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Originally published August 16, 2014 at 5:19 PM | Page modified August 22, 2014 at 5:19 PM

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Editorial: What's troubling mental-health care?

These are the next steps for Washington state on mental-health challenges, found through months of conversations with mental-health professionals, policymakers, elected officials and the people who have been caught without the help they need — people with mental illness, and their families.

More perspectives on what's troubling mental health

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The discussion on mental health continued all the week with letters to the editor, guest opinion columns and a video chat:

• Editorial: "Allow DSHS to overspend its mental-health budget to fix 'boarding' problem"

• Jonathan Martin column: "End state law that criminalizes mental health patients"

• Guest opinion: "Mental illness does not mean your life is over"

• Guest opinion: "How to help patients after the end of psychiatric boarding"

• Guest opinion: "Enforce state's mental-health parity law"

• Letters to the editor: Readers shared their ideas, thoughts on what's troubling mental health

• Video chat: Replay a three-minute recap of our Google On-Air Hangout with:
David Stone, CEO of Sound Mental Health
Cinda Johnson, co-author of "Perfect Chaos, A Daughter's Struggle to Survive Bipolar and a Mother's Journey to Save Her"
Jonathan Martin, editorial writer
Thanh Tan, editorial writer, moderator

This player was created in September 2012 to update the design of the embed player with chromeless buttons. It is used in all embedded video on The Seattle Times as well as outside sites.


MENTAL illness is a silent epidemic.

Each year, one in four adults in the U.S. — 57.7 million people — experience mental illness, a leading cause of disability. Depression alone gnaws away three times more work hours than diabetes, 20 times more than cancer.

Although mental illness is treatable, and millions recover, the stigma often forces its victims to turn inward. Only 40 percent of Americans living with mental illness ever get treatment.

"We wouldn't accept it if only 40 percent of Americans with cancers got treatment," President Obama asked last year. "Why should we accept it when it comes to mental health?"

The Affordable Care Act has enormous potential to reverse those grim statistics and bring mental-illness treatment into daylight. Lost in the politics is the fact that it is already making a difference.

About 20 million Americans gained insurance coverage that, finally, ensures mental-health coverage is on par with physical care.

Washington state is already realizing some benefits. April appointments for new patients at mental-health clinics statewide quadrupled from levels in January, when the Affordable Care Act expanded Medicaid eligibility. Clinics, especially in urban areas, open most mornings to find overflowing waiting rooms. In other parts of the state, the law has had little effect.

The act is a work in progress, requiring tweaks to control costs and modernize how care is delivered. But congressional gridlock renders change a remote possibility. Instead, states are left to use the Affordable Care Act's tools.

Washington should seize the opportunity. Here are three ways the state can deliver on the law's promise to improve mental health care. Also, read editorial page editor Kate Riley's column explaining the series.

  • Pain caused by funding cuts
  • Not enough care to meet demand
  • The empty promise of mental-health parity

  • Pain caused by funding cuts

    Gabriel Campanario / The Seattle Times

    THE Affordable Care Act leaves a funding gap in a vital part of the mental-health system: crisis response.

    Medicaid does not pay for evaluations of people suspected of needing involuntary commitment, nor for their hospitalization. This is due to an odd technical rule eliminating payment for facilities with more than 16 beds.

    Washington has filled in the gap with "state-only" money to pay for crisis response, and recently added dozens of beds at smaller facilities.

    Prescription:

    The Legislature must respond to the Supreme Court's ruling by funding at least 100 more psychiatric beds, and more robust outpatient treatment, to prevent hospitalization.

    Still, the state ranks near the bottom in psychiatric beds per capita. That led to the recent Supreme Court ruling prohibiting patients from being "boarded" in emergency rooms while awaiting care.

    Nonetheless, the Legislature recently slashed state-only funding by 20 percent. Lawmakers gambled the cut wouldn't hurt as much with broader Medicaid eligibility. A bad bet.

    With newly covered patients filling clinics, the crisis mental-health system is on life support. "We'll come out of this broke," said Ken Roughton, director of Greater Columbia Behavioral Health in Kennewick.

    Other states, such as New York, faced a similar inpatient shortage and launched a new program, called Assisted Outpatient Treatment, which allows a court to require outpatient care for chronically ill patients who have resisted preventive care.

    Story: 'My kid could've died'

    TREZ Buckland cries at the thought of the day she wouldn't let her son, who has paranoid schizophrenia, come home unless he promised to take his medications. Jon Buckland wouldn't, so when he left Harborview Medical Center's psychiatric ward that day in 2012, he was discharged to a homeless shelter.

    "What kind of a mother would do that?" she said. "My kid, my lovely wonderful young man, could've died. But if he didn't take his meds, he'd be dead."

    It was a gamble on tough love — and it worked.

    Jon, now 32, had four hospitalizations in rapid succession in 2011-12. A 3 a.m. encounter with Seattle's self-proclaimed crime fighter Phoenix Jones led to the last one, as Jon tried to explain to Jones how to "create a dragon's brain." "My brain wasn't conducive to thinking," Jon said.

    After a few hours at the homeless shelter, Jon called home, ready to take medications. He has been there since. Sober for three years, he leads Narcotics and Alcoholics Anonymous groups. As a hobby, he grows coral in a 75-gallon saltwater tank, his hermit crabs hiding amid bursts of purple, green and orange.

    Trez Buckland went back to school, earning a Ph.D. in nursing to understand her son's illness. Her prescription for reform is shared by many other families: loosen restrictive psychiatric commitment laws, and give parents a greater role in their adult children's treatment.

    "Parents can play a vital role in keeping their kids alive, and the system doesn't allow it. It's very frustrating."


    Not enough care to meet demand

    Gabriel Campanario / The Seattle Times

    MORE than 525,000 Washingtonians signed up for insurance plans through the Affordable Care Act, dropping the uninsured rate to 10.7 percent.

    That's good news, but it also presents a problem. In this state and nationally, years of wavering commitment to building up the health-care workforce leaves the cupboard mostly bare, especially for specialties like psychiatry.

    The U.S. needs about 30,000 more psychiatrists, with the need growing further away from cities. Washington's urban areas have about 11 psychiatrists per 1,000 people; rural areas, 2.4, the University of Washington's Center for Health Workforce Studies found.

    "I can't hire people fast enough," said Rick Weaver of Central Washington Comprehensive Mental Health. He has hired 170 mental-health staffers since January.

    Prescription:

    Washington's congressional delegation should encourage the Obama administration to approve the state's integration grant request. The Legislature should refocus on enticing more people to go into the mental-health-care field. Additionally, it should pass a bill allowing mental-health professionals to treat patients remotely via video link.

    The state Legislature, under budget pressure in recent years, severely cut a student-loan-repayment fund intended to entice health workers to work in underserved areas. A task force to address state health-care personnel shortages recommends restoring $3.5 million in annual funding.

    For a longer-term solution, the state has an ambitious plan to fully integrate its separate, Balkanized mental and physical health-care programs by 2020. If fully realized, this plan is estimated to save the state more than $1 billion. Gov. Jay Inslee submitted a $92 million federal grant proposal last month.

    Story: Separate silos of care

    WHEN it comes to the shortage of psychiatrists, Jürgen Unützer has diagnosed the problem. Doctors can take "a bag of cash" to do cataract surgery, or "take less money, less prestige, to work with severely disabled, poor patients ... There will never be enough specialists."

    That's an unusual concession, coming from the guy whose job is to produce psychiatrists at the University of Washington. But Unützer, the psychiatry department chairman, has a solution, and it is entering the mainstream thanks in part to the Affordable Care Act.

    He advocates for integration, based on a simple idea. Historical "silos" separating mental- and physical-health care often miss connections, such as diabetes and anxiety or severe weight gain associated with some drugs.

    Unützer has the research to prove integration works. A multistate study of 1,801 elderly patients with depression found that integrating mental-health specialists into primary-care clinics saved $3,363 per patient, and the patients stayed healthier. That model has since been rolled out to about 200 clinics statewide.

    Washington's Medicaid program is now proposing complete integration, with Unützer in on the planning. Making it work, he said, requires a shift in health-care financing to "pay for performance," which rewards doctors not for just providing a service, but for getting patients healthier.

    "It's a simple concept that makes sense to people," said Unützer. "The reality is that it's a huge challenge because we're 30 years into these separate silos."


    The empty promise of mental-health parity

    Gabriel Campanario / The Seattle Times

    MENTAL-health parity sounds great on paper. Passed by the state Legislature in 2005 and U.S. Congress in 2008, laws require health-insurance companies to cover mental-health care on par with physical-health care. The Affordable Care Act further stiffened that mandate.

    But parity has too often been an empty promise.

    Insurers have continued to impose restrictions on therapy visits, to deny types of evidence-based interventions and to gum up claims with extensive demands for prior authorization.

    New York's attorney general settled three parity cases in the past year against insurers, including a $31 million settlement against EmblemHealth for denying mental-health claims at a rate two-thirds higher than physical-health claims. In California, denials for mental-health claims were overtuned at the appeals level at a significantly higher rate than for physical-health claims.

    Prescription:

    Insurance Commissioner Mike Kreidler should push insurers to live up to the mental health parity law, and pursue enforcement against companies who fail. He should also use the existing law to compile and release insurance appeals.

    There is no data available in Washington because Insurance Commissioner Mike Kreidler hasn't compiled it. Nor has his office pursued a single mental-health parity case in the nine years since the state law took effect. Kreidler, who finally issued clarifying rules on the state parity law last month, acknowledges that "not all insurers treat it like other carriers."

    Mental-health providers such as Lauren Harris, a Shoreline therapist, already know that. She recently complained to Kreidler's office about an insurer's restrictions on visits for a client who has severe anxiety and depression. "I thought parity is what it meant. But it isn't," she said.

    Story: Insurers in denial

    THE 11-year-old girl was intellectually gifted and able to play the piano by ear. She made fantastical drawings. She loved playing Pokémon with her younger sister.

    But this spring, the girl, J.F. , was gripped by severe mental illness. She could hear animals speak, believed she had a real Pokémon family, tried to drown her younger sister and threatened to stab herself, according to medical notes.

    "It's a gut-wrenching, horrendous experience," said her mother, Amy Bushlach of Issaquah. "The closest thing I can compare it to is the death of a child, because of the severity of her illness."

    Diagnosed with a major mental illness, J.F. spent three months in inpatient mental-health treatment at Ryther Child Center. Bushlach saw her daughter "re-emerge."

    In June, Bushlach's insurance, Moda Health, denied further coverage. The daughter's doctors recommended a longer stay. Moda said it was not medically necessary because J.F. made only modest improvement.

    The Bushlachs lost an appeal, and due to pay Ryther's $13,600-a-month cost, they sent J.F. to live with grandparents, desperate to keep her away from younger siblings, including a 9-month-old.

    J.F. continues to struggle, but is reducing antipsychotic medications because of severe, possibly irreversable side effects. "We're right back to where we were before Ryther, after all that work," Bushlach said. "It's devastating."

    Editorial board members are editorial page editor Kate Riley, Frank A. Blethen, Ryan Blethen, Sharon Pian Chan, Jonathan Martin, Robert J. Vickers, Erik Smith, Thanh Tan, William K. Blethen (emeritus) and Robert C. Blethen (emeritus).


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