Special Reports

Push for treatment, not jail, for mentally ill

In Pierce County, untreated or undertreated mental illness is a major driver of law enforcement and jail costs. It gobbles up public dollars for arresting, prosecuting, adjudicating and incarcerating offenders who might have been able to avoid the criminal justice system had their underlying mental conditions been adequately addressed.

There’s only one consolation: Everybody else is in much the same boat.

Across the nation, jails and prisons are more likely than state hospitals to house the mentally ill. According to D.J. Jaffe, executive director of the nonprofit Mental Illness Policy Organization, three times as many mentally ill Americans are incarcerated as hospitalized. A single New York City jail (Riker’s Island) houses more mentally ill than all the state’s mental hospitals combined — and that state is pushing to close some of those.

In California, the mentally ill are four times as likely to be incarcerated as hospitalized, Jaffe writes. But that’s better than in Texas, where they are eight times more likely to be found in jail than in a medical setting receiving treatment.

The trend in dealing with the mentally ill for the past several decades has been to treat them in the least restrictive setting, ideally in community care, as opposed to the big state hospitals that once had reputations — deserved or not – as “snake pits” where patients were abused, drugged and held against their will. But there’s a shortage of those community care facilities.

Now, in many places (including Washington), the pendulum has swung so far that it’s all but impossible to order the mentally ill into treatment unless they are endangering themselves or on the verge of violence. The first time someone might get mental health treatment in an institutional setting is after he’s stabbed some stranger to death on a city street during a full-blown psychotic episode.

One problem is the way much mental health care is paid for: It incentivizes states not to hospitalize sick people or not to keep them for lengthy periods. That’s because Medicaid is largely prohibited from paying for long-term care of the mentally ill, putting the burden on states for that care.

Federal law needs to be changed so that the 50 percent Medicaid reimbursement allowed for non-institutional care could be used to help the most severely ill receive treatment in psychiatric hospitals when it’s been determined that that would be the best place for them.

The current system for funding and providing mental health care is broken. If it were working, jails wouldn’t be de facto treatment centers. Congress must make it easier for states and communities to help the severely ill — before they end up on the evening news.