Grading the States 2006: Utah - Narrative
NAMI traditionally has seen Utah as having tremendous potential for good. Former Governor Mike Leavitt is now the U.S. Secretary of Health & Human Services and is responsible for the implementation of President Bush's New Freedom Commission recommendations for transforming the mental health system nationwide. Senator Orrin Hatch, chairman of the U.S. Senate Judiciary Committee, has played an important role in the expansion of mental health courts and jail diversion programs nationally, and is a co-sponsor of national legislation for mental health insurance parity.
At national conventions, NAMI also has honored the LDS Church for introducing mental health parity in its health insurance coverage for church employees, and The Deseret News for outstanding news coverage of issues related to mental illness.
All of which makes the fact that the state is largely unprepared to meet the needs of residents all the more puzzling. A few key facts illustrate its deficiencies:
- When the federal government reduced Medicaid funds for Utah, the state did not make up the loss. Instead, policymakers cut $14.5 million out of community mental health centers in 2004 - a reduction of about 10 percent. Approximately 4,500 consumers were expected to lose services.
- Despite major increases in population, the state has not expanded inpatient capacity in 30 years. In 2004, budget cuts eliminated 56 beds from the state's only psychiatric hospital; they eventually were restored, but the erratic commitment reflects the state's approach to treatment. Every system requires carefully balanced levels of care. When community services also are not readily available, the entire system backs up. Waiting lists reduce access. People languish because they can't be placed elsewhere. The problem is one of overall capacity.
- The state does not provide funds to local community mental health centers to secure inpatient beds for general acute care settings. Without resources, mental health professionals frequently are forced to weigh reimbursement issues against quality of care.
Utah's challenges mirror those of other rural and frontier states. There is a chronic shortage of healthcare professionals who want to practice in rural communities - and the Division of Substance Abuse and Mental Health (DSAMH) has particularly identified psychiatric nursing shortages as being at a crisis level. For most rural mental healthcare, the state must rely on general practitioners.
Under Leavitt's governorship, Utah received a federal Medicaid waiver which allowed expansion of healthcare coverage to include some groups, but had the effect of reducing benefits for many poor and disabled persons. Coverage for the new beneficiaries also did not include mental healthcare. Old or new, Medicaid beneficiaries ended up shortchanged. Advocates report that people who need mental heath services are now waiting longer to see providers and often ending up in emergency rooms or jails, imposing greater costs on local governments and the state.
Cost-shifting to the criminal justice system has had two effects. On the one hand, because of a shortage of forensic hospital beds, there is a waiting list for inmates who need mental healthcare. On the other, the state has begun investing in Crisis Intervention Teams (CIT) and mental health courts - though their success ultimately depends on community services being available.
More positive notes include that the state legislative leaders have steered clear of Medicaid policies that would limit access to psychiatric medications. However, consumer and family advocates should not take legislators' understanding of the consequences of such policies for granted.
Restricting access to medication shifts costs elsewhere. The real question is whether policymakers can resist short-term expediency. When it comes to psychiatric medicines, one size does not fit all. With few exceptions, generics do not exist. Side effects vary among different individuals. Some medications require weeks or months to take effect; impeding optimal physician-patient choices at the outset can lead to greater suffering and costs over time. The cost of an emergency room visit and hospitalization from one relapse can greatly exceed any per-person savings from a restricted formulary. That also assumes a person in psychiatric crisis gets help in time. The costs of suicide, homelessness, or prison are even greater.
- Despite lack of state leadership, the community mental health network is promoting consumer and family education, and shifting toward a more recovery-oriented system.
- The state has one of the lowest rates nationally in the use of restraints and seclusion.
Handholds of hope exist for the state to climb upward. Priorities identified by the state in a 2005 White Paper, "Current and Emerging Issues in Public Substance Abuse and Mental Health," represent a promising path toward progress - one that would match the state's traditional values of family and community. What is needed is for state leaders to commit to providing resources to match those hopes.
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