There are millions on the streets

It’s a start.

After the Sacramento Bee exposed the Southern Nevada practice of busing severely mentally ill patients out-of-state and out-of-mind, Gov. Brian Sandoval created a Behavioral Health and Wellness Council to recommend specific solutions for Nevada’s troubled mental health system. 

The council recently released 16 recommendations for short-term fixes. The chairman of the council immediately lowered expectations by telling the Las Vegas Review-Journal that the governor “believes in mental health”—don’t we all?—but the Legislature will have to decide what to fund. Understating Nevada’s poorly resourced state budget, Dr. Joel Dvoskin, said what everyone always says, “There’s lots of worthy projects that are competing for funding.”

The recommendations are hardly previously overlooked reforms. Components like supported housing have actually been increased in recent years, before the recession led Sandoval and lawmakers to slash the mental health budget, reminiscent of many other times in Nevada’s sad history when budget cuts have targeted those with the smallest voice in the lobbying corps.

Still, it’s a start. Legislators from both parties have been working for decades on improving the legal hold process to open up inpatient facilities more quickly to those deemed a danger to self or others. The lack of competitive pay for state psychiatrists and the low daily rate for hospitalization have been brought forward by agency officials for at least that long, but every session there is a “worthy project” more in need of state funding. And the ratio of psychiatric beds to the state’s population is scandalous.

The council suggests a “Super-User Project” to focus intensive case management services on “frequent flyers” who show up repeatedly in hospital emergency rooms, detox facilities, homeless shelters, and jail. Perhaps the best illustration of this expensive repetitive cycle is found in Malcolm Glidewell’s New Yorker article, “Million Dollar Murray,” http://gladwell.com/million-dollar-murray, which focused on the trials and tribulations of Murray Barr, as chronicled by former Reno police officers Patrick O’Bryan and Steve Johns.

By providing housing, medication management, and a mental health worker unafraid to leave the office and check up on a “super-user,” huge savings can be generated while allowing mentally ill people an opportunity for stability and a better quality of life.

The council’s recommendations were unanimous but that’s not so unusual either. The treatment community has long recognized what makes a mental health system successful. But it’s easy to sign off on a recommendation to help such obviously tormented souls cope with an illness that often manifests in strange behaviors and public suffering. It’s something else entirely to find the money, or the political will to generate needed revenue, to make the system work.

There are two elements this time that may make a difference. One is the national embarrassment of the busing scandal, especially for a popular governor with higher aspirations. If Sandoval can’t fix Nevada’s broken mental health system, his rising star may begin to fade.

The other, surprisingly, is Obamacare, specifically the expansion of Medicaid to include childless adults. The extra revenue from federal Medicaid funds may alleviate the need for millions in state dollars. This “worthy project” may not have to compete with items such as corporate subsidies if the state is able to bill Medicaid for the expanded services.

There is also an opportunity to redesign Nevada’s mental health system and expand its scope to include substance abuse and other co-occurring disorders. A regional approach would incorporate outreach services to rural areas desperately in need of psychiatric and emergency care.

As Officer O’Bryan, now retired and living in New Mexico, told Glidewell: “It cost us $1 million not to do something about Murray.”  

Just imagine how many Murrays are out there on the street today.