Mental Health Services

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Arizona is under a court order to provide services for people with serious mental illnesses, as required by state law. But as part of her budget plan, Governor Jan Brewer wants to remove that law from the books and eliminate most non Title XIX (Medicaid) funding for 14,600 adults with serious mental illnesses. Attorneys Charles “Chick” Arnold and Anne Ronan discuss their concerns and possible repercussions of the Governor’s plan.

Ted Simons: Governor Jan Brewer suggests change to the state's mental health system for people with serious mental illnesses. Those laws are at the heart of a decade's old lawsuit. More on that in a moment, but first, David Majure takes us to the state capitol where advocates were meeting earlier this week.

>> This yellow sheet summarizes the proposed cuts.

David Majure: They showed up to learn more about the proposal to eliminate services for those with serious mental illnesses.

David Majure: They're protecting -- they organized the meeting of consumers who rely on services the state provides.

Mitchell Klein: They're scared as hell right now. And they don't know what to expect.

David Majure: Mitch Klein expects the worst. Especially if Arizona reverts to a crisis-based system of care for people with serious mental illnesses.

Mitchell Klein: There will be people who go to jail. Who go to the hospital and the emergency rooms. There will be people who won't be able to function anymore. There will be a significant number of people who do crash. And unfortunately, some of them will commit suicide.

David Majure: Klein says waiting for people to crash is unacceptable, especially since Arizona has laws on the books that requires the state to provide comprehensive community-based services for the seriously mentally ill.

David Majure: In 1981, a class action lawsuit was filed to compel the state to fund a community residential treatment system mandated by state law. Nearly 30 years later, services have improved but the case is not closed. Now the governor is proposing to scrap the laws that the case is based on. She says it may be a way to balance the budget.

Mitchell Klein: I don't think they're going to save a penny. I think they'll spend more than they're trying to save in the long run.

John Hokanson: The governor concedes this point. That it will be cost shifting on to the counties and cities and hospitals and the costs will not go away. This is a zero-sum game. The mentally ill need this treatment and if they don't get it from the community-based service, they'll end up in the emergency room or worse.

David Majure: Klein says he's proof it doesn't have to be that way.

Mitchell Klein: I was depressed and non-functional. I wasn't working or paying taxes.

David Majure: Severe clinical depression rocked his world and destroyed his family.

Mitchell Klein: In 1997 I was told I would never work again. Now I'm at CEO of a corporation that works with seriously mentally ill adults on a peer-to-peer basis.

David Majure: He says it's due to the medications and the services he gets in the community.

>> They're here to express their concern with budget cut backs, particularly those that effect AHCCCS and behavioral health.

David Majure: It's a message he wants the state lawmakers to hear. [Applause]

Ted Simons: Joining me are two attorneys who have spent much of their careers fighting for people with serious mental illnesses. And joining us, chick Arnold and
Anne Ronan. Thanks for joining me. And an overview. The difference between seriously mentally ill and those with general mental illness?

Anne Ronan: I would say the fundamental difference, a person found to be a person with serious mental illness needs extensive support and treatment in order to live successfully in the community. A person with what they call general mental health needs needs treatment and support, but they can function in the community with treatment. Persons with serious mental illness have difficulty working and having relationships in the community.

Ted Simons: What numbers?

Anne Ronan: I believe statewide currently enrolled in the public system are somewhere around 35,000 to 40,000 persons with serious mental illness.

Ted Simons: And the governor wants to amend the law, wipe it out that, provides community services to the seriously mentally ill, correct?

Chick Arnold: That's contained in the current budget proposal. That's correct.

Ted Simons: And amending the law kind of removes the court order and that pretty much does the trick, correct?

Chick Arnold: The trick is established by the law. It's the statute that gives rights as entitlements to persons designated as persons with serious mental illness. What the court case did was interpret that statute in an way to recognize the mandatory duty created by that statute. In the statute is changed that would have an impact on the legal case that flowed from that statute.

Ted Simons: If the statute is changed, is there legal recourse?

Chick Arnold: Well, it's unclear, exactly what the effect of a proposed change would be. There's lots of options being discussed if terms of the nature of the change and there are other statutes involved that create the kind of obligation that the statute seeks to recognize. Indeed, it happened in 1979 at a time that recognized our community's commitment to persons with serious mental illness as reflected and embodied in that statute.

Ted Simons: If the governor's plans go through, the legal recourse could be there but not quite sure?

Anne Ronan: I think like chick said, there are a number of ramifications of the governor's proposal that are unclear and we don't know what the language is and don't know what the full impact is. But what we understand is that the intention is to eliminate the obligation on the part of the state to provide services to people with serious mental illness in the community. That's the intention behind the budget proposal.

Ted Simons: And the seriously mentally ill would then be treated the same as those with general mental illnesses?

Anne Ronan: No, no, there's a distinction based on whether or not you're Medicaid eligible to some degree. Some of the services that persons with serious mental illness who are Medicaid eligible would continue. For instance, the mandate is for community-based services. So housing, and employment support and other supports that help people with serious mental illness live in the community. They would be gone as a result of this proposal, regardless of whether you were Medicaid eligible or not.

Ted Simons: Interesting, so the Medicaid eligible part is a factor but not the full factor.

Anne Ronan: Right, that's correct.

Ted Simons: The -- so the seriously mentally ill -- I want to get it right now -- by way of the governor's plan, the services would basically, possibly, not necessarily, be guaranteed only by AHCCCS eligibility. That would be the new dividing line of sorts?

Chick Arnold: That is possibly the result of the current proposal. It's critical to recognize some premises inherent. Treatment works. People in our community are better off for having received case management services that helps with people who might otherwise become isolated. Crisis services that might help address a potential crisis before it manifests itself. Vocational rehabilitation. Treatment that's been provided and support consistent with the statutory requirement works.

Ted Simons: What happens to these folks then if this goes through and these folks -- Medicaid eligible or not, especially the ones who aren't eligible. What happens?
Chick Arnold: Our community is better off with having the treatment in place. The emergency rooms are no longer the dropoff points for persons in mental health crisis. Institutional care is reduced. Those things would be expected. I expect our jail population would -- our jail population of persons were serious mental illness would rise and we'd find use of emergency rooms as crisis intervention spots. It's not a good solution for our community.

Anne Ronan: And the interesting thing, the lawsuit was actually filed back in the late '70s, early '80s, because people did not have the support in the community and they were rotating through crisis and in-patient. And this population, they're estimated close to 17,000, we would be right back where we were prior to the lawsuit for those folks.

Ted Simons: According to the governor's plan, there could still be some money for crisis services, medication, maybe some housing. Is that correct?

Anne Ronan: That is correct. It's not clear how a person would get the medication because there would be -- according to the way we understand the plan, there would be no doctors or nurse practitioners to prescribe or monitor the medication. With respect to the housing, it's not clear that people who are not Medicaid eligible would get the housing support because these dollars support housing for people who are Medicaid eligible as well. And particularly, for anybody new who comes into the system, there's no new housing, certainly.

Ted Simons: It sounds you're talking about forced evictions of folks with serious mental illnesses.

Chick Arnold: That could be the case.

Ted Simons: Wind up in jails and hospitals and on the street?

Anne Ronan: Right.

Chick Arnold: It's critical to remember the genesis of the statutory requirements. In 1979, recognized the commitment of our community. We cared about persons who were under-served and left to wander the streets. To reverse that, I would suggest would represent a dramatic shift in the lives of many in our community.

Ted Simons: Back to the finances, how do matching funds, federal matching funds factor into in this or do they?

Anne Ronan: They do not.

Ted Simons: I know the government -- the governor, I should say, seems to think that the state can take care of who it can manage to take care of, and everybody else, there are crisis services out there that should be able to handle the load. Is that just wrong?

Anne Ronan: Absolutely, and I'm not sure the governor thinks that. I don't think she believes that crisis services alone can actually provide services and support to this population. You know, they are -- at the point you need crisis services, you know, a lot of the effort and possibilities for that person are gone. The real commitment is the ongoing day-to-day support from case management and employment support and housing that keep people out of crisis that allows people to recover and live with their mental illness.

Ted Simons: Again, back to where these people go and what happens to these folks, more of them in jails, more in hospitals, where does that money come from? And how does that cost factor into what we're discussing now?

Chick Arnold: That's a terrific issue and an appropriate way to look at that would be globally and recognize the cost of not providing preventive services. The support that Anne is discussing is what was envisioned by the statute. The kinds of non-medical based support that help people succeed. That are in need of the basic life skills training and assistance.

Anne Ronan: And I think if you're talking about where does the money come from, I think to a significant degree, the cost will go back to the counties for the incarceration of people with serious mental illness. And there will be more people -- the police will have to respond to more crisis for which they have nowhere to turn and they'll be back in that neighborhood again and again, because even if they were able to get them into crisis, that person will not have the support. The private hospitals will see these people with no reimbursement. There will not be an in-patient benefit to transfer those clients to another -- a funded hospital.

Ted Simons: So basically talking about turning back the clock to pre-1980?

Anne Ronan: That's what it looks like, exactly.

Ted Simons: Is the state ready for that?

Anne Ronan: I would hope not. I don't think the communities are ready for that. We're talking about 17,000 people, potentially, who many of whom have high needs and who living in our communities with supports and they will be without those supports.

Ted Simons: But the governor and lawmakers, many say there simply is not the money and structural changes need to be made to the budget and this is one way. And I think we're familiar with the governor and her ideas regarding mental health services. This is something close to her. She said on this program, it was difficult for her to do. But there simply isn't the money.

Chick Arnold: It's critical, Ted, we not allow the financial crisis. To stifle our creativity, our imagination, how we can continue to honor the moral and statutory commitment we've made to persons with serious illness. We can't hide behind the crisis. In order to take away rights, that have been embodied in the statute.

Anne Ronan: The truth of the matter is wherever this is looked at, the cost of not providing the community-based services far exceeds the cost of providing it. I was at a housing conference in which they gave the number, and for folks who went through crisis after crisis after crisis over a year's time, they spent close to $100,000 in emergency medical and hospitalization and crisis, and to provide them with housing and case management in the community was like $25,000 a year. So it's -- it's not a budget solution.

Ted Simons: All right, well, we'll stop it right there. Great discussion. Thank you for joining us tonight on "Horizon."

Chick Arnold & Anne Ronan: Thank you.

Charles "Chick" Arnold:Attorney; Anne Ronan: Attorney;

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