Grading the States 2006: Iowa - Narrative
Iowa is a prime example of what President Bush's New Freedom Commission on Mental Health meant when it reported that the nation's mental healthcare system is "fragmented and in disarray." It must be among the most convoluted mental health systems in the country.
For individuals on Medicaid, Magellan Inc. provides mental health and substance abuse services. For individuals who are not Medicaid eligible, the state's 99counties provide services, through a combination of state funds and county funds, derived primarily from local taxes.
Iowa's counties also follow a policy known as "legal settlement" which requires that individuals be county residents, and free of the need for mental health services for at least a year before their new county is responsible for paying. These restrictions often lead to inordinate, potentially catastrophic delays in getting services when they are needed.
Although Iowa's counties are required to collect data, there is no statewide system through which this information can be shared. As a result, Iowa is among a minority of states that cannot provide an unduplicated count of whom they actually serve. The state is working to upgrade its data collection system and hopes to have the capacity to provide unduplicated counts by the end of 2006. That will be an important, fundamental step forward. It is hard to design an effective service-delivery system without first knowing the number of the people for whom you are responsible.
Surprisingly, the state mental health authority, called the Division of Mental Health and Developmental Disabilities (DMHDD), does not appear to be actively engaged in strategies to expand access to services for people with serious mental illnesses who live in rural areas of the state. Among its many attributes, as presidential candidates discover early in party primary campaigns every four years, Iowa is rural - 89 of its 99 counties are classified as such. Any presidential candidate can not be a serious contender without addressing the distinctive needs that flow from this fact. In some respects,Iowa might be the perfect stage for a well-focused comprehensive debate over mental healthcare policy, as the 2006 and 2008 elections approach.
Iowa also appears to be lagging in its implementation of evidence-based practices (EBPs). To its credit, the DMHD is forthright about the need for better progress and has established a statewide Technical Assistance Center for Evidence-Based Practices to promote their expansion. DMHD has identified Assertive Community Treatment (ACT) as one of its top priorities. Currently, four programs exist - in Des Moines, Cedar Rapids, Iowa City, and Fort Dodge.
Unfortunately, employment and housing, two critical components of recovery, do not appear to be prominent on DMHD's radar screen. Although the state reports that supported employment services are available to people with serious mental illnesses in 91 of 99 counties, DMHD does not seem to be involved with them through funding or coordination with Iowa Vocational Rehabilitation Services. DMHD also was unable to provide any information about supportive housing in Iowa, and does not employ, as many states do, a person responsible for coordinating housing services for people with serious mental illnesses.
In his 2006 State of the State address, Iowa Governor Thomas Vilsack took credit for significant accomplishments in the 2005 legislative session that benefitedpeople living with mental illness. He referenced the important milestone of enacting mental health parity legislation, a hard-won victory in a state that was home to some of the most assertive anti-parity lobbying in the country.
Iowa is experiencing significant problems with an overall lack of inpatient psychiatric beds for people with acute treatment needs. Nationwide, many community hospitals have gotten out of the business of operating psychiatric units - increasing the burden on state hospitals. The few community hospitals that continue to operate inpatient psychiatric units are overwhelmed by demand and do not have enough beds to meet that demand. For example, in Des Moines there are virtually no hospital beds available for people with acute or long-term care needs.
As acute care beds in community hospitals decrease, the number of state hospital beds decrease as well, worsening the crisis. There are only four state hospitals in Iowa right now that can serve patients with serious mental illnesses, a low number when you consider the geographic size of Iowa.
Iowa's mental health system is in serious trouble. The state needs to move forward with a bold restructuring of its mental health system, which should include removal of legal settlement rules and increased access to mental health services that work for Iowa's residents with serious mental illnesses.
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