Budget casualties: Mental health and substance abuse services
After 15 years serving adults living with severe mental illness and homelessness, a supervised group home in Campbell County has closed its doors because of state-level budget reductions.
The furniture is still there, but there are no longer residents in the Greenhouse. The now-empty facility provided a supervised setting where three to six occupants had their own beds, access to a group kitchen, living room and exercise facilities. Live-in supervisors once assisted residents in finding employment and provided guidance for daily life’s practical matters, like cooking and laundry.
It was the favorite program of Mikel Scott, Council of Community Services executive director in Campbell County, who said it offered a well-rounded set of services that went far beyond what a typical homeless shelter or food bank can do.
“The impact it had on people’s lives was so complete,” Scott said. “They had everything they needed to be stable. It wasn’t just addressing one aspect of their problems.”
The Greenhouse was a single mental health and vulnerable-population-safety-net operation affected by recent budget cuts, but it’s closure is not isolated. Reductions to the Wyoming Department of Health are expected to impact mental health and substance abuse services, starting with service reductions or closures this summer.
Those reductions leave many communities unable to provide even the most basic inpatient or outpatient mental health and substance abuse services at a time of skyrocketing need, advocates say. Many warn today’s reductions will only result in larger costs, and less-effective reactive solutions down the road.
“We have to make reductions, but we have to serve the communities we have the best we can, while also meeting the state needs — that’s a hard balancing act,” said Andi Summerville, Wyoming Association of Mental Health and Substance Abuse Centers executive director.
Campbell County Health (Gillette’s hospital) had subcontracted with the Council of Community Services to operate the Greenhouse with the goal of helping individuals with severe mental illness integrate back into the community. But in late 2014, the state’s mineral industries began a slump they have not recovered from. In 2020, COVID-19 dealt another blow to the state’s already hampered finances.
The Wyoming Department of Health gives a block grant to community health centers across the state to provide mental health and substance abuse services. In recent years that state funding came to about $44 million, split among various facilities across Wyoming. That amount was reduced by $7.5 million — roughly 17% — for the fiscal year beginning July 1.
That budgetary rollback leaves many communities in difficult positions.
“We’re going to see significant impacts come July 1,” Summerville said.
Those impacts will manifest in communities in a variety of ways, Summerville said. There could be more barriers to access and fewer hours for outpatient care; intensive outpatient (IOP) for substance abuse could see problematic limitations in how services are provided; for inpatient services, there will simply be fewer beds.
Scott said the Council of Community Services in Campbell County prepared for a roughly 20-percent cut from the Greenhouse’s $393,150 annual budget. But when the news came down that the state reductions would result in a more than 50-percent funding cut, officials decided the home could not continue operating on $150,000.
It’s a heartbreaking situation for Scott, who said that in her line of work, it is clear Wyoming communities will be paying a price to address mental health problems after the state cuts, one way or another. She expects far-reaching negative consequences to ripple from the cuts as other sectors of the system not as equipped to handle the load are burdened.
“I think in two years, three years, everyone’s going to be sitting around saying, ‘How do we reduce our ER costs? Why do we have so many people coming into the ER, multiple times? How do we reduce this? How do we prevent our police officers from having to pull their guns out on someone who’s mentally ill, or why are our jails full,’” Scott said. “If they had just [funded these programs] from the beginning, we wouldn’t be running into these problems.”
Campbell County Health sees a revolving door of patients who come to the emergency room for behavioral health issues, Adrian Garrits, a Campbell County Health trustee, said. Some patients are stabilized and discharged, only to return again. Some are placed in the hospital’s behavioral health unit, but then it is a challenge to find placement for them at the state hospital in Evanston or another long-term care facility. Many are eventually released back into communities where continuing care can fall through the cracks, Garrits said, and before long, they’re back in the emergency room.
“We see this on repeat,” Garrits said.
It’s been frustrating trying to explain to policymakers that preventative mental health and substance abuse care saves money for state and local governments in the long-run, Garrits said. While he believes that’s the case, Garrits said data to support it isn’t readily available in Wyoming. But when it comes to the state cuts to local programs, he said, communities are left to reactively patch things together the best they can.
“At the community level, we’re dealing with the symptoms of a broken system, not the root causes,” Garrits said.
Campbell County Commissioner Del Shelstad did not want to see the Greenhouse close. It was clear the center couldn’t operate with the reduced level of state funding, but he wondered if local governments could provide some sort of buffer.
“I don’t want to get rid of a service that’s needed, and my initial perspective was that these people need this service, and it’s our job as a community to make sure they get it,” Shelstad said. “What I didn’t want to see was we end up serving those people in the community in other ways. I don’t want to sound extreme, but they could end up in jail, they could end up in the hospital, they could end up in other places. And if we’re going to spend that money on them and those other places, we need to take a look at maybe just funding it directly. That was my perspective.”
After speaking with Greenhouse officials, he came up with a proposal for the county and town to split the cost of $400,000 to keep the home open.
But when he took the matter to the commission for a work session, there wasn’t an appetite to fund the Greenhouse. Budgets were already stretched thin, and the board didn’t feel it was appropriate to invest hundreds of thousands of taxpayer dollars for a home that only served up to six people at a time, Shelstad said. Additionally, the commissioners didn’t want to be roped into paying for the facility in perpetuity. The issue never went beyond the work session.
“Some of the reasoning for not funding it made sense to me, so I was stuck,” Shelstad said.
The questions raised about effectively addressing mental health and substance abuse issues without funds are illustrative of the lingering conversation in Wyoming’s current economic downturn about cutting services or raising taxes, officials said.
Shelstad doesn’t want to see his taxes raised, he said, and pointed to the state’s K-12 education system as an area that he thinks needs to be examined closely for reductions. Wyoming lawmakers failed to address a $300 million shortfall in education funding at the conclusion of the session earlier this year after the House and Senate could not agree on an approach.
The state is on the precipice of losing services as a result of state budget cuts, said Sen. Fred Baldwin, R-Kemmerer, who co-chairs Wyoming’s Select Committee on Mental Health and Substance Abuse. But willingness among lawmakers to consider revenue-generating measures remains low, he said.
“That’s the issue with everything,” Baldwin said. “Mental health, health care, education — that’s the underlying issue. There’s a strong movement to not increase any taxes, period. But the price of that is you may lose some services. That’s the toughest job the Legislature has is trying to decide: ‘Well, who are the winners and losers?’”
Medicaid expansion is another ever-present controversy for lawmakers. The state health department estimates the most recent measure, House Bill 162- Medical treatment opportunity act, would have helped enroll between 13,000 and 38,000 people and lowered rates for private insurance providers. The 2021 session saw the bipartisan-sponsored HB 162 make it farther than it had in the past before dying in a Senate committee on a 3-2 vote.
Baldwin sees a direct correlation between Medicaid expansion and the state’s unmet needs in mental health and substance abuse services. Many of those seeking help for mental health or substance abuse who end up in the ER have no insurance or means of payment, resulting in millions of dollars in uncompensated care for hospitals.
“We’re reaching a tipping point at that, too,” Baldwin said. “We’re losing hospitals and clinics, and doctors, etcetera; we’re losing health care because our cost of uncompensated care has grown so much. There’s a huge cost to society if we don’t provide those services, and it’s going to cost us somewhere else.”
The state health department figures also projected that more than $100 million in uncompensated care would have been alleviated from the backs of Wyoming’s ailing hospitals with HB 162.
Garrits said he couldn’t take a position on whether Medicaid expansion would address some of the challenges Campbell County faces with behavioral health.
“I’m not sure to what extent the folks that are having behavioral health issues would qualify for the expansion or not,” Garrits said. “My assumption would be yes, but I just don’t have the data to support it.”
The Wyoming Association of Mental Health and Substance Abuse Centers is in favor of Medicaid expansion, Summerville said.
“We might be the only [state] that doesn’t leverage the Medicaid system at all to support community mental health services,” she said.
Providing services for adults with mental health and substance abuse issues is a difficult case to make, Scott said. There’s a stigma attached to providing money for people who often can’t hold down a job, have addiction problems, have issues with violence or anger or have been through the same agencies multiple times in the past.
“If you don’t work around it all the time, or don’t have a family member with it, or you don’t struggle with it, it’s easy to see people with mental health issues as just having a bad personality defect,” Scott said. “Wyoming is so big on personal responsibility, and there is something to that, but when somebody is not in the right state of mind to make good choices, they don’t have that personal responsibility. They can’t make the right choices.”
The hospital is still in touch with the individuals who were living at the Greenhouse, said Derek Friedlan, Coordination of Care for Behavioral Health Manager at Campbell County Health. The majority are living independently and working with outpatient case manager services.
Those who are assessed as needing a long-term-care setting in Campbell County are now being sent to communities across Wyoming, Friedlan said. It’s challenging, he said, to not be able to keep them in the community.
“I think we really have to look at that when dealing with mental health, is the whole support system,” Friedlan said. “I think the hardest part about not being able to keep clients in the community is not having them in the same town as their families, or just in the town they’ve been in for a long time. They might have support systems here that are not family.”
Misty Robertson, chief nursing officer at Campbell County Health, said everyone involved was sad to see the Greenhouse close, but she’s trying to look at things optimistically.
“I hope we take this opportunity because this change had to happen to evaluate how else we can work together as a strong team to improve mental health,” Robertson said. “I hope we can take this unfortunate budget cut as an opportunity to maybe do something new or better or different that will continue to help patients.”
Scott is used to operating on a small budget, she said, but “we always find a way to do it.”
“It feels like the difference from when I started this job to now is that people in the community are much more ready to work together,” Scott said. “The agencies in town are realizing that if we’re going to continue to be able to help people, we have to do it in partnership. None of us can do it alone. It gives me some hope that people are going to work hard at least to try.”
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