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Is Missouri hazardous to your mental health?

This article first appeared in the St. Louis Beacon, March 9, 2011 - If only Trip Powers had hit bottom a few months earlier, he might not have ended up in jail with a bullet wound in his leg.

Powers, 39, is on military disability for his bipolar disorder. Last December, Powers called his mother from Seattle, where he'd lived for 18 years, saying he needed her to take care of him.

But by the time Powers landed in St. Louis on Dec. 28, the emergency department of the area's only state-funded psychiatric center had been shut down for six months, a victim of budget cuts. Otherwise, Powers would likely have been committed. Instead at 3 a.m. on Jan. 2, he crashed through a window at Denny's Restaurant on Hampton Avenue.

The Denny's skirmish, during which a police officer shot Powers after he allegedly refused attempts to take him into custody, was Powers' fourth run-in with local police in five days. In the second incident -- three days before the Denny's debacle -- Richmond Heights police recognized his mental instability and took him to the VA Hospital for evaluation.

But Powers refused treatment, which was his right under strict federal rules regarding involuntary admission: a perceived risk of harming one's self or others being required. Those rules don't apply to state mental health facilities such as Metropolitan Psychiatric Center, whose emergency department used to serve some 200 clients every month.

"Metropolitan would have kept him, because the police would have said, 'Keep him'," said Powers' mother Teri Powers.

"If he'd been involuntarily admitted, he might have gotten the treatment he needed before the incident at Denny's," said State Rep. Jeanette Mott Oxford, D-St. Louis, who has been following mental health issues in Jefferson City. Mott Oxford plans to testify about Powers' experience before the newly forming Special House Committee on Disabilities Services

Jail Time Or Hospitalization

Powers was charged with felony property damage following treatment for his leg wound, three days at the St. Louis Justice Center and nine more in the city workhouse. He then agreed to psychiatric treatment at the VA.

But for those without VA benefits or private insurance, treatment can be hard to find, unless you can foot the entire bill. And good luck getting Medicaid. A Missouri family of four has to make less than $4,410 annually to meet the criteria. Even then, it can take a year to qualify.

At least 50 percent of Missourians with mental health issues simply don't receive treatment, according to Joe Yancey, executive director of the newly combined Places for People/Community Alternatives. Many don't even seek it, but it's out of reach for many who do.

"If you don't have Medicaid, then you don't have access to the public system," Yancey said.

There are two ways those with mental illness can get Medicaid coverage, according to Mark Utterback, president and CEO of Mental Health America of Eastern Missouri.

"Jail time or hospitalization," Utterback said.

Often people are first affected by mental illness in their late teens or early 20s. That's typical for schizophrenia and bipolar disorder, he said. "You cannot access state-funded services unless you get so sick that you end up in the hospital and come out of the hospital, or end up in the corrections system," Utterback said.

Early intervention makes returning to mental health more likely, said Utterback. By the time someone winds up in jail or the hospital, they're apt to be deep into their mental illness, dimming their chances of full recovery. It's a "dire situation" that comes at a high cost to state residents, Utterback said.

"It's short sighted to cut these services because it ends up costing the taxpayers a lot more money to have somebody institutionalized or in the prison system," he said. "There's so much stigma around mental illness that there is not the kind of support for ensuring services for the mentally ill as there is for other populations."

How Did We Get Here?

In a 2005 budget-cutting move, the state tightened Medicaid eligibility based on income to the strictest level allowed -- 20 percent of the federal poverty level -- for everyone except children and seniors, i.e., most of us.

Not long after that, it also became more difficult for agencies to help those with neither Medicaid nor private insurance using Department of Mental Health general revenue funds, according to Francine Broderick, outgoing Places for People executive director.

"We used to have a pool of money we could manage, and if a person did not have Medicaid and needed services, we could decide if that was the way to spend the money," Broderick said.

Now, except for extreme situations, general revenue is used to pay the roughly 30 percent of Medicaid's cost to the state, with the other 70-or-so-percent funded by federal dollars. When it comes to cutting the budget, services for the uninsured, which must be paid in full by the state, become "low hanging fruit," Yancey said.

"When you get to a decision about where to cut, it's easier to cut something where you're paying 100 percent on it than something where you're paying 30 percent," he said.

About 75 percent of Department of Mental Health spending is for patients living in the community. Expenses for programs in institutional settings, such as hospitals, make up about 25 percent.

Even though the department's budget has actually increased since 2006, escalating medical costs mean the money doesn't go as far as it used to. In the past five years, the number of full-time DMH employees has dropped to 7,874 from 9,231. Four hundred more positions are likely to be cut in 2012. Accompanying the decreased mental health staff is a drop in in-patient beds, to 1,315 from 1,558 in the past five years.

Many state-funded community services providers are limping along until 2014 when federal health-care reform will raise the maximum income allowed for Medicaid coverage to 133 percent of the poverty level. The changes will mean a family of four will qualify even if they make $29,325 a year. Many others will be insured through mandated state pools.

But the federal health-care law is being challenged in the courts, and a definitive Supreme Court ruling, if it comes, is some time away.

Averting A Tucson Tragedy?

Waiting lists for help through community providers did not exist until last year, according to Amy Blouin, founder and executive director of the Missouri Budget Project. That's not the case anymore, she said. Blouin said the situation endangers the community by delaying treatment for potentially harmful patients.

"I think there are a lot more Missourians who are not having their needs met," she said. "I would say there are greater risks -- absolutely."

The likelihood of violence is higher in people with severe psychosis, especially those not taking their medications. But only 3.6 percent of the 1 percent of the population with schizophrenia engages in serious violence, according to the National Institutes of Health. They're much more likely to become victims of violence.

Still, references to Jared Loughner, the alleged shooter in the January Tucson rampage often come up in conversations with local mental health services providers. Loughner is accused in the shooting that that killed 6 people and wounded 13 others, including U.S. Rep. Gabrielle Giffords. He did not seek mental health care even after it became a requirement for his readmission to Pima Community College. People like that are the ones who worry Jackie Lukitsch , executive director of the National Alliance on Mental Illness in St. Louis.

"The largest lack of access to care is among those who are not only uninsured, but who are also very, very ill, and wouldn't want mental health care if it was offered for free," Lukitsch said.

Getting that population into services is time-intensive -- and expensive. On the wish list of heads of local agencies is an expansive budget for outreach and engagement.

"Let's assume the guy in Arizona was mentally ill, and that he killed those people. Let's say the family knew there was something wrong but he wasn't coming in for services," Broderick said. "You send a team or one person out to engage him and become friends with him. He begins to trust them, and, if at some point they can see he needs medication, fine; they'll assess that, and whether or not he needs an involuntary hospitalization."

Definiton Of 'System Under Strain'

Every three years, the alliance issues a mental health report card for each state. Illinois got an "F" in 2006, which rose to a "D" in 2009. Missouri maintained a solid "C" throughout the period.

NAMI's 2009 analysis of the state of mental health care in Missouri, however, is still grim. It refers to 2006, when the state "cut its Medicaid program and mental health care systems to the bone."

"Three years later, the state also receives a C; but, in many respects, the overall situation seems worse," the report stated. "Missouri eliminated more than 100,000 people from Medicaid rolls in 2005 and 2006. Since then, no adults have had their insurance restored, and early efforts in managed care have resulted in cuts to mental health provider rates."

The biggest concerns, according to the report, are the growing numbers of the uninsured, the Department of Mental Health's management of state hospital beds and a lack of community and housing support.

The report also stated that "access to mental health professionals -- in particular, psychiatrists -- is a major concern. Access to care is a persistent and severe problem; in this regard, Missouri is the definition of a system under too much strain."

Bob Bax, a spokesman for the department, provided a general response to the Beacon when asked about the strain on resources and programs.

"The department carefully reviewed programs and services to ensure the most efficient and effective system possible at a time when, all across state government, we must find ways to optimize our resources. We are working on an ongoing basis with the community to develop more capacity for short-term psychiatric inpatient stays. We will continue to advocate for mental health services and make the best use of available resources."

Lukitsch says she is concerned about what she sees as complacency when it comes to funding services for mental health.

"Why are we so OK with this mediocre status quo of a 'C'?" she said.

In light of dwindling state dollars, community agencies are "doing their best" to secure alternative funding, Blouin said. "But the access to those resources is finite. There are only so many grants and so many donations you can receive to make up for millions of dollars of cuts."

Meanwhile, Teri Powers is worried that her son might fare much worse if his behavior ever again comes to the attention of the legal system before the mental health care establishment.

"My biggest fear is that he'll decide in a matter of time that he's doing fine, that he doesn't need the medication, and he'll have another psychotic episode," Powers said. "Maybe this time, a police officer will do more severe harm."

About This Article

This story includes work from the nonprofit, Kansas City-based Midwest Center for Investigative Reporting.
The Center for Public Integrity, a nonprofit, nonpartisan organization based in Washington, D.C., used information from this story and from local news sources from across the country to compile its own  report on cuts in spending on mental health.

Nancy is a veteran journalist whose career spans television, radio, print and online media. Her passions include the arts and social justice, and she particularly delights in the stories of people living and working in that intersection.