This is the second of two parts on the crisis in health care. Last week's installment was about government's search for solutions.

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Street Asylum

Budget cuts are leaving a homeless, mentally ill population with few options.

This is the second of two parts on the crisis in health care. Last week's installment was about government's search for solutions.

You can try to befriend Juan, but he knows what you did; he knows how you and everyone else in Seattle signed "the paper" stating that you would agree to help the Seattle police persecute him. The Cuban refugee is somewhat of an iconic figure in town. He stands on the corner of Sixth Avenue and Pine Street day after day and shouts at cars and buses about how the Seattle police are communists and, in fact, how everyone in Seattle is communist. "Seattle police bully-bully," is how he starts his cyclical tirade. He has a sign that explains parts of his message with religious overtones: The Frye Apartments and Seattle police not only are communists, but "devil communists" and Satan.

Juan has been protesting on that corner ever since police evicted him from the federally subsidized Frye Apartments for failing to pay rent a few years ago. Now he sleeps in the Municipal Building shelter at night. He is missing his top teeth, which he claims the police threw in the garbage. When asked why he doesn't get new ones, he pulls an imaginary knife across his throat. The police will follow him and get him when he's put under, you see. He takes breaks in the Nordstrom foyer off Pine, where he sometimes eats lunch. You must be careful, he explains: "People can put something in your food." Why Sixth and Pine? The buildings on at least three of the corners are where people go to sign "the paper" agreeing to give Juan trouble—Nordstrom, Pacific Place, and Old Navy.

Thoughts of persecution are typical of the mentally ill homeless population, says Graydon Andrus, the clinical programs manager at the Downtown Emergency Service Center (DESC). The nature of their illness—distrust of institutions, especially government-funded ones—makes it extremely difficult for them to get help.

The DESC has an outreach program called HOST, whose case managers identify people like Juan who are mentally ill and homeless, build relationships, and encourage them to get help. The outreach workers help with applications to get Medicaid and other benefits, an overwhelming process for a sick person living on the streets. But HOST is one of many mental-health-care programs that are being hit by federal and local budget cuts. HOST is funded with a combination of dollars from ACCESS, a federal project, and Medicaid money through the King County Regional Support Network. In the past two years, Andrus says, HOST has lost $300,000 in funding. Its budget is now $800,000, compared to $1.1 million in 2000. In the face of these cuts, they try to focus efforts on people who are the most ill. "The service gap keeps growing," says Andrus.

It is common knowledge that there is a crisis in health care at just about every level of the system, but it is particularly acute for the vulnerable population at the bottom of the social and economic ladder. One of the hardest-hit services in Seattle is mental-health care for those with no means. According to Dr. Richard Kovar of Country Doctor Community Clinic on Capitol Hill, there has been a sharp upswing in the uninsured and homeless in King County and, "worst of all, a sharp increase in the mentally ill."

The numbers of low-income or homeless mentally ill people have increased, doctors say, and many can no longer get treatment in mental-health clinics. The major reason is that they need to be enrolled in a certain subset of Medicaid. If not, they are not covered at most mental-health clinics. Prospective clients must not only have so-called Medicaid Title XIX, but Medicaid CNP (Categorically Needy Person) or GAX (General Assistance Expedited). Social workers say it can take up to 12 to 14 months to establish the right kind of Medicaid. Physicians determine who is eligible: patients with a chronic mental disability that makes them ineligible for work. Among other factors, they look for extreme disorganization, bad hygiene, an inability to take care of basic needs such as shelter and food, and limited social skills.

Kovar says the increase in the mentally ill population on the streets is due also to the push to deinstitutionalize care, an influx of people from out of state, and the rising cost of medicine.

Many mental-health clinics used to have reserve funding to take on non-Medicaid clients, but budget cuts in the past couple of years have severely diminished most agencies' ability to provide mental-health care for those who don't have Medicaid coverage. In 1995, 30 percent of the Downtown Emergency Service Center's budget was reserved for non-Medicaid clients. Today, DESC Executive Director Bill Hobson says, less than 2 percent of the budget is designated for non-Medicaid clients. Frank Jose, the executive director of Washington Advocates for the Mentally Ill, says that since 2000, the amount of time social workers can spend with people who are not on Medicaid in the mental-health system in King County has declined by 84 percent, and the actual number of people served on average per month has dropped by 36 percent. He cited figures from the Mental Health, Chemical Abuse & Dependency Services Division of King County. "Fewer people are being served, and even those people are getting less service," says Jose.

Andrus says that caseworkers at the DESC try to determine who is most vulnerable among the mentally ill homeless not covered by Medicaid. Sometimes they are able to offer help by increasing their caseloads, which already are high—around 34 clients per caseworker. "The bottom line is diminishing quality of care as caseloads grow," says Andrus.

So where do the mentally ill go when mental-health clinics can't accommodate them? Primary-care community health centers, where primary-care doctors serve as psychiatrists, because many mentally ill clients need medication. Psychiatry is not the doctors' area of expertise, and treating those who need that kind of help takes away from the time internists can spend with other patients. Kovar says there is no regular relationship for the mentally ill who show up at Country Doctor, and the clinic doesn't have the resources to treat severely mentally ill patients, such as those who are schizophrenic or bipolar. However, doctors are seeing more patients with these illnesses.

Many of the untreated mentally ill homeless end up in either Harborview Medical Center or the King County Jail?expensive alternatives to regular care in a mental-health clinic. A night in the Harborview psychiatric ward costs taxpayers a whopping $908 for acute psychiatric care and $1,370 for intensive psychiatric care and evaluation, and the average stay is seven to 10 days. About 60 percent of the people who go into Harborview for crisis help are homeless, says Tina Mankowski, the director of community relations at Harborview.

James Apa, the communications manager for Public Health-Seattle & King County, says the cost for the King County Jail is $185 per night in the psychiatric unit with a suicide watch and $111 without a suicide watch.

The average cost for a year of clinical service at the Downtown Emergency Service Center is $2,448. The cost of two weeks in jail and just two or three nights at Harborview would buy an entire year's worth of treatment at the DESC.

Since all these institutions are funded mostly with tax dollars, it would make sense to boost the budgets of the more-cost-effective mental-health clinics so they can accommodate non-Medicaid clients. Hospitals and jails are geared toward short-term treatment, retention, and crisis management?not long-term care and recovery. Dr. Ron Sterling, who serves on the King County Mental Health Advisory Board, says that, ideally, money would be moved from the corrections system to mental health. He also notes that some mentally ill homeless people are aware of their dilemma, so they find a way to get incarcerated.

If Medicaid sounds like some sort of golden ticket, soon even that might not guarantee access to mental-health services. Jean Robertson, the King County Regional Support Network administrator, says that in 2003 about 50,000 more people are expected to qualify for Medicaid, but the money available will likely decrease. Robertson says that this is potentially a very serious problem resulting from Gov. Gary Locke's proposed $40 million cut to the mental-health-care system. This leaves mental-health clinics with a difficult choice. "How do we define best who we should be serving?" Robertson asks. "Do we serve more people less well, or fewer people in a more effective manner?"

Meantime, Seattle's streets are filled with severely mentally ill people who can't get the treatment they need. Not all of them shout at cars and buses; some suffer silently until they finally fall apart. The lack of mental-health services could be the final push that sends someone over the edge.

Juan says he hasn't taken medication since he got evicted. He goes to the DESC, but he says only to get his mail. The police either have to kill him or give him an apartment to get him off the corner of Sixth and Pine. He really misses being able to cook Cuban food in his own apartment.

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