Big money, tough decisions ahead as state decides how to overhaul mental health system

Washington Gov. Jay Inslee wants $273 million allocated in the 2019-20 state capital budget to begin overhauling the state’s mental health system, including repairs at Western State Hospital.
Washington Gov. Jay Inslee wants $273 million allocated in the 2019-20 state capital budget to begin overhauling the state’s mental health system, including repairs at Western State Hospital. AP

As lawmakers decide whether to study building a new Western State Hospital, they also are grappling with Gov. Jay Inslee’s multimillion-dollar proposal to build nine smaller facilities around the state for mentally-ill patients who are committed through the civil court system.

The looming budget decisions are expected to determine whether Washington state moves away from a reliance on large state psychiatric hospitals and toward treating civil patients in the communities they come from. Inslee has asked for $273 million in the 2019-21 capital budget to start that transition.

The key question confronting lawmakers is how to prioritize the many needs in the mental health system, said Rep. Steve Tharinger, a Democrat from Sequim who chairs the House Capital Budget Committee.

“This is a long-term strategy. There’s no clear pathway yet,” he said.

Inslee’s proposal calls for building four 16-bed facilities, two 48-bed facilities, and three 150-bed facilities to move nearly all of the civil patients out of Western State Hospital in Lakewood and Eastern State Hospital near Spokane by 2023.

The estimated cost of design and construction: $592 million in future capital budgets. Part of the governor’s ask from the 2019-21 capital budget is $30.9 million for pre-design and design work.

Sen. Steve O’Ban, R-University Place, questioned why the facilities would be state-owned and operated. He said private, nonprofit entities run many evaluation and treatment facilities.

“Isn’t there a benefit to having nonprofits?” O’Ban asked at Thursday’s Senate Ways & Means Committee hearing. “If they’re not performing, you can exchange it out with a better provider.”

State-owned and operated facilities can’t refuse to serve patients, and Inslee believes they help “harder-to-serve individuals” better than private, nonprofit entities, said Devon Nichols, an operating budget analyst in the Office of Financial Management, which prepares the governor’s budgets.

Because Inslee’s strategy has multiple elements, the Legislature’s budget decisions are expected to have major consequences over the next several years.

For example, the governor has asked lawmakers to maintain current levels of services at the two state hospitals until more civilly-committed patients can be moved out of those facilities and into community settings, said Nichols, the state budget analyst.

To do that, Inslee’s proposed 2019-21 capital budget calls for spending $33.5 million at Western State for critical infrastructure and building improvements and another $46.5 million to address short-term bed shortages and add modern treatment space, said Tara Lee, an Inslee spokeswoman.

Most of the spending would be on wards on Western State’s central campus for those who are civilly-committed, said Bob Hubenthal, assistant director for capital facilities management for the state Department of Social and Health Services.

Lawmakers and the executive branch will have to decide whether to continue to use tax dollars for buildings on the older central campus that may not be used in the long term, Tharinger said.

At a House Capital Budget Committee meeting Thursday, Tharinger asked if the state intends to put “money into stuff that is over 100 years old or just 50 years old.”

The governor’s proposed capital budget also calls for spending $110 million on grants to community hospitals and private health care providers to help them add beds, so civil patients don’t have to be sent to state hospitals and current patients can be released from them. That would add more than 500 beds, said Carly Kujath, capital budget assistant to the governor in the Office of Financial Management.

Inslee also wants $22.6 million for pre-design and design work for the four 16-bed and two 48-bed facilities, and $8.3 million for pre-design for the three 150-bed facilities. That work would examine potential sites, state officials say.

The facilities are a key part of the governor’s strategy to move nearly all of the civil patients out of Western State Hospital and Eastern State Hospital by 2023.

Under the governor’s plan, Western State and Eastern State would continue to provide evaluation and treatment for so-called “forensic” patients, who are part of a criminal case or who have been found not guilty by reason of insanity.

Sen. David Frockt, D-Seattle, praised Inslee’s blueprint.

“You’ve done a good job of balancing the needs to stand up the current system as best as we can as we move into a transformational direction,” Frockt told the governor’s budget aides.

Other lawmakers focused on the thorny questions surrounding Western State.

The federal government last year pulled annual funding of $53 million from Western State after the facility failed an inspection. Infractions included the restraint of patients for hours without cause and an insufficient number of sprinklers in parts of the hospital. Western State said in 2016 it would make safety and quality of care improvements to comply with federal standards.

Sen. Mark Mullet, D-Issaquah, pressed the governor’s office on when the state will regain the annual federal funding of $53 million. Nichols, the state budget analyst, referred the question to DSHS. An agency spokeswoman told The News Tribune on Friday that the state can’t get the funding back until it regains certification from the federal government.

“How do we not get into the same spot again?” Mullet asked. “Six years ago, obviously we probably should have started this process.”

Nichols replied: “The overall approach is to step away from the state hospitals on the civil side, build a new forensic hospital at Western State Hospital and then really serve people in the community so we don’t get people into this situation again.”

At the House Capital Budget Committee meeting, Rep. Norma Smith, R-Clinton, said Western State’s certification with the federal government enabled some of the old buildings to be exempt — commonly known as “grandfathered” — from various codes. That ended when the federal government decertified the psychiatric hospital last year, Smith said.

“Do you see any path forward by which we could get into compliance by remodeling aged buildings? Because it’s my understanding we’ll never be in compliance,” Smith said.

Kujath, the state capital budget official, replied that it would be “nearly impossible.”

State codes covering structural stability in the case of seismic activity and energy efficiency would be the hardest to comply with, said Hubenthal, the DSHS official.

Rep. Mari Leavitt, the University Place Democrat whose district includes Western State, asked whether the state would consider other sites outside Lakewood for a new 500-bed Western State Hospital.

The News Tribune reported Jan. 18 that the former Fort Steilacoom Golf Course is marked as the site of a future 500-bed forensic hospital and a 150-bed hospital for civilly committed patients on a draft document prepared by an architectural firm hired by the state. The 12-page document — which bears both the name of the architectural firm, SRG, and DSHS — is part of a $400,000 updated master plan for Western State that should be completed in May.

If the legislature approves $7.5 million this year for pre-design work for a new state hospital, it would look at various options including building a new 500-bed hospital at Western State or putting some beds there and others elsewhere, Hubenthal said.

In an interview, Tharinger said the study could determine if any existing buildings could be used, perhaps lowering the number of beds needed for a new Western State to 200 to 300, thereby lowering its estimated $560 million cost. Inslee’s proposal calls for the new hospital to open in 2025.

The governor also has asked the legislature to approve spending $2 million in the upcoming capital budget for pre-design for a new teaching hospital at the University of Washington that would add more mental health beds as well as train workers to combat a shortage in the field.

Rep. Sharon Tomiko Santos, D-Seattle, pointed out that UW already has a teaching hospital, Harborview Medical Center, in a partnership with King County that provides mental health services.

“Why wouldn’t we take advantage of an existing partnership and an existing model that we have?” Santos asked.

Kujath, the state capital budget official, said the proposed new teaching hospital in Seattle would be solely dedicated to mental health services and would provide an additional 150 beds for civilly-committed patients.

Dr. Jurgen Unutzer is chairman of UW’s psychiatry and behavioral health department and a key proponent of the new mental health teaching hospital. Unutzer said most people in Washington state with serious mental health or substance abuse problems don’t get any treatment.

“We need to move from the 19th-century care to 21st-century care. You’re talking about a set of services that deals with not just a bed, but it deals with housing needs, it deals with social services needs, and it deals with behavioral health needs in smart, integrated ways,” he said.