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A job for the governor

Mike Easley gave us mental health 'reform.' Time for him to face up to what it's doing in Raleigh.


Pick something the government should do. I'll take mental-health care. That puts me on the same team with Dr. Assad Meymandi, the Raleigh psychiatrist and practicing Republican, as well as state Rep. Jennifer Weiss, the good Cary Democrat. Not to mention Republican Joe Bryan, the Wake County Commissioners chair, and Democratic state Rep. Deborah Ross, and--well, I could go on, but I don't know the party affiliations of most of the 150 people who came out Monday night to talk about their own illnesses, or their children's, and about the crying need for a new psychiatric hospital in Raleigh to replace Dorothea Dix when it closes.

But I'm confident that both red and blue, liberal and conservative, were well-represented. Meymandi, who's a history buff, says the Founding Fathers from Jefferson (Mr. Limited Government) to Madison (Mr. Federalist Papers) all understood that whatever else the government would end up doing or not doing, mental-health treatment for everyone who wasn't rich was properly going to be a public responsibility, because how else could it possibly be done? And in a just society, it must be done.

Weiss's take: Don't just talk amongst yourselves. Argue your case for mental-health funding to your chambers of commerce, where the rhetoric is so often about tax-cutting and much too infrequently about the critical public services that contribute to a good business climate.

I love it when there's bipartisan agreement. Which makes it all the more disappointing to see, in the case of the Wake hospital, so many good people pointing fingers at everybody else when it comes to the question of why it's not getting done--why people with acute illnesses are being mistreated or ignored. In this vein, I could quote a variety of people, but I'm going to land on WakeMed CEO Bill Atkinson, both because he made his point so succinctly and because he and WakeMed got a bunch of fingers pointed at them Monday. "We all want the best health care possible," Atkinson said, "if somebody else will pay for it."

Let's see if I can untangle the knot here. The county wants to do this, and is pledging $15 million. The hospitals want it too, and while they're not putting money on the table yet exactly, they're already spending big sums on psychiatric patients in the most inefficient way, or at least WakeMed is, according to Atkinson. So they're "incentivized," you might say. And our state legislators all want it--blue and red, Dems and GOPers--and they've pitched the need for it to "the Speaker" and "the Pro Tem," meaning House Speaker Jim Black and Senate President Pro Tem Marc Basnight without getting anywhere, however.

So who's missing? Well, sure, state Human Services Secretary Carmen Hooker Odom is missing. She was "introduced" Monday by the indomitable Ann Akland, president of the Wake chapter of NAMI--the National Alliance for the Mentally Ill--but everybody already knew that Hooker Odom had refused to come to Wake-NAMI's forum on the hospital issue and also refused to send a representative.

But it's not Hooker Odom who's the problem, and it's not "the state," either, which was the culprit fingered by Meymandi and many, many others.

It's the governor. Mike Easley. Remember him?

It was Easley who gave us mental health "reform," and hopefully enough has been said and written about what a bust that's been that we can simply stipulate to what Ross said, which is that "what is happening is a travesty and a tragedy."

Looking rather clinically at events since the initial "state plan" came out in November 2001, a recent N.C. Psychiatric Association report notes that admissions to Dix and the other state hospitals have gone up, not down (as they were supposed to); worse, nobody is bothering to measure the results of reform on the patients.

Let's underscore that. The Easley administration promised to measure reform by whether it improved patients' outcomes or not, but it's never done the measuring.

Oh, sure, there were budget shortfalls and other "adverse events," as the forgiving NCPA report notes. And yet, as it also recognizes, nothing that's occurred wasn't predictable--or predicted.

Plain and simple, the Easley administration argued that since the federal government refuses to subsidize state hospitals (via Medicaid), but will subsidize private ones, money could be saved by closing Dix and limiting admissions at the other three state mental institutions while handing the patients over to the counties.

What's more, since "community-based" treatments were widely regarded as superior to putting all but the most severely mentally ill into distant state facilities, the state's penny-pinching would actually improve the results--or so the theory went.

In practice, however, according to the NCPA report: "Mental Health Reform is based on community capacity being developed, and since such capacity has not yet been fully developed throughout the state, it could be argued that these results are to be expected"--these results being: (1) Community hospitals not expanding to meet the need, and in fact closing psychiatric units; (2) health-care professionals getting out of the public sector in search of patients with money; and (3) more medically indigent consumers needing care and not getting it.

Why has community capacity not been developed in Wake County? Let's follow the finger-pointing a bit longer.

Akland pointed to WakeMed, formerly county-owned but now a nonprofit, and to the other two hospitals in the county, owned respectively by UNC (Rex) and Duke (Raleigh Community). Wake is the only large county (over 200,000 population) in the state without any private psychiatric hospital beds. That's disgraceful, she said.

Yes, said Maria Spaulding, the county's human services director, and what's even more embarrassing is to compare Wake County to Mecklenburg (Charlotte). Wake's hospitals have zero beds, while Mecklenburg's have 73, which is why Wake County sends its residents to Dix at about 10 times the rate that Mecklenburg's residents end up in a state hospital. Wake's admissions to Dix run between 140 and 170 a month these days, and are up almost 9 percent since the "state plan" came out.

Mecklenburg, Spaulding said, which has never had a state hospital close by (Broughton, the nearest, is in Morganton), has historically shouldered its own mental health costs--with some state aid, it should be noted--while Wake has fobbed more of its costs off on the state. "It is Wake County's responsibility" to step up now, Spaulding declared.

Well, Bryan thought he was doing that when he put a local psychiatric hospital on top of Wake County's list of priorities this year and--backed by the four other Republicans and two Democrats on the county commissioners--pledged $10 million to build it. He also got the Wake ABC board to pledge $5 million more from booze taxes.

Over to you, WakeMed. The county issued a request for proposals to build and run a 60-bed mental-health unit capable of handling, if not all of Dix's caseload, at least the most critical emergencies. But what came back wasn't a pitch from the county's biggest hospital, or from its two university-owned hospitals either. All three of them ducked, tucking themselves in behind a proposal by the privately owned (and for-profit) Holly Hill Hospital that is almost universally seen as far short of what's required.

What? Didn't WakeMed's Atkinson say in April that he was ready to take this on? No, he didn't. He said he was ready to lead on it if WakeMed could be assured that it wouldn't lose any money. And UNC and Duke (always through subordinates) said then what they said again Monday: We'd like to be involved, but don't look at us for money, either.

At least Atkinson keeps showing up. But his position is that 60 beds won't be nearly enough (UNC and Duke agree), because any psychiatric facility in Raleigh will inevitably draw patients from a wider region than just Wake County once Dix closes. Thus, $15 million--while nice--won't even pay the capital costs, let alone annual operating losses that are inevitable as long as the federal government and the state government and private insurance companies all avoid any responsibility for mental-health care.

WakeMed wants to help, Atkinson says, and is already helping in the sense that it sees about 30 patients a day with psychiatric issues in its ER (of them, about 1,400 a year have severe mental-health illnesses, he said). It's already staffing up to meet the growing need.

But WakeMed is no longer "the only game in town" because UNC and Duke have shown up as competitors, and they need to contribute too. "It can't be just us any more," Atkinson says.

Listening to all of this, I tried to think who in the world has the political clout to bring the hospitals, the county and the state together around the table to cut a deal, get the money and get this job done? Who licenses hospitals, and parcels out the new beds among them--through its certificate-of-need process--for services that do pay and that they do want, like cardiac care and sports medicine? Who's supposedly saving money with "reform" and could use some of it to leverage bigger contributions from the county and the rest? And who could prevail upon Speaker Black and Pro Tem Basnight for their help in the next state budget?

It's not Joe Bryan, though he's trying. And it's not Deborah Ross or Jennifer Weiss, though they're trying too. And it isn't Secretary Hooker Odom, unless she's turned loose on the task by her boss.

This is a job for the governor.

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