By MARY SELL, Alabama Daily News
More money for mental health care and legislation to increase access to care, especially for people in crisis, are expected in the upcoming session of the Alabama Legislature.
The potential bills will likely result in the first major discussions in Montgomery about mental health care since 2012 and 2015, when decisions were made to close three state mental health hospitals.
“I think with everything we’ve got going on in the state, all the things we’re doing well, one thing we’ve failed at is mental health,” House Majority Leader Nathaniel Ledbetter, R-Rainsville, told Alabama Daily News.
Ledbetter, at the request of Gov. Kay Ivey, has been leading conversations with state representatives about how to improve mental health care. He said Senate members, leaders from multiple state agencies and Ivey’s office are all involved and bipartisan support exists in the State House to make changes this year.
Ivey is expected to outline her goals for mental health in her State of the State address on Feb. 4. That’s also the first day of the legislative session.
Ledbetter said he expects efforts to:
- Make it easier for hospitals and law enforcement to detain people they think are in crisis and dangerous;
- Increase law enforcement’s crisis intervention team training, which is designed to reduce the risk of serious injury or death during emergency interactions with people with mental illnesses;
- Increase mental health screenings for individuals entering county jails; and
- Fund staffing a mental health professional in every public school system. Some systems already use local money to do that. “But as far as state money, it just hasn’t happened,” Ledbetter said.
Funding the need
The Alabama Department of Mental Health’s General Fund appropriation this year is about $127.9 million. Though it’s increased slightly in recent years, it’s still down from $143.2 million prior to the recession. In the early 2010s, its General Fund allocation was less than $100 million.
The agency has seen some increases in federal funding and its total funding in 2019 was just more than $1 billion. But ADMH is also responsible for services to Alabamians with developmental disabilities and substance abuse issues. Large chunks of federal funding in recent years have been dedicated to substance abuse treatment.
State hospitals were closed in part for budget reasons, Ledbetter said, and he’s not second-guessing those decisions. But as the economy improved in recent years, not enough focus has been placed on mental health.
“… I think we’ve failed — I did — by not being able to see the need,” Ledbetter said.
That need is illustrated in multiple statistics.
Suicide was the second-leading cause of death nationwide among people age 10 to 24 in 2017, according to the Centers for Disease Control and Prevention, accounting for 19% of deaths.
Suicides in Alabama increased by 21% between 1999 and 2016, according to the CDC.
Mental Health Commissioner Lynn Beshear last week told lawmakers that 75% of women in jail have one or more mental health or substance abuse diagnoses. Sixty-three percent of men in jail do.
And Alabama hospital emergency rooms are having to board individuals in a mental health crisis because there is no place for them to go, Beshear said.
Beshear and ADMH’s biggest request to lawmakers this year is $18 million to create three crisis centers around the state to provide treatment and resources to people who now likely end up in emergency rooms or with law enforcement.
There is legislative support for the plan.
“Unless we have a place to treat these people, we’re spinning our wheels,” Ledbetter said.
Lack of space
When Morgan County Probate Judge Greg Cain issues an involuntary commitment for someone with a mental health issue, that person first goes to a local hospital — not a state facility — for an evaluation.
But because of a lack of state-funded mental health facilities and space, those patients could stay at that hospital for weeks.
“I had a patient at Decatur Morgan West for 150 days,” Cain said recently. And because those patients aren’t yet in state care, that cost falls on county taxpayers, Cain said.
The patient with the five-month stay was on Medicaid, but Cain said, his office had a $169,000 bill for indigent mental health care last year. Most of that was at Decatur Morgan West, he said.
And worse, sometimes that hospital doesn’t have a bed available and there is no where for that person to go.
“If they can’t find a bed, they continue to decompensate in the community instead of getting treatment they need,” Cain said.
Or, they may get arrested and end up in jail, where they’re out of Cain’s jurisdiction.
“Now, the jail has to deal with them,” he said.
“They probably don’t need to be in jail, they need to be in a state hospital.”
The 77-patient Greil Memorial Psychiatric Hospital in Montgomery and 250-patient Searcy Hospital in Mount Vernon both closed in late 2012. The 54-patient North Alabama Regional Hospital closed in 2015. Three remaining state hospitals have room for 504 patients who need long-term care.
There were several reasons behind the hospital downsizing: cost savings for the state; compliance with a federal directive that people with disabilities shouldn’t be unnecessarily segregated from their communities; and because moving people to smaller facilities where they get more individualized attention closer to home is the right thing to do, state officials said at the time.
When plans were announced, officials pledged that services would be replaced in community-based centers, which could provide better care for less money.
“Part of what was supposed to happen (when state hospitals closed) was some of the funding was to go to communities,” Bryan Libell, executive director of Riverbend Center for Mental Health, which serves Lauderdale, Colbert and Franklin counties, said recently. “Those funds didn’t come to the community at the level we were led to believe.”
Some of Riverbend services are running on 2003-2004-level funding, Libell said.
To serve committed patients outside the three state hospitals, community mental health centers either operate or have access to approximately 215 beds in designated mental health facility crisis residential units, ADMH said last week.
But there have been complicating factors with those crisis residential units, Cain, the probate judge, said.
“If a person has another medical condition, they’re not going to accept them at a crisis residential unit,” Cain said.
Cain’s patient who had been at the local medical hospital for five months eventually got a spot at Bryce Hospital in Tuscaloosa, one of the remaining state hospitals.
“People are still mentally ill whether we have hospitals for them or not,” Cain said.
Care, not jail
Mental health services are a legislative priority this year for the Association of County Commissions of Alabama.
“I don’t think there’s a question that the lack of mental health beds has put us in a position we weren’t in a few years ago,” ACCA executive director Sonny Brasfield told Alabama Daily News.
The association is also asking for increased funding for the “Stepping Up Initiative”. Ledbetter said it’s on the list of legislative priorities.
Last year, Beshear said 21 counties participated in the national “Stepping Up” program to reduce the number of people with mental illness in jails. The program requires counties to develop a referral system with local jails and emergency rooms and provide case management for those referred to the system.
Beshear said the program faces barriers including low staff levels in county jails, inconsistent systems for data management and space and security issues for conducting assessments and screenings.
“For less than $4 million, we can get that in every jail,” Brasfield said.
Like Brasfield, Libell said if people don’t get mental health care, they become the correctional system’s responsibility.
“If the money (for mental health care) was in the community to begin with, hopefully they would never see the legal system in the first place,” Libell said.
Meanwhile, mental health providers are serving an aging population with more medical needs and medications. Libell said his need for registered nurses has increased.
And like the state’s prisons, mental health providers are facing a man-power issue, including a nationwide shortage of psychiatrists, he said.
Libell said his area is fortunate to have Shoals Hospital, which has a 20-bed acute psychiatric stabilization unit. The average patient’s stay is three to five days, according to the hospital’s website. Some are there voluntarily, while some have been committed by a probate judge.
“The inpatient unit stays full,” Libell said.
Statewide detainment law
Rep. Wes Allen, R-Troy, is a former Pike County Probate Judge. He said he’s seen the mental health issue from several sides, including that of law enforcement and care providers. He’s seen people who are a danger to themselves and others.
In 2019, Allen and a few other lawmakers passed county specific bills to make it easier for hospitals and law enforcement to detain people deemed in need of mental health treatment.
In Pike County, House Bill 471 now allows a hospital’s attending physician, nurse practitioner or physician assistant to detain and provide treatment to people for up to 72 hours if the individual “appears to be mentally ill, is a danger to himself or herself or others, and requires immediate treatment.” It also lets law enforcement officers take people into protective custody for the same reasons and transport them to a hospital or designated facility. Individuals don’t have to be charged with a crime and if they don’t consent to transport, officers may use reasonable force.
Without his law, unless someone commits a crime, there wasn’t much law enforcement could do for someone in crisis, Allen said.
“If someone is in distress, we want to get them help,” he said.
Since it was enacted last year, Allen said the law has only been used once or twice.
“It’s for those acute situations where you know without a shadow of a doubt that this person has problems and is a danger to themselves and others,” he said.
Similar bills were enacted in Dale, Houston and Barbour counties.
Ledbetter said there will be a statewide version of this legislation this year.
In total, Ledbetter said efforts this year will make a difference in the care of Alabamians.
“I think we can save lives,” he said.