Budget Cuts Hit County’s Mentally Ill

Los Angeles County has started to cut services for some of its neediest residents, the thousands of mentally ill people who rely on the government for treatment and medication.

The reductions come after the Board of Supervisors trimmed $28.6 million from the Department of Mental Health’s budget in June. The cuts are squeezing all parts of the public mental health system, including the outpatient clinics that treat walk-in clients and the locked psychiatric units at state hospitals.

“There are going to be an awful lot of people caught in the cracks,” said Dr. Marvin Southard, the county’s mental health director. “You can’t cut almost $30 million from a chronically underfunded system without negative consequences. People will probably die as a result of the curtailments we are creating, but we are still trying to minimize the harm.”

The county’s $28.6-million cut represents just 3% of the mental health department’s overall budget, which is mostly funded by state and federal dollars. But only the county’s contribution pays to care for people without health insurance, so the cut hits them hard.

In one of the biggest cuts, the county eliminated funding for 65 out of 307 beds at state hospitals, sending those patients -- many who have been institutionalized for years -- into less restrictive mental health facilities. More than two dozen patients have already been moved.

One of those patients, Erick Johnson, a 42-year-old diagnosed with schizophrenia, had lived in a locked ward at Metropolitan State Hospital in Norwalk for nine years. The prospect of leaving was profoundly unsettling for him.

“Erick was not happy,” said Debra Hinton, his older sister, “and I feel that a person in his situation, at least let them have some happiness in their life.”

Hinton agreed to visit the center where Johnson now lives, La Casa Mental Health Rehabilitation Center in Long Beach, a psychiatric facility that tries to prepare people with schizophrenia, bipolar disorder or major depression to return to their communities.

She liked the less-restrictive atmosphere, which includes a pool, a gymnasium, an aviary and classrooms where about 190 patients learn social skills and other lessons.

At La Casa, a compound of locked units where the average stay is roughly six months, staff members are trying to adjust to the rapid influx from the state hospitals. More than a dozen patients, including Johnson, have moved in since June, and more are on the way.

“It’s kind of challenging our philosophy,” said Dr. Ken Foxman, La Casa’s clinical director. “I don’t know if we’re going to be able to get them ready for the community in six months or a year. We need to be more patient. Although we may have this fantasy of them living with their family or in their own apartment, they may not be ready for that.”

Most of La Casa’s clients eventually move to board-and-care homes or go to live with their families.

Although driven by dollars, the county’s decision to transfer patients to cheaper, less-restrictive facilities is in line with a 1999 U.S. Supreme Court ruling that guarantees patients in state mental hospitals the right to move to community homes, if their doctors approve.

But California, along with many other states, has been slow to build a comprehensive network of alternative housing and in-home services to help mentally ill people.

Los Angeles County has been particularly sluggish, Southard said. “Up to this point, Los Angeles has relied more on locked placements than any other place in California,” he said. “It’s because we didn’t create adequate community resources, so the alternative was to lock people up.”

Now, as county patients leave hospital settings, it is creating a ripple effect throughout the mental health system. Many of them will settle into facilities known as institutions for mental disease, or IMDs, which provide skilled nursing with psychiatric treatment.

But the county is also cutting 85 of its 733 IMD beds, which all were occupied, pushing some patients into less-restrictive community placements such as licensed board-and-care homes.

The shift has some advocates hoping that the increase of patients in transition will lead to an improvement in community-based services, such as residential treatment programs, case management, crisis intervention teams and peer support groups.

“It’s more important to get stuff moving in the community than to conserve some of those beds,” said Richard Van Horn, president of the National Mental Health Assn. of Greater Los Angeles. On the other hand, he cautioned, “it means pushing and wedging people into programs, and they may or may not be ready for that.”

At the same time, the county is also cutting services at the other end of the public mental health system, the outpatient clinics that see walk-in patients. To save money, the county has decided to restrict treatment for many of the 35,000 patients without health insurance, tugging loose another thread in the fraying safety net for the poor.

In some of the bleakest corners of the county, half of the caseloads comprise uninsured patients. Take the Downtown Mental Health Center on South Maple Avenue, in the heart of skid row, where a bedraggled line of homeless people forms at about 6 a.m. each day.

Clinic workers are now aggressively pushing to enroll the uninsured in government aid programs for the poor and disabled. But that often takes months, and illegal immigrants do not generally qualify. In the meantime, mental health clinics are limiting treatment for those with no way to pay for it.

Everyone who comes in will still get an initial assessment, but uninsured people with less severe conditions, such as mild depression or anxiety, may be referred to a clinic outside the Department of Mental Health, said Dr. Roderick Shaner, the department’s medical director. Others who need counseling will be steered toward group therapy rather than individual therapy.

To help save about $9 million in medication costs, uninsured clients are now receiving just a 30-day supply. They can come back for more in a month, but the new policy aims to reduce medication wasted by patients who lose or fail to take it after the county has already paid for it.

The changes will affect people like Levi James, 27, who grew up in Compton and suffers from schizophrenia. James said he started hearing voices four years ago, dropped out of college and eventually became homeless. “Psychologically, I was helpless,” he said. “I needed some type of way to cope.”

After a series of hospitalizations, he was referred to the downtown clinic in February, where psychiatric social worker Anil Thomas helped James secure housing, regular therapy, medication, a substance abuse program and financial assistance. But he still has no insurance, leaving the county to pick up the tab for his care.

Under the new restrictions, James will have to make more frequent trips to pick up his medication and may receive less individual therapy and fewer services.

When asked how the changes might affect him, he looked agitated and began fiddling with his hands. He glanced at the ceiling, as if someone had spoken, and then said he still sometimes hears voices.

“I just need to take my medicine,” James said softly.