North Carolina’s historic opportunity to stop warehousing people with mental illness
These are tough times in North Carolina. The economy continues to struggle. Anti-government zealots have seized control of many of the reins of government. Public employees are dispirited. Essential public programs have been damaged by needless, often spiteful funding cuts. A new report to be released by the N.C. Budget and Tax Center tomorrow will confirm that the General Assembly’s decision to reduce public spending and cut taxes is actually harming the private sector even further. What’s next – a series of natural disasters?!
Fortunately (and in all seriousness), there actually is a large, cognizable and critically important problem confronting the state that our leaders have it within their power to address in short order – namely, the issue of what to do about the thousands of North Carolinians with mental illness who are being shuttered away and warehoused in “rest homes.”
Indeed, contrary to the throwing-his-hands-in-the-air lament of the Perdue administration’s top administrator that a “perfect storm” of circumstances has conspired to make it impossible to act, there is actually a safe, sane and responsible path forward. Now is the time to get going.
A review of the basic facts
As reported in this space almost a year ago, North Carolina is home to a shameful and inexcusable set of circumstances when it comes to the treatment of as many as 8,000 or so people with mental illness. Here is a plain English explanation of the problem:
Federal law has long commanded states to deinstitutionalize persons with mental illness; it’s illegal to use federal money to gather up such individuals and lock them away in big hospitals as was the favored practice during the last century. According to the law, persons with mental illness must be provided with services that allow them to live as normal lives as possible in community-based settings.
Unfortunately, but not surprisingly, pulling off such a feat is challenging. Mental illness is complicated as heck and every individual and family is different. Resources and good facilities are scarce. One doesn’t have to be an expert in the field to understand why it might be hard to fashion appropriate, in-home or close-to-home solutions for everyone who needs them – especially in this era of shrinking public budgets.
To make matters even more complicated, the state is home to a powerful and politically-connected network of businesses that has figured out a way to make a lot of money off of these people – the “adult care home” or “rest home” industry. This industry originally arose to provide a basic place to live for elderly adults of modest income. The facilities are typically of moderate size and located in rural, out-of-the-way places in which land costs are lower. Though the facilities don’t provide much in the way of services, they do give people a place in out of the rain and food to eat. They’re also generally good at getting people to take their medications regularly.
Unfortunately, while these facilities are less institutional than giant, centralized state hospitals, they clearly fall way short of what federal law requires. By any honest assessment, they are little more than warehouses in which people are “dealt with” – i.e. kept out of sight and mind as virtual inmates. There are no real therapies provided and little is done to help people manage their illnesses and regain something akin to normal lives. Cigarette smoking and television are dominant time-fillers. Indeed, as long as the residents don’t cause any trouble and take their “meds,” the homes have an enormous incentive to hold onto them and their public reimbursements as long as possible. Not surprisingly, industry influence in the halls of government is formidable.
A challenge to the status quo
Advocates for people with mental illness and vulnerable seniors have long recognized and complained about this situation. Unfortunately, for a variety of reasons – bureaucratic inertia, feared costs, the influence of the rest home lobby to name a few – nothing has really been done.
In recent months however, things have begun to change. Thanks in large measure to the determined advocacy of the excellent lawyers at Disability Rights North Carolina, the federal government has stepped into the mix. Officials at the Centers for Medicare and Medicaid Services and the U.S. Department of Justice have taken separate but complementary initiatives to demand action from the state. Indeed, there’s a strong argument to be made that the state might well be on the hook for millions and millions of dollars in Medicaid reimbursements it used to house people in these facilities in contravention of federal law.
This is from a WRAL.com story on the recent Justice Department action:
“‘Adult care homes are institutional settings that segregate residents from the community and impede residents’ interactions with people who do not have disabilities,’ Assistant Attorney General Thomas E. Perez says the letter, dated July 28 and sent to Attorney General Roy Cooper.
Keeping the mentally ill in adult care homes violates the Americans with Disabilities Act, Perez said. The state not only places the mentally ill in such homes, but encourages them financially to stay there instead of going to communities by providing about $550 to those who live in adult care centers, the letter said.”
All in all, it’s a pretty damning state of affairs.
Unfortunately, the response of both the state and the industry has been decidedly unhelpful. Worried about jeopardizing millions in federal reimbursements and the absurd budget cutting demands of the General Assembly, HHS Secretary Lanier Cansler has launched into a big stall – begging for more time to study the matter and offering no concrete solutions.
Meanwhile and perhaps even more outrageously, the rest home industry has launched a political spin campaign in which it has claimed that mental health advocates and federal officials want to throw people out in the street. Got that? The victims here are the heroic and overworked homes who are being picked on by those meddlesome do-gooders!
Plentiful solutions
Fortunately, notwithstanding Cansler’s bureaucratic delay and the industry’s desperate and dishonest attempt to hold onto its profits, there are reasonable solutions to the dilemma of how to serve these individuals. Other states (Delaware for example) have entered into step-by-step, court-supervised plans of action to transition away from the practice of warehousing people unlawfully.
Though certainly formidable in its size and scope, North Carolina’s problem is subject to similar treatment. Think about it: If there are roughly 8,000 individuals in need of improved services, that’s less than one for every 1,000 North Carolinians. Times are tight, but North Carolina can clearly do what’s necessary to help 8,000 people.
With a concrete plan and determined action, the state is certainly capable of whittling away at this number – maybe not tomorrow, but certainly within 12 to 24 months. It’s mostly a matter of putting some people in charge of the process and giving them a mandate, the staff and funding to get the job done.
And certainly, no one has to be discharged to “the street.”
Some people could graduate to smaller, community-based group homes. With the right subsidies and services, (lots of which already exist) many could actually live independently. The key is to develop a mechanism for assuring the individualized care that people require.
Will it be easy? Of course not; mental illness is a nasty, vexing problem. Many of the people in need will very tough to accommodate. And although the federal funds currently being misdirected to the rest home industry will be there, the transition will certainly cost the state money.
Nonetheless, it’s something that clearly has to happen. Federal law, common sense and morality dictate that we act and do so immediately. With the right “can do” attitude it’s quite possible to turn this supposed “perfect storm” into a situation in which the stars actually align for historic and extremely positive change.
Let’s hope this simple truth dawns on Governor Perdue, Secretary Cansler and state lawmakers very soon.
