A 1988 state law designed to move people out of institutions and into community-based care has never been properly funded. The looming budget deficit may further decimate the system.
THE COLUMBUS DISPATCH
CHRIS RUSSELL | DISPATCH
With no home for the night, a client of Southeast Inc., a mental-health and recovery agency, sleeps outside its Downtown offices.
Mental-health care in Ohio
‘An illusion of treatment’
1988 act worked well, for a few years
Son’s lonely ride through mental illness ends
Clients easily fall through safety net
Ohio’s mental-health system, once a national model, is on the verge of collapse as the state careens toward the biggest budget crisis in memory.
Thousands have been slashed from the mental-health-care rolls. Others might have to wait months to see a psychiatrist. State funding for mental-health services has been decimated, Medicaid is gobbling up scarce local dollars, and hundreds of small group homes for the mentally ill have closed.
Prisons, nursing facilities and homeless shelters are the new homes for thousands of mentally ill Ohioans, advocates say.
“Our state leaders have washed their hands of Ohioans who are suffering from mental illness,” said Terry Russell, a veteran of 37 years at the local and state level in Ohio’s mental-health system. “If we are to be judged by how we treat the sickest in our society, we should all be ashamed.”
There is no shortage of blame. Some is aimed at Gov. Ted Strickland, a former prison psychologist and Methodist minister. His budget, approved by the legislature, cut funding to mental-health programs by 35 percent in the past three years as the state grappled with plummeting revenue.
But Ohio’s history of broken promises stretches back much further than the current governor:
• The Mental Health Act of 1988, designed to move people out of state hospitals and into a community-based system of care, was never adequately funded. Money did not follow patients home as former Gov. Richard F. Celeste and others promised.
• Medicaid, the state and federal health-care program for the poor and disabled, has grown dramatically. Ohio’s share of those costs has swollen to the point that Medicaid consumes nearly all local mental-health funds.
• Those in need of services who are uninsured and do not qualify for Medicaid are finding it increasingly difficult and often impossible to get help.
The plight of Ohio’s mentally ill is expected to get worse next year as state officials face a projected $8 billion budget shortfall.
The National Alliance on Mental Illness estimates 418,000 Ohioans – including 124,000 children, suffer from serious mental illness (major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder, post-traumatic stress disorder). Fewer than one in four are receiving services.
Last month, the advocacy group listed Ohio among the 10 worst states for mental-health budget cuts.
“We’re in trouble. … The mental-health system is on the verge of collapse,” said Cheri L. Walter, chief executive officer of the Ohio Association of County Behavioral Health Authorities. “The mentally ill in Ohio are homeless, living on the streets, and in jail.”
While services are being provided to larger numbers of Ohioans, Walter calls it “an illusion of treatment.”
“People may get an assessment and a visit, but need more. If they get services, it will take them longer. If they are part of the working poor, they may or may not get services at all,” she said.
“We’re at a 10-year high for suicides, and murder-suicides have exploded. With the economy being in the state it is, more and more people are extremely stressed.”
Susan Ackerman, a fellow at the Cleveland-based Center for Community Solutions, said the lack of investment in mental-health services is leading to higher costs elsewhere.
“Failure to meet the needs of people with mental illness in a community setting has resulted in increased hospitalizations, nursing-home placements and incarceration,” Ackerman wrote in a recent report. “Not only are these alternatives inappropriate – and in many cases inhumane – but they also are significantly more expensive.”
Ohio now houses more mentally ill people in nursing homes than in state psychiatric hospitals.
“People are falling through the cracks,” said Carolyn Givens, executive director of the Ohio Suicide Prevention Foundation.
Ohio’s mental-health system, she said, is dying a “death by 1,000 paper cuts.”
The state Mental Health Act of 1988 was intended as a seismic change, shifting the focus from institutional care to community-based services. The law expanded the role of Ohio’s 53 county boards of mental health or combined alcohol, drug-addiction and mental-health boards, which rely on federal, state and local funding to provide services in hospitals and through community agencies.
The idea was to encourage local treatment, which is less expensive and allows counties to maximize their funding. The law did succeed in downsizing state psychiatric hospitals, from an average daily population of 3,823 patients in 1988 to about 1,000 today.
But more money was needed to meet growing demand for community services. Instead, the state, facing a devastating shortfall of money, cut funding by more than $100 million over the past three years.
Ohio’s next governor, either Strickland, the incumbent Democrat, or John Kasich, his Republican challenger, will decide the fate of the failing system. Both told The Dispatch that mental health will be a high priority.
“Some of the decisions I’ve had to make are really painful to me,” said Strickland, who privately has told friends he has lost sleep over the fate of mentally ill Ohioans.
“I wish we could have given more money to mental health. That’s my field, and it’s been painful to me as I’ve traveled around Ohio and I’ve bumped into people who used to be my friends complaining to me that they feel like they haven’t gotten what they needed, and I understand that.”
Kasich doesn’t talk specifically about his plans, but has said he feels strongly about maintaining “programs that affect people who have no where else to go – the mentally ill, the developmentally disabled.”
Kasich has first-hand experience with the issue. His younger brother, Rick, has struggled for years with mental-health problems.
Fear and anger inside
County officials struggling to provide care, such as David A. Royer, chief executive officer of the Franklin County Alcohol Drug and Mental Health Board, say the state is failing to meet its obligation and undermining the Mental Health Act.
In a harshly worded letter to state Mental Health Director Sandra Stephenson this year, Royer wrote: “The governor and you are effectively dismantling the act. This decision is a decision that I believe will be a bitter legacy for years to come for people with mental illness and the system that supports them and their families.”
By December – only halfway through the state’s fiscal year – Franklin County expects to exhaust its state aid, along with $4 million in local levy revenue, on Medicaid costs. Royer said he won’t use more local dollars because he needs money to serve the 35 percent of patients who are not covered by Medicaid. Non-Medicaid services, he said, already have been cut by $14 million since October 2008.
“Mental-health services are more than state hospitals and Medicaid,” Royer said in an interview. “To succeed you need the local, state and federal governments, but what we’ve witnessed is that the state is failing to meet its base obligation.”
Stephenson took the helm of the state agency in 2007 after 20 years in the trenches as director of Southeast Inc., a mental-health-care agency in Franklin County. She had to make drastic cuts to the agency she had just left and others across the state.
She acknowledged that the Mental Health Act was “not funded properly from the beginning” but stressed that more people are being served. Statistics support that, but critics say numbers don’t show the kind of services being provided.
The state has agreed to provide additional funds to Franklin County and also is propping up three other agencies in danger of collapse, Stephenson said.
While she doesn’t agree that the whole system is on the verge of collapse, she said there is “unevenness” in services across the state.
Where are they?
Most people who have insurance and can afford counseling and medications can live stable lives at home. Not so those who fall through the cracks: They end up in nursing homes, homeless shelters, jails and prisons.
At least 1,683 individuals with serious mental illness (out of a total of 9,400) living in nursing homes in Ohio could be served in less restrictive and expensive ways, officials say.
Then there is the price tag for the thousands locked up.
In Franklin County jails, one in four inmates is on medication for mental illness, said Chief Deputy Sheriff Mark J. Barrett. Last year, the sheriff’s office spent nearly $1 million on medication and additional money for psychiatrists, counselors and liaisons to help the mentally ill.
“It’s a never-ending cycle for many of these people,” he said. “We have one guy, we call him our frequent flier because he has been in our jail 230 times over the last 10 years.”
Barrett said many of those jailed with mental illness live on the street and act out after they stop taking their medications. Their families often are frustrated and have given up on them.
In state prisons, about one in five inmates suffers from mental illness. Roughly 4,700 are diagnosed with serious mental illnesses and nearly 7,700 inmates are on anti-psychotic or other mental-health medications.
The tab for taxpayers: $5.2million in the fiscal year that ended June 30.
Some former hospital patients live in small group homes, “mom and pop” operations such as the one Bertha Powell runs on Sunbury Road. She gets $27 a day to house and feed each of eight male residents.
Powell, in her 70s, pulled a bubbling casserole from the oven one day recently and sliced two tomatoes from her garden for a salad. It was nearly noon and she knew the men would be hungry.
“They like to eat,” she chuckled.
Powell has spent most of her life cooking, cleaning and doing laundry for somebody. She cared for her five brothers and sisters after her mother died and later raised seven children and a grandchild while working for the Postal Service.
She retired in 1999 and then, after praying about it, decided to do “something Christ-like” by converting the two-story house where she raised her family to a home for mentally ill men. She lives next door.
“We’re like family,” she said. “We sit down together. We eat together. I know when someone isn’t feeling well.”
Frank Herrera, 60, a resident at Powell’s home, is a Lorain native who is diagnosed as paranoid schizophrenic. He served 11 years in prison for assault before coming to Columbus. During the winter of 2004, his “home” was the woods not far from Nationwide Arena.
“It was like living in hell,” Herrera said. “I had to survive looking in Dumpsters for food and sleeping in layers of clothing. I didn’t have nowhere to go.
“I found plastic. I found blankets. I felt miserable. Nobody cared. I was out on my own.”
Fortunately for Herrera, he was picked up by the police and taken to the Franklin County jail. He was sent to a halfway house and eventually landed at Powell’s home.
“I got a place to live. The food is hot. They treat me real good. I get along with everybody,” he said. “I love it. It beats living on the streets.”
In an older home not far from the Ohio State University campus, Johanna Queck has been running a similar group home since 1985. Cuts in state funding limit her to five people instead of the eight she once had.
“I just don’t know how much longer I can stay open with five people,” she said. “We didn’t get a raise. The electric goes up. The gas goes up. The groceries go up. We get nothing.
“I don’t want to close. I don’t want to put these people out on the streets. … We are their family. We take care of them. … But if I lose another one, I won’t have any choice.”
One resident, Mary Brown, 58, was in a state hospital before coming to Queck’s group home.
“This in reality is the only place I really like.” At other places, she said, “they treated me bad. … It was like being in jail. I hated it.”
She added: “This house makes me feel more free. Without this place, I’d be lost.”
Dispatch reporter Mark Niquette contributed to this story