Breakdowns waiting to happen
State cuts to Medicaid funding leave the mentally ill with dwindling options for treatment
A14-year-old with large brown eyes and tightly cropped hair told me a few weeks ago that voices were telling him to kill people. A day before the Sandy Hook school massacre, he threatened to light his house on fire and stab everyone in the family, according to his mother. This boy — whom I’ll call Trevor — is a severe case, presenting the early, violent symptoms of schizophrenia at an age when the illness often begins to emerge. Untreated, his condition poses a serious danger to himself and those around him.
I am an outpatient therapist, working primarily with children and adolescents from disadvantaged backgrounds. Trevor is on Medicaid, yet cuts to Medicaid funding in recent years, here in North Carolina and throughout the country, mean that children like him slip through the cracks. In the best scenarios, cuts to reimbursement rates result in shortened therapy sessions and restrictions on the number of visits clients are allotted; in the worst, practices that serve the poor are going under.
Trevor’s coverage provides for mental health care, but most psychiatrists in his area do not accept it because of the low reimbursement rates. Those offices that do have two- to three-month waiting lists. Trevor needs psychiatric care and cannot wait months to get it. Last October, when my concern about Trevor first began to escalate, I made a dozen calls and finally managed to get him in to see a psychiatrist near his home. The doctor, according to Trevor’s mother, spent 15 minutes with the boy. He diagnosed Trevor with obsessive compulsive disorder, prescribed no medication and suggested that Trevor continue to see me weekly. From what I know of Trevor, 15 minutes is insufficient to gather the information necessary for a diagnosis.
Trevor’s statements to me in December — referred to as homicidal ideation — demanded, both legally and ethically, that I send him to an emergency room. In North Carolina, as in many states, there aren’t enough hospital beds to accommodate mentally ill individuals in crisis. Physical maladies and injuries take precedence, and those with mental-health issues often do not get out of a waiting room. Trevor spent five hours at the emergency room, then was sent home with instructions to call the hospital’s adolescent mental health team the following day; his mother was unable to reach a member of that team when she called, she told me.
For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3 billion has been slashed from state mental health budgets nationwide since 2009, according to the National Association of State Mental Health Program Directors. South Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.
The director of our clinic in Southern Pines, N.C., in the center of the state, has told me that this year’s cuts are likely to force us to close. Our facility offers mental-health and substance-abuse counseling to 75 to 100 clients a week, half of whom are 18 years old or younger. Typically, they are referred to us from child protective services, doctor’s offices or the local domestic violence/sexual assault agency.
Where will all this leave Trevor? He lives about 50 minutes away in a town of several hundred people. His worried mother can barely afford to bring him to our office, and she needs a great deal of encouragement and education on her son’s condition to continue seeking help. Although we are scheduled for weekly appointments, they come only when they have enough money for gas. I maximize our time by conducting both individual and family sessions when they come, even though Medicaid pays for only 45 minutes and I must keep other clients waiting.
In my professional opinion, Trevor needs to be admitted to an inpatient facility for evaluation and monitoring. That’s not an option for the poor in our fractured system. Instead, he’ll wait weeks to learn whether the intensive in-home therapy I’ve recommended will be granted. That service costs the state more than three times the outpatient treatment option, and it is approved only when outpatient therapy has proved insufficient.
In this country, there is a clear pattern of violence being unleashed on innocent groups by young men who have not received the quality and scope of care that their school administrators, parents and therapists knew they needed. The pattern extends beyond the headline tragedies and affects many communities.
As my clinic awaits further information on funding cuts, I worry for Trevor and hope that his mom can afford gas to bring him to his next appointment. I worry for thousands of kids like Trevor, and hundreds of therapists like me, who see firsthand what’s at stake.
Gallup polling last month found that more than 80 percent of Americans support increased spending for youth mental health programs. In practice, our states are moving in the opposite direction. That cannot continue.