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Grading the States 2006: South Carolina - Narrative

Ask people familiar with South Carolina to rate the state's mental health system, and the answer you get is "average."

Still, the state has significant problems. Specifically, it has fared poorly in providing access to crisis and acute care treatment. Over the past several years, the South Carolina Department of Mental Health (DMH) has reduced the number of inpatient psychiatric beds it operates.

While these reductions originally represented a desire to provide more care in a community setting, in recent years the cuts have been budget-driven. DMH bed reductions went too far, leaving hospital emergency departments and local jails as the only alternative for many patients who need a state psychiatric hospital bed. Nearly 50 percent of DMH acute care beds, those intended for short stays, are now occupied by long-term patients who were displaced when the state started the process of closing the last of its long-term psychiatric hospitals.

DMH's waiting list for its forensic facility also has reached a length that is unacceptable, from both a legal and a patient care point of view. A recent surge in emergency admissions from jails (e.g., suicide risks) has decreased available beds for court-ordered, pre-trial evaluations and restorations to competency for trial.

While DMH to its credit appears to realize the shortcomings in the system, prospects for relief are uncertain. Governor Mark Sanford recently released his executive budget that funds a mere 30 percent of what the department requested. If the governor prevails, the crisis in hospital emergency rooms and jails will continue.

Since 2001, DMH has lost $30 million in funding - dropping below its 1998 level, even as the cost of programs increased by more than $45 million. Advocates support selling state-owned land near the primary state hospital and dedicating proceeds to the improvement of mental health services - but the governor instead is pushing to put them in the state's general fund.

The state also is taking aim at Medicaid.

South Carolina enjoys a federal match rate of approximately 70 percent on Medicaid expenditures, but is seeking reforms that would impose a cap on expenditures for each Medicaid beneficiary. Some analysts consider the proposals "the most radical changes ever made in a state Medicaid program." If a strict cap is adopted, the state stands to suffer significant economic consequences - it would be prohibited from seeking additional funds in the event of a natural disaster, public health emergency, advances in medical technology and medicines, or expanding long-term care for an aging population.

Concern also exists as the state soon will be drafting reforms aimed at people with serious mental illnesses. Currently, the state plan goes beyond federal requirements to support Assertive Community Treatment (ACT) and peer specialists. There is no guarantee that these critical services will remain intact.

The state's existing Medicaid program also provides open access to medications for people diagnosed with mental illnesses - in spite of executive and legislative threats during the past two years to restrict access.

Open access is essential for effective treatment and recovery. To date South Carolina has held the line in preserving that commitment. Advocates see the issue as critical.

Despite its average reputation, South Carolina has made some commendable improvements in the system of care - which is all the more reason to protect it from radical reforms. Despite difficult budget cuts, DMH has demonstrated commitment to providing evidence-based practices (EBPs). Through agency leadership and consistent stakeholder advocacy, the state has developed and implemented ACT, supported employment programs, housing initiatives, and other programs that meet fidelity standards.

Another significant achievement was the legislature's passage of mental health insurance parity in 2005, which the governor chose to allow to become law without hissignature.

Police and judges have supported better services and diversion programs for people with mental illnesses. Expansion of mental health courts and recent legislation authorizing diversion from incarceration for minor offenders with mental illness are promising developments.

DMH deserves credit for incorporating the findings of President Bush's New Freedom Commission into its operational approach—moving toward a focus on recovery and involvement of consumers and families in meaningful roles. The agency has adopted a strategic plan that lays the groundwork for significant, cost-effective improvements in the years ahead.

The wild card is whether the state's elected officials will support it.

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