstitutionalize them. Those who castigate institutional psychiatry for its present and past deficiencies may be quite ignorant of what occurs when mentally disordered patients are forced into the criminal justice system.”

(As an aside, it’s worth noting for history’s sake that the deinstitutionalization of America’s mentally ill in the second half of the 20th century is not, in my understanding, primarily the result of heartless cost-cutting, and has more to do with adressing the rights of the mentally ill and responding to not-uncommon abuses in and of mental hospitals.)

Incarcerating people is often cheaper than treating mental illnesses, depending on how it’s done. In the 1992 publication “Criminalizing the Seriously Mentally Ill: The Abuse of Jails As Mental Hospitals,” by Torrey and multiple co-authors, it’s estimated that a medium-sized county jail costs about $46 per day per inmate, while an inpatient psychiatric hospital costs $250 per. Excellent comprehensive outpatient care, according to the authors (and based on a program in Dane County, Wisconsin) costs $55 per day including room and board: $22 for rehab, psychiatric services, and 24-hour crisis intervention, $16 for brief inpatient care and other medical expenses, and $17 for room and board. So incarceration may still be cheaper, but the external costs are worth considering.

 

Photograph: BitterScripts (CC by 2.0)

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