In Iowa, mental health services reform stalls

From the Des Moines Register:

Jeni Hodgkins (pictured), who suffers from bipolar disorder, is one of hundreds of Iowans waiting for mental health services from a county-based system that state lawmakers have long acknowledged is broken.

Both Republican and Democratic legislators and Iowa's governor have said they want to reform the system this legislative session, to reduce waiting lists and provide more equitable services. But reform efforts have stalled because of differences in approaches by the Iowa House and Senate.

Hodgkins, of Creston, has been on and off medications and has participated in numerous state health programs since she was diagnosed at age 17.

She has not been on medications for the disorder for about four years. Her latest attempt to seek help led her about a month ago to book an appointment at a mental health center in Creston, where the earliest she could get an appointment is June 29. Hodgkins hopes the June appointment can help her gain better control over fogs of depression and crying that sometimes bring her life to a halt.

"For the most part I'm able to manage, but there are some times it's so severe that I don't want to do anything," said Hodgkins, 32, a married mother of three children who works at McDonald's about 15 hours a week.

Like Hodgkins, hundreds of Iowans - more than 700 in Polk County alone - remain on waiting lists for mental health care in a patchwork system that differs among Iowa's 99 counties. The system serves those who can't afford to pay for mental health services without government help.

All told, providing government mental health services for low-income Iowans yearly costs $1.3 billion, of which around $500 million is from state and county contributions; the rest comes from federal allocations.

Hodgkins doesn't have health insurance and, with a total annual family income of around $25,000, can't afford to pay doctor bills. That leaves her at the mercy of social programs, one known as IowaCare, that she says would require her to see a doctor in Iowa City, nearly three hours away.

"The way I see it is, Iowa doesn't care," Hodgkins said.

Lawmakers this year spent an additional $20 million to trim the mental health waiting lists. But unless lawmakers can work out a long-term solution, most agree the lists will grow again.

Lawmakers seek to reduce disparities between county-run services. Polk County, for example, has programs targeted at specific populations as a way to reduce jail sentencing - an emphasis not available in some rural areas.

Some lawmakers also recognize that lack of money has led some counties to cut mental health services, forcing some Iowans to wait more than a year for certain services and prompting others to give up seeking treatment.

Beyond the suffering that accompanies the waits, there's an economic impact, mental health advocates say.

Many Iowans who seek help, like Hodgkins, remain fully or partially unemployed. Sometimes relatively inexpensive treatments could help them lead more productive lives.

"When families can't access mental health services, it's hard to function," said Kristie Davidson, who is with MATURA Action Corporation, a family-focused social service program in southern Iowa.

Recent high-profile cases in Iowa - including the shooting death this month of Keokuk County Deputy Sheriff Eric Stein - have pushed mental health care to the forefront of public discussion. Stein's killer suffered from mental illness for decades, his family said.

The House and Senate have outlined separate plans in which the state would take over administration of mental health programs for all 99 counties. The transition would start in July 2012.

The Senate version, Senate File 525, calls for eight mental health regions consisting of contiguous counties. Each region would include one of the state's larger cities: Ames, Cedar Rapids, Council Bluffs, Davenport, Des Moines, Iowa City, Sioux City and Waterloo.

The House version, House File 626, creates a statewide system. Republican representatives say their goal is to eliminate a $125 million mental health tax that counties collect, and have the state and federal governments fully pay for the costs. But that's not yet written into the bill.

Both plans intend to streamline and improve services. But state officials, some legislators and some mental health advocates have concerns with the plans.

One of them: What happens when the state runs short on cash, or when the political will shifts against providing services?

Bill Peterson, executive director of the Iowa State Association of Counties, also questions the proposition promoted by some legislators that shifting control from locally elected officials to the state will make providing services less expensive.

Those involved in the discussions note that counties collect and report data on mental health services differently. So state officials don't have clear data to properly assess programs statewide.

The size of the mental health waiting lists may be misleading, for example, because the same person can be on multiple lists for different types of mental health treatments. A person also might be receiving some services, but be on a waiting list for other treatments.

"It makes it very difficult to even figure out how much the system costs or how much we need to move forward in a redesign," said Rep. Renee Schulte, R-Cedar Rapids, who has worked with the House proposal. "One of the advantages of having a state-run system is we could get a handle" on statewide needs and costs.

Gov. Terry Branstad said this month that a uniform system would help the state better manage and control costs.

"It may well cost some more money, but I think the focus ought to really be on providing the best services, making sure they're accessible everywhere in Iowa," Branstad said.

Chuck Palmer, director of the Iowa Department of Human Services, will meet with House and Senate officials Monday in an effort to help both sides come to agreement. Under both plans, DHS would work with legislators through the next year to hash out specific details, which would go before the Legislature for approval in the session that begins in January.

Sen. Jack Hatch, D-Des Moines, said the Senate plan calls for more county cooperation and, he believes, presents a better framework for reform.

"The House is reading from the same book, but they're on a different chapter," Hatch said.

Lynn Ferrell, executive director of Polk County Health Services, questions whether it's the right book.

"It's difficult to see what exactly these bills do to fix the problems in the current system," Ferrell said. Most problems stem from inadequate funding, he said, "and there's nothing in them that says anything about adequately funding the services."