Mebane Rash and Aisander Duda, N.C. Center for Public Policy Research
Friday Center, Chapel Hill
8:15-11:30am, January 22, 2010
[Mebane Rash] Ten years after mental health care reform legislation was
enacted in North Carolina, one of the unintended consequences plays out in
emergency rooms across our state each and every day. At one community hospital
with 24 beds in the emergency room, there were about 2,000 visits last year by
patients with mental illness or substance abuse – on average, about five visits each
day. It costs the hospital $500 dollars a day to hold a person in the ER for
treatment, and this hospital estimates that it spends $1 million dollars on treatment
of mental health patients in the ER each year, most of it uncompensated.
Last May, a 16-year-old girl stayed in the emergency room for nine days
until a psychiatric bed opened up for her. She was not evaluated by a psychiatrist,
and she did not receive mental health treatment during her ER stay. ER physicians
could sedate her and try to keep her comfortable, but they did not have the
expertise to initiate psychiatric treatment.
In June, things got so bad that for two weeks, there were nine or more
patients in the ER at all times with mental health or substance abuse issues. Not
only has there been an increase in the numbers of patients, but they are staying
longer and longer as they wait for beds to open up – the average statewide is 2.8
days. There have been as many as 15 people being held in this ER for mental
health issues – more than half the capacity of the emergency room. The longest
stay has been 10 days. Imagine waiting in an ER for 10 days.
This hospital has had to create a transition unit for holding mental health
patients – 7 beds that used to be reserved for patients with chest pain. This hospital
has had to hire sitters – certified nursing assistants that provide one-to-one
monitoring of patients that are suicidal or psychotic. This hospital has had to ramp
up security to help with violent patients.
Emergency rooms like this one are on the front lines of mental health care in
North Carolina, even though they are not funded and staffed to do so, even though
the environment in the ER is the opposite of what many mental health patients
need, and even though many ERs are unable to provide treatment. In the ERs
across our state, hope is hard to find if you are a mental health patient.
My name is Mebane Rash, and I am an attorney with the North Carolina
Center for Public Policy Research. But this is not just a job for me. I have a parent
that is bipolar. I have an uncle with autism and mental retardation that lives in a
group home in Person County. And, just after graduating from law school, I
worked on the implementation of the Thomas S. class action with Carolina Legal
Assistance, a mental disability law project. My guess is that you are here today
because personally or professionally this issue touches your life too. I spoke last
year at this breakfast, and I want to thank you for inviting me back today to give
you an update of our evaluation of mental health reform.
The Center is a nonpartisan nonprofit that studies the most important public
policy issues facing North Carolina. Part think tank, part watchdog, our Board of
Directors looks just like our state in terms of gender, race, political party
affiliation, from the East, West, and Piedmont.
There are several things in my mind that distinguish the work of the Center:
we are independent, our policy analysis is research-based, and we never lose sight
of the public in public policy. We take our research to policymakers, the media,
and interested citizens across the state, just like this group, because we want our
work to make a difference.
Today, I am going to talk first about the Center’s study. And then I want to
share with you some numbers – numbers that I hope will make it easier for you to
talk about the scope of mental health issues in your communities. I also will talk
about the recent elections and the state budget – and what both may mean for you
as advocates. Then, I am going to turn it over to my colleague, Aisander Duda, to
tell you about our research on how mental health reform has worked in other states.
[Slide 2: Part I] The Report. The goal of the Center’s evaluation of mental
health reform is to produce high-quality public policy research, to educate the
public about these issues, to raise the level of public debate, and to improve public
We released the first part of our study in March 2009. This was an in-depth
look at the history of mental health reform in North Carolina since Dorothea Dix
came here in the 1840s. This part of our report won a national award for most
distinguished policy research.
[Slide 3: Part II] The next phase of our research will be released this
winter, spring, and summer as individual articles on our website before being
published together in our journal, North Carolina Insight. There are articles on the
mental health system and who it serves; an essay on depression; an evaluation of
the three-way contracts between the state, local management entities, and hospitals
to purchase bed space for short-term inpatient crisis care; and a look at how the old
Mental Health Study Commission worked and whether we needs parts of it again
now– like independent staffing and the inclusion of consumers. All of these
articles assess the consequences – good and bad – of mental health reform over the
[Slide 4: Part III] The final phase of our research looks at mental health
reform in other states, and Aisander will talk with you about that. But we also are
going to conduct a comprehensive survey of both the public and private mental
health work force in this state – positions, titles, number of vacancies, wage range,
turnover rate, education, training, experience, and demographics – believe it or not,
the state does not have this basic information. Based on our research on the needs
of the patients, funding streams, the work force survey, experiences in other states,
and interviews with those in the field, we will make findings and recommendations
designed to continue to improve the provision of mental health services in North
[Slide 5: Prevalence] Let’s talk first about prevalence – how many people
in your counties are estimated to have a mental illness, a developmental disability,
or substance abuse. To generate these numbers, we took the Division’s estimates
of prevalence and applied them to the most recent certified population estimates
for Chatham, Orange, Person, and Durham counties. So these are estimates as of
July 2009, using data last updated in September 2010.
Statewide, the Center estimates that just over 15 percent of North Carolina’s
population needs mental health care: roughly 9,000 of those people reside in
Chatham County; over 21,000 live in Orange County; 5,600 are in Person County;
and more than 40,000 call Durham County home.
[Slide 6: Number in Need/Served] To evaluate access to mental health
treatment, it is important to look at the number of people who actually receive
services through the state’s public system of care. The state’s 2010 reports are just
out, and here you can see how many people in your counties were treated in the
state’s psychiatric hospitals, developmental centers, alcohol and drug abuse
treatment centers, the Wright and Whitaker Programs, the neuro-medical facilities,
and in the community through the local management entities last year. In both the
O-P-C local management entity and the Durham LME, more than 20 percent of
those in need received treatment through the state’s public system of care.
Given the revenue shortfall we face this year, mental health consumers need
your help now more than ever. Whether you like the new political landscape or
not, this issue is not partisan, and those in need need you to remain involved.
[Slide 7: The Legislature] The New Republican Majority. Let’s talk
about the elections. On November 1st, the day before the elections, Democrats in
the state Senate held a 30-20 majority. The next day, voters gave Republicans a
31-19 majority. That is more than 3/5 – enough to override a Governor’s veto.
Republican Phil Berger will replace Marc Basnight as leader of the state Senate.
Senator Berger will appoint all Senate committee chairs and make all committee
Again last November 1st, Democrats held a 68-52 majority in the state
House. The next day, voters gave Republicans 67 seats. One unaffiliated
candidate (Bert Jones) was also elected, and he has said he will join the Republican
caucus, so Republicans will end up with a 68-52 majority in the House. But House
Republicans are short of the 72 votes needed to overturn a Governor’s veto.
Representative Thom Tillis of Charlotte will be the new Speaker of the House.
Between redistricting, the budget, and their first 100 days agenda,
Republicans in both houses will be busy. They already are at work, and in the
House they have consolidated many of the standing committees. Health, Aging,
and Mental Health will be combined into a Health and Human Services
Committee, with a Subcommittee on mental health. Health and Human Services in
the House is currently scheduled to meet on Wednesdays at 10 am. The legislative
session starts on Wednesday, January 26th at noon.
All of the legislators representing your districts were re-elected (Senators
Bob Atwater, Ellie Kinnaird, and Floyd McKissick; and Representatives Bill
Faison, Joe Hackney, Larry Hall, Verla Insko, Paul Luebke, Mickey Michaux, and
Winkie Wilkins), and all of them are Democrats. In the House, Joe Hackney will
be the Minority Leader. I think you need to engage your legislators in a
conversation about how to be productive on mental health issues over the next
decade. In our office, we call this a 10-year election because this General
Assembly will draw new legislative and congressional districts based on the 2010
census data. My guess is that you are going to need friends in both political parties
if you want your voice to be heard. The Center produces a citizen’s guide to the
legislature, and it will be online this year for the first time. I hope you will find it
helpful in your work as advocates.
[Slide 8: The Budget] The Budget. Right now, here’s what we know
about the budget. The most recent estimates from the legislature’s Fiscal Research
Division put the deficit at $3.7 billion dollars. That’s close to a fifth (19.5%) of the
total ($18.9 billion) state budget.
Governor Perdue held back 1 percent of every state agency’s funds in
August. Then she cut another 2½ percent in December. She froze hiring and
clamped down on pay raises, purchases, and travel. She’s also asked every agency
to prepare plans where they’d cut 5, 10, or 15% from their budgets. I attended a
budget briefing held by Secretary Lanier Cansler of Health and Human Services
recently. You should expect cuts. The question is what is going to be cut, and
that’s where you can make a difference.
[Slide 9: The MH Budget] In 2009, in North Carolina, $3.3 billion dollars
was spent on mental health services. About 70 percent of those dollars come from
Medicaid, and 21 percent are appropriations from the state. About 77 percent of
those dollars are spent on community services, and 21 percent is spent on state
facilities, like mental hospitals. [Slide 10: Medicaid MH Services] Secretary
Cansler says that Medicaid in North Carolina puts more money into the economy
than agriculture. Optional Medicaid services for adults comprise over 17 percent
of the state appropriation to the Department of Health and Human Services. The
Mental Health, Developmental Disability, and Substance Abuse Division’s budget
comprises more than 10 percent of the state appropriation to DHHS. We need to
think about where we think the system can realistically absorb additional cuts.
In our research on mental health reform, one of the places we are looking to
for hope is the innovative money-saving approaches other states are taking in these
tough economic times. My colleague is going to tell you now about our visits to
[Slide 11: Other States] [Aisander Duda] Good morning, my name is
Aisander Duda and I am a project consultant on the Center’s study of North
Carolina’s mental health reform. I would like to thank all of you for inviting me
here this morning.
[Slide 12: Cansler Quote] Two weeks ago, Department of Health and
Human Services Secretary Lanier Cansler declared “Mental health reform is over.”
He said, “Now we are about building a mental health system and doing the things
that we need to do to build a strong system across the state.” Cansler’s changes to
the system are intended to provide more consistent and stable service provision in
Still, there is much about our current system that is in flux. There is a brandnew
provider model, CABHAs or Critical Access Behavioral Health Agencies, that
has been up and running for just under a month. Our ability to serve people in
crisis in the community is still being ramped up. And, there are pockets of the
state that even now do not have access to the services they need. We are fortunate
to have a Secretary that is open to new ideas and fresh perspectives in both
evaluating and running our mental health system. I think he has the hardest job in
state government right now.
[Slide 13: 50 States] During the course of this study, I’ve been a part of
closely evaluating North Carolina’s mental health system and also researching how
other states have reformed their systems. Remember that to implement the U.S.
Supreme Court’s Olmstead decision all states had to reform their mental health
systems. So we’ve visited other states to see what we can learn from their
The Center looked at all 50 states and selected six to visit and study in depth.
Three of those states [CLICK] – Kansas, Massachusetts, Minnesota – have
innovative or higher-performing mental health systems, while the other three
[CLICK] – Georgia, Michigan, and Nevada – are lower-performing and serve as a
cautionary tale for us. [Slide 14: Four Factors] We used four factors to evaluate
these states: governance, coverage, work force, and funding.
While I wish I had time to tell you about each state, this breakfast would
probably turn into a dinner by the time I finished. So instead I’d like to tell you
about three national trends that became apparent as I looked at what states around
the country were doing to comply with the U.S. Supreme Court decision and serve
those with mental illness.
[Slide 15: Funding] The first national trend that I found in conducting this
study was the search for new and more efficient funding models. Particularly in
the current economic environment, this is a crucial element in running an effective
and cost-conscious system. North Carolina is currently trying a new funding
model, called a federal 1915(b)(c) Combined Waiver for the Medicaid program.
Without going into too much detail and putting everyone down for a Saturday
morning nap, Medicaid waivers allow states to fund and operate systems outside
federal guidelines. This gives states more flexibility, more bargaining chips in
dealing with private providers, and long-term cost savings. [CLICK] In North
Carolina, the Piedmont Behavioral Health Local Management Entity has been
operating under this type of waiver for several years, with other LMEs are
scheduled to begin using this funding model within the next year.
[CLICK] Michigan has implemented its federal 1915(b)(c) Waiver
statewide and has had mixed results. On one hand, the state has been able to save
money and increase provider quality, but on the other hand Michigan has struggled
to match federal dollars with state dollars because of its economy and the
economic downturn. The state has seen consumers forced into dire situations in
order to get on the Medicaid rolls to obtain coverage. As one Michigan area
mental health director told me, “We’ve had to tell people who ask for help to come
back to us when they’ve lost their job, their house, and their support; because at
that point they will qualify for Medicaid and get the services they need.”
[SLIDE 16: Consumers] The second trend is in many ways the most
important trend I saw in my research – the inclusion of consumers in both their
treatment and in the governance of the system. In states that are really doing
things well, mental health consumers do everything from sitting on oversight
boards [pause] to working in recovery as Peer Support Specialists helping other
consumers [pause] to helping plan their own treatment and medication
management with doctors.
[CLICK] Even in Georgia, which is the birthplace of Peer Support,
consumers trained as Peer Support Specialists run several “Peer Support and
Wellness Centers.” These are stand-alone houses that offer temporary bed space
for adults for up to a week at a time, a 24/7 Peer Support phone line, and wellness
activities like learning about how to shop and eat healthy foods. They also offer
seminars on disability resources in the community. It’s like a Clubhouse on
steroids, completely consumer-run. The house that I visited was a beautiful twostory
house tucked into a wooded area just outside of Atlanta. If there was a place
to seek peace, rest, and community, this was it.
[CLICK] I was also lucky enough to visit the Genesis Clubhouse in
Worchester, Massachusetts. This Clubhouse is an international training facility
and has one of the most robust programs to provide employment I have ever seen.
On top of the in-house jobs that the Genesis Club offered, they also have five
different levels of work opportunities in the community for their members. In the
last year alone, 162 of their members working full or part-time earned nearly one
million dollars in total salary.
[Slide 17: Prisons vs. MH] Last, but not least, among the emerging trends is
each state’s approach towards dealing with mental illness and substance abuse in
jails and prisons or in the mental health system. A psychiatrist who works in
western North Carolina told me that state governments have two options when it
comes to serving their mentally ill populations: (1) the Department of Corrections
can be the unseen arm of mental health system – housing people in prisons with
little or no treatment – or (2) the mental health system can be the unseen arm of the
Department of Corrections – with citizens being served at a much lower cost in the
community with treatment that prevents them from ending up back in jail.
There is no better example of this than the state of Georgia. [CLICK] One
in 13 people who are residents of Georgia are either currently incarcerated or
paroled. It is estimated that 60 to 70 percent of those inmates require either mental
health or substance abuse services, or both. When it comes to funding principles,
the state of Georgia has chosen to fund the prison system first and foremost,
leaving those with mental illness with few options and little hope of staying in the
community and out of jail.
[CLICK] By contrast, the state of Minnesota has done a very good job
funding its community mental health system, requiring less work of local Sheriff’s
offices. There only 35 percent of inmates require mental health services in the
state’s prisons. For comparison’s sake, Minnesota ranks 12th in the nation in per
capita state spending on community mental health services, while Georgia is
ranked 46th in the nation.
Now I want to return to what Mebane mentioned about North Carolina’s
hospital emergency rooms. In New York, the mental health system was designed
for emergency rooms to be on the front lines of mental health care. There is a
psychiatric ER in each of their LMEs. It provides a single portal of entry into the
mental health system. Psychistric ERs are the home base for Assertive Community
Treatment teams. These teams are designed to provide comprehensive,
community-based psychiatric treatment, rehabilitation, and support. These ERs are
funded and staffed to identify who needs help the most, what help they need, and
where they should get it. The only psychistric ER in the Southeastern United
States is in Charlotte, and it is funded by the LME mostly with local dollars.
Another unintended consequence of North Carolina’s reform is our use of
adult care homes to house those with mental health issues. In 2009, 64 percent of
all residents in adult care homes in North Carolina had mental illness,
developmental disabilities, or dementia. Currently, there is a federal investigation
of North Carolina’s use of adult care homes. In New York, a federal district court
judge has held that adult care homes are institutions that segregate residents from
the community and impede residents’ interactions with people who do not have
[Slide 18: Contact] It is our hope that state leaders in the executive and
legislative branches will continue to evaluate the mental health system. It is our
hope that the state will continue to think about the governance, coverage, work
force, and funding of the mental health system of care. It is our hope that this state
will continue to improve mental health services statewide or at least not allow the
services to deteriorate during the state’s current budget woes. It is our hope that
leaders will look inside and outside our borders for good ideas and worthwhile
innovations that can make a difference to consumers in North Carolina. Thank