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How Mentally Ill Americans Are Falling Through The Cracks In The Social Safety Net

By Sy Mukherjee  

"How Mentally Ill Americans Are Falling Through The Cracks In The Social Safety Net"

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James F.C. Brown, a mental patient with schizophrenia

The Sacramento Bee published a powerful story on Sunday about James Flavy Coy Brown, a mentally ill Southern man with a history of schizophrenia and depression who was unceremoniously dumped by the Nevada facility that was supposed to be giving him care. Although Brown’s tale is a harrowing one, it is by no means unique, as millions of mentally ill Americans — and especially those with housing insecurity — find themselves falling through the cracks in the social safety net.

Brown, who was being observed at the Rawson-Neal mental health facility in Nevada, was discharged and put on a bus to California. Doctors claimed that he would have better luck finding care there, since Nevada’s massive cuts to mental health services left him with few treatment and housing options in the state. Brown’s story has prompted federal and state investigations into possible misconduct by Rawson-Neal and other psychiatric facilities in Nevada, particularly since the Bee reports that preliminary findings indicate that this isn’t new behavior — Rawson-Neal alone “bused about 100 state psychiatric patients to California between July 1, 2012, and the end of February, and scores more to other states.”

As advocates explain, dumping mental patients onto buses is almost entirely a consequence of insufficient funding for mental health and housing programs:

Brown’s experience starkly underscores gaps in the public health care system that plague mental patients across the country, advocates say, including a lack of suitable housing and crisis intervention care.

His Sacramento saga began in early February shortly after he landed in Rawson-Neal. Although his hospital discharge papers list his place of residence as Catholic Charities of Las Vegas, Brown said his last real home was a small group facility that shut down.

According to a state investigation, he spent 72 hours in the hospital’s observation unit before a doctor discharged him to a Greyhound bus to Sacramento. The discharge orders noted he should be given a three-day supply of Thorazine, Klonopin and Cymbalta to treat his schizophrenia, anxiety disorder and depression, plus “Ensure and snacks for a 15-hour bus ride.”

According to the National Alliance on Mental Illness (NAMI), Nevada — which had paltry funding for mental health services to begin with — instituted the fifth largest cut to mental health funding of any state between 2009 and 2012, with over 28 percent in decreased appropriations. The fact that doctors believed Brown would receive better care in California is a particularly sad state of affairs, as the Golden State is seventh on that same list after making a 21.2 percent cut to mental health services. Those cuts have led California’s sprawling private prison system to become de facto asylums, and in Sacramento specifically, “ERs have seen a spike in mentally ill patients since Sacramento County’s mental health facility shuttered its crisis intervention clinic and closed half its beds in 2009 amid budget cuts.”

That’s partly why advocates for the mentally ill have hung their hats on Obamacare’s expansion of Medicaid, which California and Nevada have both decided to participate in. Between the law’s eligibility expansion, generous federal funding, and parity rules extending minimum levels of mental health benefits to all Americans, some 32 million Americans who previously did not have access to mental health care are expected to gain it in one form or another. That is particularly significant seeing as poor access and excess costs are Americans’ top barriers to receiving treatment.

Unfortunately, even if the Medicaid expansion had occurred years ago, Brown may not have benefited from it due to his housing insecurity. Social exclusion and poverty are significant risk factors for mental illness, and the homeless consequently have sky-high rates of chronic and severe mental health problems. While Medicaid expansion would address the eligibility issue for homeless Americans, lack of identification or a Social Security card presents a nearly insurmountable barrier to enrollment. The Kaiser Family Foundation also finds that literacy and language barriers and a distrust of public institutions makes it difficult to to enroll the homeless in Medicaid or Social Security disability insurance.

And the issue becomes even more complicated considering that certain efforts to improve mental health care can actually undermine efforts to help the homeless. For instance, since the 1960s, states have been cutting down on beds in public psychiatric hospitals in an effort to shift towards more community-oriented, non-institutionalized care. Specialists agree that this is a much more effective form of treatment, since it integrates patients into society rather than sequestering them from it. But in the case of the homeless, who by definition lack a community or support system in which to be integrated, it often leads to untreated ailments and jail time. Brown may have found a happy ending to his story, but millions of Americans don’t — and likely won’t, even under Obamacare.

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