Break­downs wait­ing to hap­pen

State cuts to Med­i­caid fund­ing leave the men­tally ill with dwin­dling op­tions for treat­ment

The Washington Post Sunday - - SUNDAY OPINION - BY ALYX BECK­WITH The writer, who lives in Raleigh, N.C., is a li­censed out­pa­tient ther­a­pist.

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.

TI­MOTHY ARCHIBALD/GETTY IM­AGES

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