Rural areas reap little from Prop. 63
Adismayed Chuck Finck stood at his daughter’s hospital bedside in Redding, a winding two-hour drive from his home in the alfalfa-rich Big Valley.
It was Cheryl Medeiros’ fourth hospitalization for psychiatric-related problems in the last few years, each time hours from the family’s home in Modoc County, in the state’s remote northeastern corner.
This time, Medeiros, 34, who has been diagnosed with schizophrenia, bipolar illness and severe postpartum depression, had been rushed to the hospital by ambulance after swallowing half a bottle of anti-anxiety pills. She then contracted pneumonia from inhaling vomit, which meant days in intensive care.
Finck, 58, and his wife, Chelley, 57, knew from experience that their daughter would soon be returned to the same rural void in mental health services that had virtually ensured her repeated hospitalizations.
In some parts of the state, Proposition 63, a voter-approved surtax on those with income above $1 million, is pumping millions of dollars into innovative new treatments for the mentally ill.
But many rural residents have been left out of Proposition 63’s richest benefits. Not only do rural counties receive far less of the new funding because of their smaller populations, they also have enormous needs, lagging far behind more populous counties in the types of services offered. The Proposition 63 money can’t begin to fill those chasms.
Five of California’s 58 counties don’t have a single psychiatrist. About 30 have no inpatient psychiatric beds, necessitating costly and traumatic trips for patients in crisis. Follow-up care is difficult to coordinate. There is little or no supervised housing that would allow the severely ill to live independently yet close to home. Mental health professionals are difficult to recruit and nearly impossible to retain.
Exporting severely ill patients for both short- and long-term care dramatically increases costs. Sending one resident to a state mental hospital for a year, for example, would consume about 10% of Modoc County’s budget, depriving others of basic services.
Adding to the burden is a disproportionately needy population, spread over thousands of square miles mostly unserved by public transportation.
In Siskiyou County, mental health staffers traveled 840,000 miles last year to retrieve clients for care and take them to far-off psychiatric hospitals. As officials there noted in their Proposition 63 grant proposal, a “huge unmet need” remains in a place where poverty, suicide and depression rates exceed state and national averages.
The new funds help, say the counties; it’s just that demand far outstrips their potential. In Trinity County, $455,600 in Proposition 63 money in the coming year will go in part to a consumer drop-in center and to comprehensive treatment for four patients. But the county -- which relies on video sessions with tele-medicine consultants -- will still lack the services of even a visiting psychiatrist.
In Modoc County, where Medeiros and her parents live far from the county seat, the $412,000 Proposition 63 boost this year is offset by a budget crisis that recently caused the county to lay off half its mental health clinicians. Even with the new funds, Modoc County’s mental health budget is about 25% smaller than it was in 2004.
“The perception was, ‘There’s all this new money that’s being added,” said Karen Stockton, Modoc County Health Services director. “People think we can do all these wonderful things. But we’re looking at them and telling them, ‘We can’t.’ ”
As Medeiros’ hospital discharge date neared in late May, a frustrated Finck called the county department seeking help.
Wasn’t there some kind of intensive help they could offer to keep Medeiros safe, he asked? Something to end the cycle of ambulance trips and short-term hospital stays?
The county told Medeiros it had one avenue remaining. It could seek to become her conservator and place her in a board-and-care home. Because Modoc has no such facilities, the placement would be at least 330 miles away in the Central Valley.
For the Fincks, who can barely afford gas to Redding, taking that option would cut their daughter off from family support.
Mental illness hit
Medeiros’ large blue eyes and flashes of childlike innocence offer a glimpse of the happy teen she once was, glamorous in her feathered blond mane and content in her Christian faith.
Then, in her early 20s, mental illness hit. She once lay in bed in horror, convinced her organs were slowly dying. During one hospitalization, she believed she was encased in a glass box that might shatter.
In four counties over seven years, she learned firsthand about the gaps in rural mental health services.
In Tehama County, a visiting psychiatrist tossed a book on the table and told Medeiros to pick her own medication, she and her parents said.
Three years ago, after a divorce, she moved into her parents’ remote home in Lookout in the Big Valley. The valley in the Southern Cascade Mountains cleaves Modoc and Lassen counties but sits far from the seat of either, offering a life of stark beauty but few services.
At first, the county arranged to take Medeiros -- on disability and covered by Medi-Cal -- to the Modoc County seat of Alturas 50 miles away. Every month or so, she briefly visited the county psychiatrist. Since none reside in Modoc, the county retains one from Oregon who drops in twice a month.
A case manager encouraged Medeiros to join group sessions on social skills or visit the Al- turas pool in an occasional outing with other clients. But Medeiros said the gatherings hardly seemed worth the half-day trip. She quit.
Her next stop was at a clinic just over the Lassen County line, where she found a sympathetic and effective physician assistant and had video consultations with a tele-psychiatrist who provided counseling and medication.
But the physician assistant retired this summer, and the tele-psychiatrist stopped working a month before Medeiros’ overdose, leaving several thousand patients across the remote north in limbo. Medeiros says the system has “treated me lower than what I am. They’re breaking my trust.”
Medeiros reluctantly returned to Alturas for sporadic services. But daily life was haunted by unpredictable panic and distraction. At 3 a.m. recently, her mother -- who has bipolar disorder -- awoke just in time to find her daughter sipping facial cleanser. She did not require treatment.
Housebound, Medeiros was bored and lonely. She longed for her sons. The two eldest live with her ex-husband in Reno, and her youngest, born in August 2006, was taken by Lassen County’s Child Protective Services while Medeiros was hospitalized.
She wistfully described the treatment she craves, unaware that it is very like what thousands of men and women in more populated places are getting, thanks to Proposition 63.
“I need to be close to some- one who helps me with my meds, just someone to talk to, some- one to calm me down,” said Medeiros, who yearns for a “support network” and a place to go, with arts and crafts or guitar classes, massage to relax her and “a little job to help with my self-esteem.”
“A lot of mentally ill people are like kids,” she said. “We need encouragement to stand strong.”
Many rural counties had high expectations after Proposition 63 was passed.
For some, the funds were a miracle. Sierra County’s mental health budget was “devastated” by state cuts in 2004, said Health and Human Services Director Carol Roberts. The new money, $344,800, represented a nearly 50% increase in its budget and will allow the county to restore intensive services to children and youths that had been eliminated.
But for many rural counties, the new programs -- which must conform to strict state guidelines -- are layered on top of strained core services. In some cases, core services are not offered.
Thrilled Modoc County mental health officials were initially told they might receive $2 million a year from Proposition 63.
But as the state refined its funding formula, some rural counties saw their Proposition 63 money shrivel. In Modoc County, which received less than a quarter of what it had initially expected, deep cuts to core mental health services followed. With its clinical staff down to six, it eliminated services last year in some remote pockets.
Meanwhile, Proposition 63’s bureaucratic demands have hit rural government hard. The law requires counties to hold extensive community meetings on how funds should be spent, to compile statistics on need and to closely track results.
“It’s been a huge burden,” said Nancy Antoon, interim director of Trinity County Behavioral Health Services. Although she is thrilled with her county’s Proposition 63-funded drop-in center, she said, “There have been days when I’ve thought: What if I said ‘No, thanks’? “
Alpine County, the state’s least populous with 1,200 residents, did just that, initially calculating that it would cost more to accept the funds than to turn them away.
“These programs are not meant for counties with fewer than 100,000 residents,” said mental health Director Judy Molnar. “It just doesn’t work.”
The county has since changed course, beginning the cumbersome application process in hopes of landing funds for a new building in one of Proposition 63’s later phases.
“That’s the problem” with Proposition 63, said Al Urmer, the Los Angeles administrator who runs Alpine’s tiny department under contract. “You can’t just apply for what you want. You have to jump through all the hoops.”
Regardless, Proposition 63 has brought the immense needs of many rural counties into the open.
Jobs and housing are scarce. Methamphetamine use is rampant. And a growing population of the aging suffers from depression and prescription drug and alcohol abuse.
Poverty and disability rates are high: During the last census, for example, 28% of Modoc County residents between the ages of 16 and 64 reported being disabled, compared with 19% statewide. The suicide rate in many northern rural counties, meanwhile, is as much as double the state average.
With need everywhere, overwhelmed Modoc County officials -- and community members who by law are part of the decision-making process -- faced tough choices about how to spend their Proposition 63 funds.
A small amount is going to train a nascent group of mentally ill men and women to run a peer counseling line. A new family support group will reach out to parents like the Fincks. And teleconferencing equipment will bring specialists to Alturas remotely and help clinicians advance their education through long-distance learning.
But the style of care that Proposition 63 was designed to facilitate for the severely ill -- a “whatever it takes” regime that includes housing, job training and psychiatric and medical care -- will go to just five youths and five seniors. All must live near the county seat.
As officials struggle to make Proposition 63 dollars stretch while staying true to its philosophical intent, caseloads for bread-and-butter care have risen.
“We can do all these wonderful things for a select few consumers,” Modoc County’s Stockton said bluntly. “But we are having to give up some of the basic things we did for the whole.”
Jobs top wish list
Limitations surface nearly daily. In Alturas during a recent noon hour, members of the client group Rays of Hope filed into Stockton’s office for a meeting. The drop-in center that the group envisioned -- with computers, a library for research on illness and a place to simply be -- did not get funded.
Meanwhile, the area’s mentally ill are eager for benefits that a small rural county like theirs is unlikely to deliver. At the top of their wish list: jobs and training in mental health careers for people like them.
Stockton listened carefully at a recent meeting with the group, then broke the news: Her department won’t be able to provide much unless the state steps in to help group members train for credentialed professions. Lower-skill peer counseling jobs, she said, will probably add up to only a single position countywide.
Still, for a county where mentally ill men and women have never come together to articulate their needs, the sheer existence of Rays of Hope is a victory.
“This is the first time in the history of forever that the interests of the consumer are being listened to,” Cheryl Maxson, a mental health advocate living with bipolar disorder and sporting a “Revolution of Empowerment” T-shirt from the California Network of Mental Health Clients, told the small group.
Rare collaborations are also underway. Modoc is entering into agreements with Lassen and Siskiyou counties to serve some residents far from Alturas. That might bring Medeiros relief or at least a chance to talk with those who have suffered similarly.
In Bieber in Lassen County, the Big Valley Family Resource Center will soon employ a mental health caseworker. And the Lassen Aurora Network, a peer group that offers yoga and life skills classes in that county’s seat of Susanville, is expanding to Bieber to host peer counseling sessions and other activities.
Lillian Arnold, who heads the resource center and sits on the peer group’s board, received a grant to learn Sign Chi Do, a therapeutic blend of martial arts and sign language that she will begin teaching.
Medeiros hoped she would benefit from the new program. Still, years of disappointment had left her skeptical.
“When I moved up here, my life really ended, because there’s nothing,” she said. “The odds are stacked against me.”
Late last month, Medeiros once again became paranoid and delusional and was hospitalized. This time, her family agreed to a temporary conservatorship. At an October court hearing, Modoc County will seek to have her placed in a board-and-care facility in Modesto, hundreds of miles from home.
Begin text of infobox
Small counties, big numbers
Number of miles driven by Siskiyou County mental health staffers last year to transport residents to care, including out-of-county hospitalization
Dollars set aside in Trinity County this year for direct care of the mentally ill, including hospitalizations, board-and-care placements and emergency medication
Amount required to send one resident to a state mental hospital for one year
Number of small counties where disability rates exceed the state average
Sources: California Hospital Assn., California Psychiatric Assn., California Dept. of Social Services, Siskiyou and Trinity County mental health officials, U.S. Census Bureau
One in a series of occasional articles on California’s troubled mental health system.
On Latimes.com: Find previous articles on mental health at www.latimes.com/breakdown