Behavioral health providers agree that following detention or arrest, the best place for many people with mental illness or addictions is in community treatment, not in jail or prison. Not only is it good public policy from a health perspective, but it saves money for the counties and states, since treatment in the community is far less costly than incarceration.
But this rarely happens in reality, since the jail diversion programs that make this possible are only beginning to take shape nationwide. Donald L. Polzin, executive director of the Gulf Bend Center in Victoria, Texas, and chair of the Justice Committee for NACBHDD (the National Association of County Behavioral Health and Developmental Disabilities Directors), is working to communicate “best practices” for diverting people with mental illness away from prisons and jails.
Most people who end up in jail who have mental illness are not dangerous and have not committed any violent crime, said Polzin. Two of every three people with a mental illness who end up in jail “are there because they have decompensated in some way, become a nuisance, trespassed, done this or that which is not socially acceptable,” said Polzin. “They commit a minor misdemeanor offense, and then they sit in jail because they are not able to post bond.”
Root of the problem
Those with a mental illness who are fortunate enough to have benefits such as Medicaid or SSI find those benefits are suspended or terminated by federal law when they enter incarceration, even before trial when they are presumed innocent. Thus, he explains, the costs for any mental health treatment they receive – as well as the jail costs – become ‘100-percent county costs,’ he said, noting that in most cases, counties run the most of the nation’s jails. He called the costs of such treatment “a huge burden for counties.”
In cases involving non-violent, mentally ill detainees, it makes far more sense to divert from jail, retain or gain access to available benefits and provide treatment in the community, said Polzin. He adds that up to now, “we have invested a lot of money in treating symptoms rather than in root causes, with root causes (of many detentions and bookings) being substance abuse or mental illness. “
But getting adequate money to do this is a problem, said Polzin. While prisons are a big for-profit industry in many states, including Texas, funding for mental health treatment just isn’t there. “We’re 50th in the nation in per capita funding for mental health,” said Polzin. And, no matter how much support there is for diversion from jail, “the problem we run into is that you have to have something to divert to,” he said. And this is where the funding pinch really hurts. “We need to invest in treatment, so that we have a well-developed safety net to catch these people.” Otherwise, a revolving door cycle begins: the mentally ill will find themselves in jail not once, but many times.
Fortunately, NACBHDD’s parent organization, the National Association of Counties (NACo) is aware of this problem and working with people like Polzin to fix it. “We’re working with NACo to change their legislative platform to address Medicaid’s ‘inmate exception rule’,” said Polzin. This step, if successful, would allow mental health providers to use Medicaid funds to treat people awaiting trial while they are in jail and prison.
But Polzin explains that this change, which would simply continue benefits to those detained but presumed innocent, is proving “a steep hill to climb.” Efforts to change the rule through the Centers for Medicare and Medicaid Services (CMS) have been unsuccessful. “CMS is not able to make a change in the regulations, so we have had to change our strategy to try to find legislative champions – people in Congress who will help us,” said Polzin. He notes that in 2014, the Affordable Care Act will provide a bit of relief. Under the ACA, pre-adjudicated detainees who obtained their health insurance coverage plans through state health insurance exchanges will keep their benefits. But until it is changed, Medicaid’s inmate exception rule remains the law of the land.
Sadly, Polzin notes, even after the Sandy Hook shootings brought about heightened awareness of mental illness, public spending is still more on the side of locking people up than treating them. “People are willing to spend $17,000-plus per person a year” in local jails, he said. “A lot of this has to do with stigma and lack of understanding.”
Polzin said that compared to rural areas, metropolitan areas of Texas tend to have a greater investment in mental illness. “There’s a more sophisticated system in place, with crisis assessment centers, drop-off points for psychiatric assessment,” he said. “Out in the rural community, it’s not as sophisticated, the investment is not as great, and we’re having to burn a lot of shoe leather educating law enforcement and the first responders.”
What Polzin is doing is essential, however: helping give first responders to mental health crises the protocol they need to help get people to his mobile crisis team, diverting them not only from jail but from costly emergency department treatment.
Successful programs are operating
One of the best models working models of jail diversion—the system in San Antonio (Bexar County), Texas—was described in a Behavioral Healthcarearticle in late 2011. While most successful jail diversion programs are located in metropolitan areas, Polzin said that rural areas, including his own, have been “fairly effective” with similar models built around community-based treatment and support that reduces recidivism.
He notes that the culture of mental health providers is very different from that of corrections professionals, but unless there is communication between the two groups, it is difficult to make the diversion plan work. As a mental health provider, “you have to work with the sheriffs and the police chiefs. The idea is to keep people who are not dangerous out of jail, if they are only there because they have a mental illness.”