Counties manage mental health system well

By Craig Wood

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I was disappointed to read the Feb. 6 Gazette editorial stating that Iowa's mental health care system is in “dire need of reform.” While I can certainly agree with the sentiment that, as the editorial stated, “Iowa must do better for our most vulnerable residents,” I thought it unfortunate that the editorial went on to blame the problems on the county-operated system. Somehow, a “lack of uniformity” translates as “inefficiencies,” which results in a “broken and uncoordinated” system.

Those of us who have spent the better part of our lives working in this system take pride in the good that we have done for people. There are 55,000 people receiving services financed with county-managed funds. In Linn County, and I know in many counties, we frequently receive testimonials about how services have improved the quality of life and even saved the lives of people.

It has been said that the problem is that there is not a standard set of “core” services that every county must provide. That statement is inaccurate. There are laws on the books that specify what all counties must provide. The reason that there is not uniformity is that most counties exceed what is required by law.

For example, there is no law that says counties must pay hospitals for inpatient mental health services. Chapter 230 of the Iowa Code requires counties to pay for services of people committed to a state hospital (i.e. state mental health institution). Almost all counties will pay local hospitals for inpatient psychiatric services because it is good fiscal management to do so and because it is better for the person who needs the services. There is no law that says counties must pay for psychiatric medications, but many counties do.

The problem is that the existing set of core services needs to be expanded. It has not been expanded because it would cost money.

It also has been suggested that the county system is inefficient. Financial reports turned in to the state by the counties show that on a statewide basis, out of the

$335 million spent by counties, only 1.3 percent was spent on administration. That is extremely efficient. In addition, only 10 percent of our funds go for institutions and hospitals, while the rest goes for community-based or home-based services.

The editorial mentioned waiting lists as being a symptom of Iowa's broken system. A recent survey of state waiting lists for home and community based services revealed that there were 39 states with longer waiting lists than Iowa for the Medicaid waiver service for people with mental retardation, and in Iowa this waiver waiting list is managed by counties. Iowa had about 200 on the waiting list while many other states had thousands.

In any event, waiting lists are not necessarily a symptom of a systems problem but of a funding problem. Linn County will have a waiting list for its services in fiscal 2012 unless state funding is increased. Hopefully, we will not achieve uniformity in this state by reducing all counties to the bare minimum.

I am sympathetic with the problem expressed by the hospitals of having to bill many different payers, and the Iowa State Association of Counties has been lobbying for several years to have those costs taken over by the state. The reality is that hospital costs statewide represent only 1.2 percent of our budgets, and we would just as soon have the state manage that plus take the state institutions and court costs as well.

But we do believe that local services ought to be locally managed because we think we can do it better than Des Moines.

Craig Wood is the director of Linn County Mental Health and Developmental Disability Services. He is also vice-chair of the Governor's Commission on Mental Health and Disability Services. Comments: craig.wood@linncounty.org