Both people with psychiatric disorders and the psychiatric services and systems designed to serve them took center stage in 1999-2000. In Olmstead v. L.C., dubbed by one advocate as the "Dred Scott case of people with disabilities," the Supreme Court supported consumers of psychiatric services against inadequate systems of care.

The Olmstead Decision
     In July 1999, the decision clearly challenged Federal, state, and local governments to develop more opportunities for individuals with disabilities through more accessible systems of cost-effective community-based services.      The Olmstead decision interpreted Title II of the Americans with Disabilities Act (ADA) and its implementing regulation, requiring States to administer their services, programs, and activities "in the most integrated setting appropriate to the needs of qualified individuals with disabilities." The US Supreme Court decreed that: it is unlawful to unnecessarily hospitalize disabled citizens.      In June 2000, the Division of MH/DD/SAS established an 18-member steering committee of advocates, consumers, family members, and professionals to oversee the development of a comprehensive Olmstead plan covering the institutions operated by the Division.      The Olmstead decision requires states to work with consumers to provide services in the least restrictive setting, as opposed to the setting the state deems most convenient or inexpensive.      During this same period, a number of national and North Carolina-based reports were released assessing public mental health services and the experiences of consumers or patients who use those services. The Surgeon General's Report on Mental Health (DHHS 1999) and the North Carolina State Auditor's Study of State Psychiatric Hospitals and Area Mental Health Programs (April 2000), are lengthy, detailed, sometimes technically cumbersome, productions of mental health researchers, providers, and policy professionals. The October 1999 John Locke Foundation policy report, Rhetoric or Reform: The Future of Mental Health in North Carolina, and the Charlotte Observer Series, North Carolina's Troubled Mental Health System (January 2000), are more succinct. They espouse a political perspective (in the Locke Foundation case), or highlight and humanize a complex mixture of policy, politics, and problems (Charlotte Observer). The National Council on Disability added its voice to the national debate by issuing its first report ever on people with psychiatric disabilities, From Privileges to Rights: People Labeled with Psychiatric Disabilities Speak for Themselves (NCD, January 2000).
     Why all the attention to psychiatric services and the lives of people with psychiatric disabilities? And, more importantly, what do we do now with the findings and recommendations of these physically and politically hefty reports?

Findings
There is uncommon consensus within North Carolina and in the reports mentioned above that our mental health services, policies, system organization, and financing systems fall short of basic, much less regional and national standards. The past decade has seen an erosion of innovation, quality of services and staffing, consumer outcomes, and funding at virtually every level. Inpatient services are arguably over-used, and outpatient services vary widely in their quality, type, and availability. As each report makes clear in its own way, the most egregious indicators of what is "broke" are too many lives needlessly damaged, wasted, and on occasion lost. There are, to be sure, pockets of excellence among Area Mental Health Programs, and within hospitals. But these are often in spite of state and local policies and funding mechanisms. In a state experiencing unprecedented prosperity, growth, and technological advances, and with an abundance of talented psychiatric researchers, we have to ask ourselves tough questions about how we have left this most public of all our health obligations to such decline and disarray.
     Herein lies part of the answer - the exceptionally public and therefore political nature of mental health care. Mental health care for those with the most severe disorders such as schizophrenia and affective disorders is, compared to care for physical illness, inordinately publicly funded and provided. From this view, the fate and fortunes of mental health care should be seen as comparable to public education rather than general health care. Both the good news and the bad news is that fixing the North Carolina mental health system is a public responsibility, borne mutually by the legislature, the executive branch, counties, cities, consumers of psychiatric services and their families, and the public at large. It is OUR responsibility. Each constituency has a stake in and requires a heeded voice in the reforms that are necessarily ahead.

Mental Health Study Commission In the good old days there was a Mental Health Study Commission, chaired by Kenneth Royall, Jr. from 1973-85, and co-chaired by him from 1986-92. Royall served in the NC legislature from 1967 until 1992, first in the House and later in the Senate and chaired the Appropriations Committee. A Democrat from Durham, he had a great deal of power. It was during his reign that Division of MH/DD/SAS got an increased budget, began to go after Medicaid dollars, and developed long-range plans - plans that were never fully funded. Since Royall's days, the influence of this group has waned.

     Leadership, effective authority, vision, and expertise have all been found lacking in the assessments of North Carolina's system. The legislature has all but abandoned a historically workable policy mechanism, the Mental Health Study Commission.      The State Auditor's report calls for a fixed point of authority and responsibility, primarily at the county or multi-county Area Program level, and consolidation, coordination, and focus at the state level. However, this recommendation is highly problematic because of the very large differences in financial resources and extant service infrastructure among Area Programs. Due to the apparent inability of the state Division of Mental Health/Developmental Disabilities/Substance Abuse Services (DMH/DD/SAS) to manage fiscally and to provide and practice best practices in psychiatric services, similar questions have to be posed about a central state authority.

Medicaid Funding and Disproportionate Share Payments(DSH)      When Medicaid was established in 1966, the intent was to share the cost of health care for the poor between the federal and state governments. Historically, North Carolina has paid about one-third and the federal government two-thirds of the state's Medicaid costs. Medicaid pays directly for psychiatric inpatient care provided in general hospitals to clients of all ages. However, in "stand-alone" psychiatric hospitals such as the state's four hospitals, the federal government provides Medicaid coverage for psychiatric treatment only for patients younger than 21 or older than 64, based on the principle that mental health services are the responsibility of states and localities.      Some of the federal money goes directly to providers, while additional money goes to hospitals. The federal government makes Disproportionate Share (DSH) funds available to states to supplement funding to hospitals and providers that serve larger numbers than expected of Medicaid-funded and other low-income patients. North Carolina and other states, seeing a two-for-one funding opportunity, developed mechanisms to increase Medicaid billings and thereby bring more federal health money into the state. Of course, that also meant increased state spending. Medicaid payments for psychiatric services in the community in 1998 provided 38.7 percent of total funding for the Area Programs. Four years prior, they provided only 17.8 percent.      However, DSH hospital funds are not handled in a straightforward manner. North Carolina received $398 million in 2000, $257 million of which goes to providers other than state psychiatric hospitals. The remainder of the money, $141 million, goes from the federal government to the Division of Medical Assistance to state psychiatric hospitals and then into the state treasury's General Fund. The justification is that other state money is allocated to these hospitals and that DSH funds are reimbursement.      DSH funds were originally considered to be one-time monies, but have become recurring. Therefore the reverted money is spent in the North Carolina recurring budget. It passes through the hospitals and goes for who knows what.      For this reason, the psychiatric hospitals will not be negatively affected when and if Congress puts a stop to these machinations, now anticipated in 2007. But the state coffers will be. It can be argued that the state used other funds to cover the hospitals and that the money game was a wash. But there is no way to know that for sure. In fact, funding for MH/DD/SAS from the General Fund, when adjusted for population increase and inflation, decreased by 2.6 percent from 1987 to 1998. During this same period the General Fund itself increased by 19 percent.      NAMI, a mental illness advocacy group, argues that this mental health-related DSH money, as long as it continues, should be consistently committed to the Mental Health system and used to bring community services to a higher level. Once more patients can be served in the community, it will be possible to close entire hospital units. This will free up funds presently used by hospitals that can then go to the community to replace the short-term DSH funds. (See Bridge Funding below.)      It costs an average of $325 a day to keep a patient in a psychiatric hospital, compared with $60 for group housing and programs and $15 for those living in supervised apartments.

     If we are to repair and reform North Carolina's mental health system, there is no substitute for the considered attention and enduring commitment of the executive and legislative branches of state government. The scope of change needed in North Carolina requires a governor for whom mental health care is a high priority, and who is willing to invest the human and fiscal resources to these ends. This means, perhaps, searching outside of the state for expert mental health leadership for DMH/DD/SAS - something most states do and which North Carolina has never done. This means directing the tens of millions of dollars in Disproportionate Share funds that have come to North Carolina for psychiatric services to psychiatric services for those most in need.
     This means an involved, informed, and influential collaboration between consumers, their families, mental health professionals, and state leaders to shape, implement, and monitor a new mental health system. This means that county citizens and governments develop and enhance where necessary their willingness and ability to be the locus of a community-based system of care.
     At present, Area Programs have insufficient incentives to prevent or reduce the need for hospitalization of psychiatric consumers. Why? Because state psychiatric hospital budgets are separate from community budgets, and Area Programs do not pay directly for the hospital services they use.
     In order for effective changes to occur, the process must be fair, inclusive, and non-partisan. When legislators are more concerned about preserving jobs at state psychiatric facilities than they are about the quality of care, we have predictable results. When administrators are more adept at blaming others than at proposing and implementing solutions, we see the results. While it is easy to blame the costs of consent decrees in the Willie M. and Thomas S. suits for system shortcomings, we have to ask why this litigation was necessary in the first place. Why did it take court orders to compel the care system to provide these necessary services?
     Our goals must prioritize improving the services and outcomes over saving money - at least initially. One way to frame the aims of reform would be: More resources better spent, more people better served.
      The State Auditor's report calls for "bridge funding" as the system is transformed. This "bridge funding" - additional money allocated by the state to the Area Programs for at least two years - is intended to increase the Area Programs' capacity so that they can reduce hospitalizations. Then, as hospital use decreases, the money saved would be transferred to Area Programs permanently. In addition, the report points out that Medicaid policy in North Carolina has been too often at odds and out of sync with mental health policy. We need to develop the expertise in North Carolina to use Medicaid resources for the benefit of psychiatric consumers rather than to design services around Medicaid payment policies as we have in the past.
     The Locke Foundation analysis of system shortcomings does not diverge substantively from the others, but their solutions do. There is no credible empirical basis for their claim that "people with serious psychiatric disorders cannot live independently nor participate in the labor force and thus must be considered wards of the state." In fact, there is much evidence to the contrary. Indeed, treating persons with psychiatric disorders as dependent and unable to participate in the conduct and direction of their care contributes directly to ineffective, under-used care. Worst of all, such a philosophy results in an over-reliance on forced treatment in both hospital and outpatient settings like the kind proposed as a solution in North Carolina.
A Client-Centered System      Why do so many North Carolinians find the psychiatric services we provide so aversive and so unappealing that they have to be forced to use them? We make no progress by attributing this to their illnesses alone. The first core recommendation of the National Council on Disability states that:
     Laws that allow the use of involuntary treatments such as forced drugging and inpatient and outpatient commitment should be viewed as inherently suspect because they are incompatible with the principle of self-determination. Public policy needs to move in the direction of a totally voluntary community-based mental health system that safeguards human dignity and respects individual autonomy.
     In the best mental health systems, consumers of services participate actively in the planning, implementing, and assessment of services, and often play significant roles as providers of care. The second NCD recommendation summarizes this approach:
     People labeled with psychiatric disabilities should have a major role in the direction and control of programs and services designed for their benefit. This central role must be played by people labeled with psychiatric disabilities themselves, and should not be confused with the roles that family members, professional advocates, and others often play when consumer input is sought.
     North Carolinians face a clear choice. We can continue to fund studies and to read about the casualties of our mental health system, or we can devote our resources and energies to fundamentally altering this system.
     None of the analyses suggest that this will be a simple or easy process. But it will be made less difficult and more successful by looking forward instead of back, by taking advantage of expertise and experience from outside our borders and adapted to our needs, by devoting our own creativity and resources necessary to renew this most public system of care and rehabilitation.
     Citizens of North Carolina with psychiatric disorders have much to contribute to their families and loved ones, and to their neighbors and co-workers. Ironically, they are often being held back and denied the opportunity to lead more meaningful and productive lives by a system of care which is intended for their benefit. It is our obligation to include them in our deliberations, plans, and actions. It is our obligation to work with them to remove these barriers. It is our responsibility to deploy our attention, commitment, and actions to the repair and reform of mental health care in North Carolina.