The Arizona Legislature approved a budget earlier this year that included significant cuts to adult mental health services and restricted eligibility for many.
In the wake of a shooting spree that left six dead and 13 wounded, including U.S. Rep. Gabrielle Giffords, many wonder what sort of treatment the state has available for people with mental illnesses and how a person like accused shooter Jared Loughner could be ordered to have a psychiatric evaluation.
State law requires that counties provide mental-health services. Pima County spends some $20 million per year on various services, according to Pima County Administrator Chuck Huckelberry.
In southern Arizona, Community Partnership of Arizona is responsible for coordinating behavioral health treatment and prevention services. The group works with a network of providers to deliver services, primarily to qualify patients for the Arizona Health Care Cost Containment System, the state’s Medicaid system.
“Arizona right now has quite a rich benefit for people on AHCCCS,” said Dr. Edward M. Gentile, CPSAs chief medical officer.
In general, people who fall at or below the federal poverty line, about $18,000 annual income for a family of three, can qualify for AHCCCS covered services.
Services can include hospitalization, in-patient or out-patient therapy, medication, and, importantly, case-management services.
“The Arizona system is built around the case-management model,” Gentile said.
Case management helps keep patients on track with treatment plans and helps make sure people keep up with any court-ordered treatment regiment.
What the law says
Title 36 of Arizona law allows anyone to petition for a court-ordered evaluation of another person.
A court-ordered evaluation may be ordered if a person is considered a danger to their self or to others, is gravely disabled and unable to care for basic physical needs, or is persistently or acutely disabled and impaired to the point they can’t take of themselves.
Following an application, an initial interview is conducted of the person to determine if a court-ordered evaluation is needed.
If grounds for an evaluation are found, the Pima County Attorney’s Office petitions for a court order.
If doctors find grounds for court-ordered treatment, a judge then decides whether there is clear and convincing evidence that a person poses a threat to their self or others and is unwilling or unable to accept treatment on their own.
Court-ordered treatment, usually conducted on an outpatient basis, lasts one year. Longer-term treatment can be ordered at the end of that year.
In Pima County, an average of 1,800 court-ordered evaluation processes are initiated each year, said Amelia Cramer with the Pima County Attorney’s Office.
About 30 percent of cases receive some sort of court-ordered treatment, Pima County Administrator Chuck Huckelberry said.
Cuts to available services
Statewide budget cuts, however, have impacted the ability to provide services and put additional burdens on the county, Huckelberry said.
The legislature, for example, cut the level of reimbursements to counties.
Reimbursement to regional behavior health systems throughout the state has been cut for those who do not qualify for AHCCCS. In Pima County, as much as 35 percent of court-ordered treatment cases involve people who don’t qualify for AHCCCS, Huckelberry said.
The cuts include reimbursements for case management, counseling, housing, drugs and hospitalization, according to a July 6 memo Huckelberry wrote to the Board of Supervisors.
County officials said court-ordered treatment has become ineffective for those people who funding cuts rendered ineligible for case-management services.
“It’s taken the teeth out of court-ordered treatment,” said Pat Benchick, Pima County behavioral health administrator.
He said without case-management, there’s no way to ensure patients are getting ordered treatment.
Courts have begun to stop ordering treatment for people not covered by AHCCCS, Benchick said.
Huckelberry said that the cuts from the state level wouldn’t eliminate the costs of providing services for those patients who aren’t eligible for AHCCCS.
“The need for those services don’t go away,” Huckelberry said.
In fact, he said the cost of services the state previously provided to mental health patients likely would still be born by the public as more patients are treated in hospital emergency rooms.
Federal law prohibits turning away patients from emergency rooms, and that’s where many people would seek care if they don’t qualify for AHCCCS, Huckelberry said.
State officials have noted the cuts as well.
A July memo from Dr. Laura Nelson from the Arizona Department of Health Services Division of Behavior Health said the department would have a budget of $40 million in fiscal 2011 to serve adults with severe mental illness. That is a drastic reduction of the $90 million budget for the same services the previous year.
More cuts could be approved this year.
Gov. Jan Brewer has proposed in her 2012 budget recommendation that the state further limit AHCCCS eligibility.
The proposal could make an additional 280,000 Arizonans ineligible for AHCCCS coverage.
Throughout the court-ordered evaluation and treatment processes, the patient retains their rights and can have legal counsel present.
The patient also can have an evaluation done by an independent physician and can halt the legal proceedings by agreeing to submit to voluntary treatment.
“Court-ordered treatment is something that generates Constitutional concerns,” said Jennifer Alewelt, an attorney with the Phoenix-based Arizona Center for Disability Law who advocates on behalf of people with mental illnesses.
Alewelt said people do not have to accept treatment for mental illness and shouldn’t be forced to unless they prove a danger to themselves or others. Like any illness, people have the right not to be treated.
“Do we want to lock up everybody for being weird, and what is the threshold?” she said. “It’s not something to be taken lightly.”