Time to overhaul Washington state’s broken mental-health system
Washington state needs to overhaul the mental-health system, writes editorial columnist Jonathan Martin.
Times editorial columnist
Washington state’s public mental-health system is so fractured and dysfunctional that the absurd has become the norm.
For evidence, look no further than the emergency rooms of King County hospitals. Each day, 20 or so mentally ill patients are parked there, sometimes in hallways, restrained, heavily medicated, waiting, waiting, waiting, often for days on end.
The reason is simple: We’ve collectively cut so many beds in psychiatric units that there is no other place for them to go.
The practice, known as “boarding,” is dangerous to nurses, demoralizing for hospitals and head-slappingly inefficient with our scarce public dollars.
It is also humiliating for patients. A father in Issaquah sobbed as he told me how his daughter was parked on a gurney in a hall for 28 hours, so zonked on antipsychotic medications she wet herself over and over.
Yet it has become routine: 2,163 patients were boarded in 2012 in King County alone, staying two days on average.
King County has a staffer devoted just to managing such boarders. Harborview Medical Center and Valley Medical Center created special sections just for them. The state has a special license for it, a “single bed certification” — a psychiatric ward for one, right in the middle of an ER.
The talk I hear this year from the White House, Congress and the state Legislature about a pressing need to reform mental health is encouraging and deflating. At least it’s now considered pressing, after decades of corrosive neglect.
But reforms often seem more focused on protecting the public from the mentally ill than in speeding their recovery.
These are our neighbors, classmates, uncles and daughters. They’re sick because of an unlucky roll of the genetic dice. They deserve better.
We haven’t had a full makeover of the mental-health system since 1989, when management of the outpatient system was farmed out to counties.
State Sen. Mike Carrell, chair of the Senate Human Services & Corrections committee, says it’s time for another.
“It’s like a house we’ve built on to over time,” said Carrell, R-Lakewood. “We need to step back and ask, ‘Is this really working?’ ”
I agree. Past debates about fixing public mental-health care got bogged down by conflicting incentives in the system’s funding. The state pays for long-term inpatient care at Western and Eastern state hospitals, but has little power over county-based outpatient care. Both sides have been beggared by five years of cuts. Finger-pointing abounds.
“We have a broken health-care system, but at least it’s sort of a system. Mental health doesn’t even have a system,” said Dan Dixon, a vice president at Swedish Medical Center. “It’s mostly an ad-hoc arrangement.”
A good first step toward fixing it is SB 5234, which puts performance-based strings — less jail time and more jobs for patients — on funding for outpatient care.
The state should also welcome the Affordable Care Act, aka Obamacare, with open arms. Its expansion of Medicaid, the lifeblood of the mental-health system, makes health-care analysts giddy about its potential to break down bureaucratic walls between mental health, substance abuse and primary health care.
The federal money could boost treatment, including dedicated psychiatric beds. And it could reduce the diffuse public costs — police, jails, courts and uncompensated hospital care — that are never factored into more mental-health spending.
That is all promising, at least on paper.
But I think to go further, we also need a collective burst of outrage.
Washington has more mentally ill patients in jail than in hospitals. It ranks last in the country in community psychiatric beds per capita, with ward after ward closing because reimbursement rates don’t come near to their costs.
So when patients gets so sick they are involuntarily detained for treatment, there’s often no place for them to go. ERs must take everyone, so the patients end up there, like orphaned passengers.
One mother I talked with, a nurse, vividly recalls her son’s moans as he was strapped down with four-point restraints while being boarded. Years later, he still hasn’t recovered from the humiliation.
State Sen. Nathan Schlicher, D-Gig Harbor, an emergency-room doctor at St. Joseph’s Medical Center, said hospitals manage boarders by moving them to other floors; a psychotic patient goes to an orthopedic or oncology bed.
That’s trouble, because those rooms aren’t equipped. Schlicher recalled a mentally ill patient, a trained Green Beret, using a thermometer to attack a security guard. Boarding, he said, “is an unmitigated disaster.”
“It’s one thing to see it on paper, but you see it in person, and you quickly realize how broken the system is,” he said.
Jonathan Martin's column appears regularly on editorial pages of The Times. His email address is firstname.lastname@example.org