Editorial: Vermont’s Mental Health System in Crisis

Tuesday, March 13, 2018

On some seemingly intractable issues such as gun violence, making progress is difficult because no agreement exists on the nature of the problem, let alone what should be done about it. But even where consensus exists, it’s no guarantee that the way forward will be obvious.

A case in point, perhaps, is the crisis in Vermont’s mental health system. The immediate problem is that patients often languish for days in hospital emergency departments without getting the care they need while waiting for one of the 188 beds in the mental health system to open up.

The alternative weekly Seven Days reports that lawmakers and the Scott administration generally agree that more beds are needed in the system, although some mental health advocates argue that a better solution is investing in prevention and early intervention. While that’s true in the long term, it can take time for those investments to pay off. So that solution doesn’t necessarily address the very pressing problem that now exists.

But if there’s general agreement that more beds are needed, the administration and lawmakers appear sharply divided on where and how they should be added. Human Services Secretary Al Gobeille has proposed spending $2.9 million to build a temporary 12-bed forensic psychiatric unit at the Northwest State Correctional Facility in Swanton that would house patients who have entered the mental health system by way of the criminal justice system. That includes defendants awaiting a psychiatric assessment; those who have been found incompetent to stand trial or who have been found not guilty by reason of insanity; and inmates who experience a mental health crisis while serving their sentences. Patients in these categories take up about half the 25 beds at the new Vermont Psychiatric Care Hospital in Berlin, which, along with the Rutland Regional Medical Center and the Brattleboro Retreat, provides care for the state’s most acutely ill patients — those who have been hospitalized against their will and are in the custody of the Department of Mental Health. The new forensic unit presumably would open up beds for other patients at the state hospital in Berlin.

According to Seven Days, Gobeille’s plan met with a chilly reception from two House committees, whose members object both to spending money on a temporary facility and to locating a mental health unit at a prison instead of at a hospital. Those objections have force. And they have to be seen in the context of a much larger problem facing the state’s mental health system.

In 2021, the federal government will begin phasing out over six years an exemption to a rule under which Vermont has been allowed to use Medicaid funds to pay for beds at mental health facilities with more than 16 beds. The 16-bed rule is in place to prevent states from warehousing patients in large facilities, and anyone familiar with the horrors of the huge “mental hospitals” of the previous century can readily understand why. The federal contribution currently covers 55 percent of what the state spends on mental health beds; Vermont could ultimately lose $23 million annually in federal funding unless it makes the necessary changes to conform to that rule.

There’s no time to lose in figuring this all out. If building a temporary forensic unit at a prison is not the answer, and we’re not convinced that it is, then figuring out where a permanent one could be located and rapidly developed surely is. Meanwhile, lawmakers and administration officials need to assess how whatever they do to address the immediate need for more psychiatric beds fits into the evolving picture of highly decentralized in-patient capacity in the system. They must also determine whether rising hospitalization figures for mental illness are unavoidable or could be stemmed by making the investments advocates suggest in community therapy and support. This problem requires a comprehensive solution that provides that familiar formulation: the right treatment in the right place at the right time for those suffering from mental illness. It’s certainly a challenge, but one Vermont needs to embrace.