Mindful Reform

It's time for lawmakers to reconsider how we treat and care for the mentally ill.

When the Legislature begins its 105-day session on Jan. 10, no issue before it will be more pressing or affect more people than how we deal with mental illness—or don't. From enacting mental-health insurance parity, which would help people of all ages and income levels, to undertaking progressive reform in the treatment of state hospital patients, lawmakers need to act.

They need to act with compassion and wisdom and a collaborative spirit, though that's hard to envision in deeply divided Olympia. Democrats control the House by a sizable majority and the Senate by a thin margin. The Democratic caucus in the House is itself divided between aggressive budget cutters and proponents of expanded social services. Republican Dino Rossi, meanwhile—Washington's presumptive governor-elect at press time, barring an increasingly possible win by Democrat Christine Gregoire in the ongoing re-recount—is committed to tax and regulatory breaks for business and to shaking up the bureaucracy.

The Legislature has a social agenda and the power of the purse, but Rossi wields the veto pen. And both parties must tussle over a projected $1.8 billion budget deficit for the 2005–06 biennium. (Outgoing Democratic Gov. Gary Locke last week proposed new "sin" taxes to help bridge the gap, noting that cuts to social services still will be necessary.)

But when it comes to the issues we outline here, the Legislature and the governor must not hesitate, lest many thousands of people become irredeemably lost. Some of these are problems that Washington lags other states in solving, problems that are pushing local social-service providers to the breaking point. Some of these challenges affect actual business productivity, when you consider how many high-functioning family breadwinners would be more effective if they could afford a modest level of mental-health care—if insurance companies covered medical care of the brain as well as they cover big and small failings of the body's other organs.

This year, Seattle Weekly has focused on some of the state's most acute mental-health challenges. These are our suggestions for legislators, based on what we've learned about an underfunded and poorly managed system.

Mental-Health Insurance Parity

For as long as there has been health insurance in Washington, the state has permitted discrimination: Insurance companies can offer lesser benefits for treating mental illness than they do for so-called physical ailments.

If a patient has cancer, there are few limits on how many times he or she can visit a physician and be reimbursed, and co-payments and pharmacy privileges are the same as for people with strep throat. When it comes to treating depression, bipolar disorder, and schizophrenia, however, the same companies are allowed to limit doctor visits (in some cases, to two visits annually), charge larger co-pays, and offer reduced pharmacy benefits—if they offer mental-health coverage at all.

The rationale is that mental illnesses are not the same as physical ones. This outdated presumption perpetuates the social stigma surrounding mental illness and is contradicted by, among other things, ample scientific evidence that mental illnesses derive in part from the same sorts of flawed genetics as cancer.

Since the mid-1990s, 38 states have changed their insurance laws to eliminate this discrimination, including progressive bastions like Alabama and Arkansas. Over the past seven years, advocates for the mentally ill in this state have repeatedly proposed similar legislation. Each attempt has been shot down, principally after lobbying by business groups and insurance companies, which have convinced some legislators that equalizing benefits would explode health care costs. It's fashionable among conservative politicians and the Rossi camp to paint parity as a "mandated cost."

Such talk does not pass the sniff test. Around the country, where states have enacted parity legislation, insurance premium increases have been negligible. A recently released study by PricewaterhouseCoopers, a respected accounting firm, projects that parity in Washington would boost premiums by less than one-half of 1 percent. At the most, that works out to an average increase of about $3 per month per covered employee, according to the study. Three bucks is the cost of a grande latte, including sales tax.

Such a small increase sounds more like a smart business investment than a draconian mandated cost. Besides, as in other states, parity would lead to reduced employee absenteeism, fewer disability claims, and increased productivity. It's time for the Legislature to pass this important legislation, which would help potentially hundreds of thousands of Washingtonians, and whoever the governor is should sign the bill without delay.

Non-Medicaid Funding

King County is on the verge of shunting an estimated 2,000 low-income mentally ill people off the public mental-health rolls come Jan. 1. In Pierce County, it's another 1,700. Spokane County cut off services to 900 such people in October.

Each of these people fails to qualify for the federal Medicaid program, despite the seriousness of their illnesses and their lack of income. Medicaid is funded by a combination of federal and state dollars. For the past decade, local public mental-health providers, known as regional support networks (RSNs), have been able to cover these needs through savings in the treatment of patients who are covered by Medicaid. Earlier this year, the feds changed the rules and will no longer allow Medicaid money to be diverted to people not officially covered by Medicaid.

In the opening days of the session, the Legislature must pass an emergency appropriation to cover non-Medicaid patients until July 1, when the new budget year begins. King County needs $4.5 million, and Pierce County requires $2 million. Spokane County needs $1.2 million. Other RSNs need emergency funding, as well. After that, the Legislature needs to appropriate funding—upward of $80 million, by some estimates—to cover these same people in the 2005–06 budget.

If anyone thinks there is no correlation between booting people off the public health rolls and trouble on the streets, they ought to look south to Oregon, where the Legislature cut funding for medication for 2,000 schizophrenics. As a result, some former patients wound up dead. If our Legislature and the governor fail to act, thousands of Washingtonians will be loosed to face their demons under bridges and against alley walls.

Program for Adaptive Living Skills

As we reported in August, the Program for Adaptive Living Skills (PALS) at Western State Hospital in Steilacoom takes people who have been medically discharged from the hospital and stuffs as many as 100 of them into a facility on the hospital's campus while they await housing and treatment in the community. In essence, they are prisoners to this arrangement, for upward of eight years, because there seldom are adequate resources in the community and because these patients are not foolish enough to walk out the facility doors and fend for themselves on the streets, though they are free to do so.

Almost three years ago, the state Department of Social and Health Services began to move PALS patients into homes in the community and offered them aggressive psychosocial treatment, in addition to suitable medication. Patients who had been in Western for more than a decade gained a measure of dignity and normalcy while the state halved its costs of caring for them. The initiative was known as Expanding Community Services (ECS), and it has worked so well that few participants have had to return to Western. But DSHS halted the program last year.

The Legislature should move swiftly to restart this effective and humane program, as well as end the weird limbo that is PALS. The good news is that such action would require no new state money beyond PALS's current $5 million, the funds of which can simply be shifted to resources in the community.

There will, of course, be other issues involving the mentally ill that come before the Legislature in the forthcoming session, such as the acute lack of psychiatric hospital beds in Washington's communities. They, too, deserve consideration but are too complicated for the scope of this article. All of these issues, big and small, affect real people with sometimes debilitating illnesses in profound ways. For too long, the Legislature has made excuses for its failure to deal with such problems. For example, some lawmakers have shied away from voting in favor of insurance parity by claiming not to understand the issue. That and other issues have been fleshed out in previous years and are well known to elected officials. It is long past time for them to act on that knowledge.



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