NAMIGrading the States: A Report on America's Health Care System for Serious Mental Illness
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Grading the States 2006: Washington - Narrative

In 2005, the Evergreen State averted disaster by significantly increasing state investment in its mental healthcare system.

Previously, Washington had relied to an unusual degree on federal Medicaid funds for mental health services. As federal Medicaid cuts kicked in, the system stared at an $82 million loss of funds over two years.

Governor Christine Gregoire, in partnership with key legislators such as House Speaker Frank Chopp, Representative Eileen Cody, and Senator James Hargrove, stepped into the breach and replaced the lost federal revenue with close to $80 million in state dollars.

Despite the 11th hour reprieve, mental health funding in the state "has not kept pace with healthcare inflation in recent years." The inevitable result has been aninadequate supply of services.

Management of the state system lies with the Washington Department of Social and Health Services, Mental Health Division (MHD), which contracts with 14 Regional Services Networks (RSNs) to provide inpatient and outpatient treatment and services under a managed care model. Despite its oversight responsibility, the MHD does not appear to have a complete handle on priorities and outcomes.

In its 2005 Mental Health Block Grant Plan submitted to the federal government, MHD acknowledged that it is "unable to clearly identify where funds are being spent, how much is spent on certain client groups, and whether funds provided are sufficient to accomplish the goals set forth in statute, rule and contract." The MHD was also unable to provide clear responses to the questions about evidence-based practices (EBPs) on our survey. 

The problem, it appears, lies in lack of accountability to the state on the part of the 14 RSNs responsible for regional mental health services. The state thus has very limited oversight over regional services and does not even have a handle on what services are provided in specific regions. Although local control over mental health services may be appropriate, the state must play a critical role in setting standards, conducting oversight, and monitoring performance. 

In an effort to address this problem, the Washington legislature in 2005 passed legislation establishing a more competitive process for selecting RSNs to manage regional mental health systems. Existing RSNs must demonstrate that they meet certain qualification standards. If they cannot, the legislation requires a competitive bidding process. This process is underway, and six of 14 RSNs have not scored high enough to avoid competitive bidding.              

There are also concerns in Washington State about a lack of hospital beds. Before 2005, Washington eliminated 150 beds from its two state psychiatric hospitals over several years, but less than half of the savings was reinvested in community-based mental health services. In 2005, the legislature imposed a moratorium onfurther reductions. Even so, a critical shortage exists. In 2003, 25 counties reported that they had no community inpatient or evaluation and treatment center beds for individuals in crisis or under civil commitment orders.

General hospital reductions or closures of psychiatric wards have exacerbated the problem. Lack of community-based services, including crisis prevention, alsocontributes to the shortage. Individuals often continue to occupy beds, because community services are not readily available, preventing them from being discharged.

Despite these significant problems, Washington is making progress in other areas.

Important initiatives are underway to improve the organization and coordination of services. Particularly interesting, but controversial, is the Washington Medicaid Integration Project, a pilot program in Snohomish County to integrate into one system medical care, mental health services, substance abuse treatment, and long-term care.  

A federal Transformation State Incentive Grant (TSIG) will help facilitate comprehensive mental health services planning and coordination among key agencies, including medical assistance, housing, and vocational rehabilitation.

Washington also has moved commendably to decriminalize mental illness by developing alternatives to incarceration. Jail diversion programs are present in at least four counties. Five Mental Health Courts also exist. In addition, the legislature provided funds in 2005 for additional counselors to help facilitate timely restoration of Medicaid and Medicare benefits for individuals with mental illnesses leaving correctional facilities.

The state also is helping consumers find and maintain employment. It reports that supported employment services are available in 10 of the 14 RSNs, with Medicaid provided under a federal waiver. The state also is supporting consumer-run services, especially clubhouses.

If the leadership exhibited during the 2005 fiscal crisis extends into 2006, when the state has its first budget surplus in years, the Evergreen State will have an opportunity to make additional progress of a kind that could make it a national leader and heroic success story. It is an opportunity that should not be lost.

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