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Recent tragedy reminds public about importance of ‘safety net’ servicescomment (0)

January 3, 2013

By James L. Dill

As we enter a new year, the nation remains shocked and saddened by the horrific event that occurred in Newtown, Conn., in December. The school shootings at Sandy Hook Elementary School in Newtown, as with the other mass killings, bring with them renewed focus on the prevalence of violence in our country, calls for the review of gun policies, and the inadequacy of access to appropriate mental health treatment and care for countless people who need it. 

2013 also marks the 50th anniversary of the passage of the Community Mental Health Act of 1963, which was passed during the presidency of President John F. Kennedy. This legislation changed the direction of public mental health care away from large institutions toward a community-based system of outpatient, residential and support services.

The movement has brought successes and failures, but the challenge of preserving the infrastructure of the safety net of public mental health services in light of declining public resources will be formidable. Assuring that public safety isn’t compromised, given the expectation of continuing funding reductions, is unrealistic. 

As Christian believers we need to enter into the public debate that is now before us regarding public mental health policy and violence. As we do so, we need to enter such discussions fully informed about the potential consequences of the decisions we make. All too often, issues are addressed and decisions made only after horrific tragedies occur. Timely access to appropriate mental health services requires sufficient funding to assure that services are provided.  

Tragedies like the one in Newtown remind us that we are all vulnerable when public safety net services are compromised. Whether or not mental illness was a factor in the Newtown shootings remains to be determined. Serious mental illness has been substantiated in some mass shootings. In others, it has not. 

Serious mental illness is generally understood now to have a physiological basis to it and is beyond the scope of this paper and writer to address in clinical terms. The widespread prevalence of illicit drugs, breakups and breakdowns in family stability, excessive preoccupation with violence in movies, television and video games, among other societal changes, have contributed to serious emotional problems among ever increasing numbers of individuals.

The current community-based system of safety net services generally includes a continuum of outpatient therapy/counseling services, day treatment services, case management, crisis teams, assertive community treatment teams, group homes and access to inpatient hospital care. Such services are conceived as alternatives to more costly state hospital care. 

While great pains are being taken to preserve the community safety net, mental health advocates and others claim the services are not enough. The existing community mental health services have been sufficient to permit a substantial reduction in the size and number of costly state-operated mental hospitals, but that is only one of the anticipated objectives of the public sector safety net. The safety net has not been developed anywhere near the capacity required to meet the ever increasing mental health needs of a complex and increasingly vulnerable citizenry. 

For a number of years, Alabama’s General Fund Budget was subsidized through federal dollars. The economic downturn of 2008 brought with it a decline in state revenues, but Alabama’s General Fund Budget didn’t receive an immediate hit because of federal stimulus funds. Once the stimulus funding expired, the state’s General Fund Budget could no longer meet the basic core functions of state government, i.e. Medicaid, public health, public safety, mental health, human resources and corrections.  

Since 2009, the General Fund Budget appropriation to the Department of Mental Health (DMH) has been cut 28 percent, by approximately $40 million. Such cuts are clearly taking their toll on the infrastructure of Alabama’s public system of mental health care. These cuts have forced the DMH administrators to choose between cutting the safety net of care for some of Alabama’s most vulnerable citizens and reducing the size of state mental hospitals even further. The obvious and correct choice was to do the latter and leave the array of community services that comprise the safety net intact, if possible.  

The first round of cuts resulted in the number of state hospital beds being reduced to 900. Then Gov. Robert Bentley authorized the closure of Greil Hospital in Montgomery and Searcy Hospital in Mount Vernon near Mobile. The closure of Greil and Searcy was achieved by October 2012, producing significant savings but not quite enough in savings to totally eliminate the current deficit. 

While more than 100,000 individuals seek treatment and care in community mental health centers annually, countless others are served within the primary health care system and in private psychiatric practices throughout the state. Regrettably, too many individuals with serious mental illness run afoul of the law and wind up in jails and prisons. Still too many others go untreated for various reasons and may be seen in shelters, on the streets and in underpasses. 

The decisions facing mental health officials in Alabama are serious. Should the DMH close another state hospital? Should the community safety net system be reduced by eliminating certain services or further restricting who has access to publicly funded mental health services? If so, which services should be eliminated? Which type of mental health diagnoses should be denied access to treatment? What would be the impact of restricting access to much-needed medications that contribute greatly to the stabilization of the symptoms of mental illness?

There are four state mental hospitals in operation in Alabama at this time. The Taylor Hardin Secure Medical Facility in Tuscaloosa is devoted exclusively to serving forensic patients. Bryce Hospital in Tuscaloosa and North Alabama Regional Hospital in Decatur serve patients who are committed through the various probate courts. The Harper Facility in Tuscaloosa serves geriatric patients. 

It is probable that another hospital could be closed to help offset the deficit without compromising public safety, but there would remain a sizeable deficit projected for fiscal year 2014 that cannot be satisfied through further state hospital reductions beyond that. 

The issue of hundreds of thousands of Alabama citizens with inadequate or no health care coverage also is a concern. 

The Affordable Care Act offers additional funding through expanded Medicaid coverage and insurance exchanges. It appears that the State of Alabama will refuse the additional federal aid even though state-matching funds would be no more than 10 percent of the cost of the expanded care and nothing for the next three years. 

The State of Alabama persistently ranks at or near the bottom in state funding for essential public services, and many times this is touted as a good thing. However, the relationship of public funding to the quality of life for all Alabamians is systematically ignored. 

Without increases in state revenues, which are highly improbable, there remains little choice but to cut the safety net of community-based services. When the safety net infrastructure is compromised, so is public safety.  

In Matthew 25 we find the Lord’s commandment to take care of “the least of those among us.” Some say caring for the vulnerable and needy among us is the work of the church and private charity alone and not appropriate for government. It is indeed the work of the church and private charity, but the collective needs of our most vulnerable populations cannot be met through the corporate church or charity alone. 

In Romans 13 we find that government is given to us by God for “His purposes” and “our good.” The argument that caring for the “least of those among us” is not an appropriate role for government simply lacks scriptural merit. The government’s role in this matter is indispensible and within the purview of Scripture. 

Editor’s Note — James L. Dill, Ed.D., is executive director of the Alabama Council of Community Mental Health Boards.

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