Hours before Gov. John Bel Edwards opened the special legislative session Monday with a silent prayer for the 17 victims in the Florida school shooting, the Louisiana Legislative Auditor released a report pointing out significant gaps in treating individuals, particularly adolescents, with mental health issues.
“Budget cuts have affected the state’s ability to provide comprehensive and appropriate specialized behavioral health services to Medicaid recipients. These challenges have resulted in gaps in services and a lack of data integration among providers, which contributes to fragmented care,” Auditor Daryl Purpera wrote.
The Louisiana analysis was not tied to last week’s shooting at Marjory Stoneman Douglas High School in Broward County, Fla., and its release during intense questioning over how so many people missed mental illness signals of the alleged 19-year-old shooter was coincidental.
But the context of national debate gave auditors pause.
“There’s always a risk – because of the gaps we found – that he would fallen through the cracks here,” said Assistant Legislative Auditor Karen LeBlanc, who as director of Performance Audit Services oversaw the study.
“It should certainly be on everyone’s radar,” said Chris Magee, the auditor’s data analytics manager who worked on the report. “There are not many states lower in the rankings than Louisiana. That kind of supports what we’re finding.”
Louisiana is one of the five states in the nation with the highest prevalence of mental illness and, before Gov. John Bel Edwards expanded Medicaid eligibility in 2016, had one of the lowest rates of access to care, he said.
“We work everyday to ensure that doesn’t happen,” Michelle Alletto, deputy secretary at the Louisiana Department of Health, said of the possibility of an individual falling through the cracks.
“All I can say is that we recognize there are a lot of barriers to children and their families for getting into care and staying in care. We’ve tried very hard to remove as many of those barriers as we can,” she said.
Since the decision to expand Medicaid under the federal Affordable Care Act, treatments are available for most people with mental health issues, Alletto said. LDH is focusing on quality of the programs offered, she said.
The primary goal of the program is keeping children out of institutional care by offering counseling and treatment to them and their families in or close to their homes. The program handles about 2,400 children, she said.
Where once the state paid doctors and clinics directly for treatments, LDH now contracts insurance companies to manage the health care for the 1.6 million Louisiana residents on Medicaid.
“Their role has shifted,” LeBlanc said of LDH. “They can look at the data, at the statistics, but they don’t have a report that can say how each individual’s case managed. This is something they agree with and something they’re working on.”
Auditors say that 60 percent of the $445 million spent on services that were not scientifically shown to efficiently produce positive outcomes and reduce costs.
Only 7.4 percent of the individuals served by the private companies had a behavioral health diagnosis. (Neither the private companies nor the state can force a person onto the "managed care" system operated by the companies, so it's hard to put that percentage into context, Alletto said.)
The report noted that Louisiana has no state psychiatric facilities for adolescents and that budget cuts have led to the closure of all but two state hospitals for adults. Teenagers go to one of four private facilities that can handle 134 patients.
Adults with behavioral health needs often end up going to nursing homes or prisons, which don't normally provide services that address mental illness. For example, of the 4,084 individuals with a primary behavioral health diagnosis in nursing facilities, 49 percent did not receive any specialized behavioral health services.
Karen Stubbs, the assistant secretary in charge of LDH’s Office of Behavioral Health, doesn’t disagree with the 49 percent number. The health department has been changing how patients are admitted to nursing homes. They’re getting face-to-face evaluations, for instance. And their cases are being reassessed frequently to determine if the physical problems that required round-the-clock nursing care have resolved, so they can be released and put into programs that address mental illness issues.
The federal government doesn’t require states to provide mental health services. Doing so is an optional expense for the state.
“Mental health is absolutely something that is vulnerable to (budget) reduction,” LDH’s Alletto said, adding that those programs face a 19 percent cut in funding this year. “We’re trying to preserve mental health rehab care. We think it is important.”