The Sequester: A Mental-Health Crisis

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If you've been reading The New York TimesThe Washington Post and hearing statements by Republicans denouncing the sequester "hype," you may have been lulled into thinking that it won't be so bad after all. The country has apparently reacted with a "collective yawn" to the $85 billion across-the-board cuts that began last Friday, the Associated Press proclaims. "The sword of Damocles turns out to be made of Styrofoam," the Times reports.

But the sword feels much sharper for families, advocates, and local officials who rely on government funding to treat and care for those with mental illness. Starting April 1, cuts to the Mental Health Block Grant program alone will deprive over 373,000 seriously mentally ill and seriously emotional disturbed children of services, according to a White House fact sheet. Experts also say that nearly 9,000 homeless people with serious mental illness won't receive the outreach and social-work assistance offered by PATH, a vital federally funded program that helps 90,000 people a year to transition to permanent housing. The big picture for the crisis: Disoriented, suffering people may end up jailed, or resort to suicide because the wait for treatment is too long. "We know fewer people will get services and more people will end up in the forensic [justice] system and on the street," says Debbie Plotnick, senior director of state policy for Mental Health America (MHA), a mental-health advocacy group.

While the sequester cuts are projected to harm the beneficiaries and employees of a broad array of programs, the mentally ill are perhaps our most vulnerable citizens. All flat cuts aren't created equal; a furlough for a Reston, Virginia, Defense Department worker doesn't have the same consequences as it does for a young man with severe bipolar disorder waiting an extra month to see a psychiatrist. Mental-health cuts pose a special harm to individuals and society even compared to the budgetary Sophie's Choices for the poor posed by the sequester. The untreated mentally ill are the least able to navigate bureaucratic mazes to find other resources and the most likely to deteriorate quickly when services dry up.

The White House's modest estimates of the damage may sound bad enough, but the projections from its risk-averse Office of Management and Budget are based on a narrow look at reductions in just two programs and on a modest 8.2 percent estimate of across-the-board non-defense cuts. In truth, when you take into account the reductions to other federal programs and the expected plunge in state revenues from a sequester-driven economic downturn, the impact on the seriously mentally ill could well be bleaker than current White House projections. "It's across the board and it's just devastating," says Carol Caruso, the executive director of the suburban Montgomery County, Pennsylvania, chapter of the National Alliance on Mental Illness. Having previously struggled to obtain health-care services for a foster son with severe mental illness, she says today, "It's sad that the folks in Washington couldn't get this settled before it happens."

The sequester cuts are not the first time mental-health spending has been slashed in recent years. According to an in-depth Mental Health America (MHA) policy analysis last fall, mental-health budgets in states across the country have already been cut by $4 billion over the past three years. This amounted to "the largest single combined reduction to mental health spending since de-institutionalization in the 1970s." The post-1970s disarray in most state and local mental health systems largely accounts for the nearly 500,000 mentally ill people who are housed today in the "New Asylums" of jails and prisons.

Now comes this latest assault. A closer look at the scope of the sequester's impact shows that it's far more damaging than even the White House, denounced as "alarmist" by the GOP, is predicting for mental-health programs. Based on initial government estimates of approximately 10 percent in domestic cuts during the first year, the MHA report examined the chilling impact on ten behavioral-service programs hit by the sequester—not just the two that the White House has cited in its fact sheets. Among its conclusions: "1.13 million children and adults will be at risk of losing access to any type of public mental health support."

For Plotnick of Mental Health America and the families worried about losing vital services, these sorts of concerns aren't overblown. When working for the group's Philadelphia-area affiliate, she witnessed the reality of sweeping behavioral health-care cuts of 10 percent in the draconian 2012 budget implemented last July by Republican governor Tom Corbett. Three-month waits in Philadelphia to see a psychiatrist in a public clinic have stretched to as long as four months, Plotnick and other advocates say. The city's five mobile-crisis teams—manned by a nurse and social worker in a mini-van to counsel and evaluate people—have been cut to just one 24/7 van for the city, and one for West Philadelphia. Just as critically, preventive programs that can forestall psychiatric crises have been pared down, including outpatient counseling and outreach services. As a result, Plotnick observes, "There are people you're not going to reach to get into a program, and they aren't going to get services." Equally troubling, these sorts of failures can bring about the worst outcomes everyone fears: suicides, jailings or encounters with the police where the untreated mentally ill end up as victims of violence. It also makes them more vulnerable to the last-resort, highly controversial measure of involuntary commitment. 

Joseph Rogers knows first-hand what accessing quality care can mean. He is now the chief advocacy officer for the Mental Health Association of Southeastern Pennsylvania, which he built into a powerful voice for reform after recovering from severe bipolar disorder following years of hospitalization and homelessness. He says of Governor Corbett's cuts and the sequester, "What you get is an eroding effect." His own agency was forced to drop a successful peer-counseling program for "dually diagnosed" people with mental illness and substance abuse, the primary illness afflicting about 50 percent of the homeless. 

In Pennsylvania, the cuts have been so damaging that they've driven a moderate Republican legislator—a type as rare in Washington as unicorns—to introduce a bill to restore $84 million in funding for behavioral health care. The money would be drawn from the 2012 budget's $300 million reserve fund. State representative Gene DiGirolamo, a Republican from Bucks County and sponsor of the legislation, told The American Prospect, "We hear all the time when people get put on waiting lists, they usually end up in the criminal justice system somehow." He adds: "When you start cutting funds back on a local and county level for services, that's a recipe for disaster. If they do not get help or treatment, there's a lot of ways they can end up tragically in the emergency room or dying." The lesson in Pennsylvania: What may seem like minor cuts from afar can be devastating on the ground. 

Ironically, all these risks from the sequester come at a time when federal and state legislators and even some budget-slashing governors are looking to increase mental-health spending in the wake of the Newtown, Connecticut tragedy. Although the risk of stigmatizing the mentally ill has escalated, the prospects for expanding community-based mental-health care had never seemed brighter. Even Governor Scott Walker of Wisconsin, the union-busting devil figure who recently defeated a recall vote, was hailed by mental-health reformers for proposing to add $30 million in funding.

But now, with the onslaught of the sequester, "We're crippling everything important," says Plotnick.

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