When it comes time for the budget ax to fall, the services in most demand tend to be the first to go. There's wide consensus that people with mental illness need a broader range of services, but the system isn't structured to provide that kind of care. Mental health care providers have had to focus on treating people with the most serious afflictions, while those with less immediate problems have gone without. Because of funding imbalances in the system, agencies are becoming increasingly reliant on the tried and true services that can be billed back to the federal government through Medicaid.
Community Support Services is an Akron agency that does case management for mental health consumers, and helps them find jobs and places to live. One of its employees, whom we'll call Janine, is also a former client.
Janine: I was on social security disability for six years. And I got bored. I had to do something. I mean I had to DO something-I was gonna go crazy just sitting around here.
CSS helped her find work with a cleaning service that often employs people with mental illness. Doctors say it's important that consumers returning to work find a situation that has tolerance for the emotional ups and downs of recovery. Janine says even her supervisor was supportive.
Janine: He was just wonderful to me, I'd be crying all the time, I was still real sick and everything, and he'd say to me, 'Now listen here, you have potential, you'll get further, but you have to do this first. This is just the first thing you have to do'.
Four years later Janine had worked her way through a two-year college degree in office administration.
Janine: So I got a job in the office, which was good because Social Security was gonna cut me off. You know. (laughs) And they took away my Medicaid card and I had to pay for my own medications full for about six months until I got on the hospitalization plan here.
Without CSS's help, Janine might still be on Medicaid today. However, the vocational support services that get people off public assistance are just the kind of programs that tend to be vulnerable to cutbacks, because they cannot be billed to Medicaid. The agency's COO Terry Dulton says a number of key services hang in the balance, dangling by budgetary threads.
Terry Dulton: If ours were cut... you would end up through attrition or whatever, less case managers, which would increase caseload sizes, housing, there may be less dollars available to support people living in their apartments.
All of which could make the difference between a person staying healthy, or sliding back into dependence. Looking forward to next year's budget cycle, CEO Art Wickersham goes one step further.
Art Wickersham: Probably what's going to happen to the system, it's going to shrink. Where we work with the most severely disabled population, our definition of that is going to tighten up. So the people who got into the system this year, are not going to get in next year.
While no cuts are planned at CSS at present, Wickersham says it's a fact that demand for services is going up, and funding has not been increased accordingly.
One of the leading clinical voices in the region says he's disturbed by the way budget cuts and other restraints have tipped the local menu of services out of balance. Dr. Mark Warren is medical director at Laurelwood Hospital and Counseling Center. Laurelwood serves as the public psychiatric hospital for Lake County, and also accepts sixty percent of its client base from Cuyahoga County. He's not happy at the idea of sending some people home with little hope of follow-up care. But he points out many Cuyahoga County agencies have limited or closed intake recently, under extreme fiscal pressure.
Mark Warren: Our current notion is that... someone who is sick enough to come to a psychiatric hospital should not at the moment of discharge go back to the life that they were leading before they got here.
Clinicians have become so distressed about the lack of resources that Laurelwood has spent the past five years making major investments in its own support services.
The harder the system is pressed by fiscal imbalance, the more difficult it becomes to provide the basics. St. John West Shore hospital in Westlake is in the process of closing its six-bed psychiatric inpatient facility. Its resources will be diverted into surgical bed space, and into a new unit that will offer outpatient psychiatric care for children and teens. Hospital President Fred DeGrandis says the decision to do this was complicated, and not based on any one fiscal year. The hospital reasoned in part that patients needing a longer stay might be better served at St John's sister hospital, St. Vincent Charity, which has a larger, more advanced psychiatric unit. DeGrandis says the economics of mental health care are clearly uneven, and he hopes that consumers will demand greater parity with more conventional ailments.
Fred DeGrandis: If we think about the kind of health insurance policies that exist everywhere in the employed setting as it related to MH services. They're just drastically different. No one would accept a limited number of uses for your cardiologists per year. And yet employers-AND employees!-as it related to MH generally have caps and limits on the number and the access they have in a commercial plan, to MH services. I'm completely convinced there needs to be substantial education and ultimate change. But that's the current environment economically that exists.
At this point, providers around the state are waiting to see what transpires in state budget negotiations. If they have to absorb spending cuts, they'll know by the end of next month. In Cleveland. I'm April Baer, 90.3.