The Iowa Legislature this year moved the funding of mental health care from a county levy to state tax dollars.
It was just the latest in a long line of legislation over the past 11 years aimed at fixing Iowa’s broken mental health system.
“It has been a perpetual change for us,” said Ryanne Wood, Lee County community and disability services coordinator.
Iowa’s mental health system came under scrutiny in June 2009, when a schizophrenic 24-year-old named Mark Becker walked into a high school weight room and shot famed Aplington-Parkersburg football coach Ed Thomas, who later died at a hospital.
During his interview with police, Becker spoke about angels, demons and a plot to hurt the children of Parkersburg. In court, his defense attorneys would say that he suffered from paranoid schizophrenia and should not be held responsible for his actions, though a jury disagreed and he was sentenced to life in prison without the possibility of parole in 2010.
Becker’s mental health problems were known to law enforcement officers. He had been committed three times in the 10 months before Thomas was killed, including a hospitalization that ended less than 18 hours before the shooting.
Wood, who has worked in mental health for 15 years, said there were always discussions about the fact that Iowa’s 99 counties meant there were 99 mental health systems. Something needed to be done, but the question remained: What?
“From the state’s perspective, there was a big push to be more consistent across all the counties,” Wood said.
The beginning: A shocking murder was a call to action across Iowa
When Thomas was killed, Wood said everyone felt it was time to make changes. Wood, who is now the chief executive officer of the Southeast Iowa Link mental health region, said discussions about how to make Iowa’s mental health system more effective began right away. There was a mental health bill passed in 2010 aimed at making sure law enforcement knew when crime suspects were released from mental health hospitals. But the big changes did not come for several years.
Years of talks culminated in the passage of Senate File 440. This bill regionalized Iowa’s mental health system. Regions meant that counties could pool their resources together in an attempt to provide better care.
In order to form regions, the counties had to prove they had access to a number of services. One of those services that the SEIL region needed to prove it had was access to mental health beds. This wasn’t initially difficult: One of Iowa’s four mental health institutions sat in the middle of the region.
But the Mental Health Institute in Mount Pleasant didn’t stick around for long. It was closed by then-Gov. Terry Branstad in 2015. That meant that the SEIL region ended up with eight mental health beds, all at Southeast Iowa Regional Medical Center’s West Burlington Campus. The SEIL region has about 160,000 residents.
“He did not have to ask the Legislature (to close the hospital),” said Sen. Tom Courtney (D-Burlington), who represented the 44th Senate district when the legislation was passed instituting the regions.
Courtney said the Legislature had decided to fund all four of the state’s mental health institutions, but Branstad decided he would close the hospitals anyway,
Wood said there was a bit of nervousness surrounding regions in the first place. What would happen if money got short? Would that mean that some areas of the region would be better served than others due to lack of money?
Wood contended this is the kind of thing that can happen when services are regionalized.
“There was a fear that local access points would be going away,” Wood said.
But in a lot of ways, the regions turned out for the better. Each county continues to have its own mental health disability services coordinator and, because resources are pooled together, the regions can provide more services with less money than it would have taken if each county had to provide the service itself. It’s not about Lee or Des Moines counties, Wood said, it’s about all eight counties in the SEIL region.
Having a regionalized mental health system also means that the employees of the regions can spend more time learning about their respective issues. Wood doesn’t need to know every minute detail about the funding or writing contracts, she has someone in her region that can handle that. As CEO, Wood performs the administrative functions and oversees the region.
Mental health regions keep bearing larger burden with less funding
However, the regions are not the end of the story. Since regions were established in 2013, the legislators are continuing to add more rules, more services to be funded and less ability to fund those services. The state gave the children’s mental health system to the regions and expanded the number of services that had to be offered by the regions, all without any money from the state or the authority of county governments to raise taxes.
Wood said that all of the changes have been made with the center of the state in mind. She said that there have been good intentions all around, but that’s not enough to capture the reality of the challenges of providing mental health care in the most rural parts of the state.
One of the best examples of this Is the challenge currently facing the SEIL region: The state’s new funding program for mental health. The program billed itself as an increase to mental health funding, and it is on paper. The regions set are to get millions of dollars in new funding.
But the reality is that, without additional changes, the bill represents a permanent funding cut to the SEIL region. Currently, SEIL is funded at about $43 per resident, but the new legislation will not allow SEIL to be funded to that level for the next five years.
That’s without factoring in any growth. Even if the system were to grow at a cost of just 1.5% per year, the SEIL region would need $46 per capita of funding by the time its funding would be restored in Fiscal Year 2026.
Beyond that, the Legislature only allowed a growth of up to 1.5% per year, and that growth is based on change in the sales tax collections, not the cost of services increasing. If the state does not see any and change in its sales tax collections, the regions won’t see any change in their funding.
Courtney hopes the change will help the mental health system, but he is skeptical that the legislators will keep their promise to fund the state’s mental health system. He thinks it’s only a matter of time before the state decides it needs that money for something else, such as tax cuts.
One state senator sees success, although not during his time in office
But not all the changes to the mental health system have involved the regions, and not all of them were inspired by what happened in Parkersburg.
Tom Greene worked as a pharmacist before he took up the mantle of state senator. Working as a pharmacist, he realized there are a handful of people with mental health issues who are on medication but don’t really require the attention of a psychiatrist every couple of months to refill that prescription.
“There were so many patients who said ‘has the doctor called yet?'” he said of his inspiration to write the bill.
When Greene got his degree, pharmacists needed only four years of education. Now, pharmacists get just as much education as doctors, except their education is specifically about the drugs that are used to treat a variety of ailments.
Greene saw an opportunity. What if pharmacists could get permission from doctors to manage the prescriptions of those who have mental illness and are stable with their medication? Greene introduced this bill into the legislature, becoming one of his signature pieces of legislation.
Unfortunately, Greene said that he wasn’t able to get Democrats to support his bill and it wasn’t passed in his four years as a senator. He said the lobbyists for doctors in Iowa opposed the bill, thinking that the bill was a way of replacing doctors.
But Greene said his bill wasn’t about decreasing the need for psychiatrists, it was a recognition that Iowa had too few of them. The bill was about a partnership so that someone who just needed a maintenance appointment with a psychiatrist could meet with a pharmacist instead. Greene hoped this would free up the psychiatrist to meet with more pressing cases.
This spring, Gov. Kim Reynolds did manage to get the bill through, and she invited Greene to the signing ceremony.
“I just think it’s a win, win, win. I really do,” Greene said