Half of young adults (ages 18 to 24) reported episodes of anxiety or depression last year, as did a third of adults as a whole. Mental health was declining among high school students prior to the pandemic, but things have only grown worse since then. Nearly 110,000 Americans died from drug overdoses last year, driven primarily by fentanyl. Meanwhile, roughly three-quarters of the nation’s counties report that access to services is limited due to shortages of behavioral health workers.
“This is a nation that is struggling with an epidemic of mental health challenges,” says Dow Constantine, the county executive in King County, Wash. “Every community has families who are grieving. Every community has people who have lost, or are afraid of losing, friends and loved ones.”
Constantine is serving as the co-chair, along with Los Angeles County Supervisor Kathryn Barger, of the Commission on Mental Health and Wellbeing for the National Association of Counties (NACo). The commission intends to release its findings and recommendations next year.
What’s already clear is that counties — which provide mental and behavioral health care through clinics, hospitals and jails — will be unable to address the scope of the need alone. The commission is calling for the federal government to ease or abolish outdated Medicaid regulations that limit access to mental health services much more stringently than medical care.
Governing spoke with Barger and Constantine at NACo’s annual meeting in Austin, which ended on Monday. Here are edited excerpts from that interview:
Governing: What has been happening in your counties that made you want to address this issue nationally?
Constantine: It stood out as an unaddressed problem that is intertwined with so many of the other challenges we face locally. You know, as county officials, we are charged with delivering the core local services and solving real, immediate local problems. And as I looked at the things that were occupying my time, it was overcrowding in our jails in a clogged-up criminal justice system. It was overcrowding in our hospitals and the inability of people to get in and get treatment. It was homelessness, which is famously a challenge in our region and in many urban regions around the country. The intersection of so many other problems was an unmet need for behavioral health care and for mental health care.
Barger: I've been with the county of L.A. for 35 years, and I've seen it get worse and worse and worse. We are housing many individuals who are in jail because of their mental illness. This is not right. We needed a commission with NACo that would bring together all stakeholders and our county partners.
Governing: As you examine mental health, what are some of the biggest challenges?
Constantine: The difficulty in recruiting and retaining people to care for those in need is one aspect of the challenge we face. We have to develop better systems for recruiting and training folks, as well as increased compensation to keep qualified people in this field. In addition to that, we also have to address, at the federal level, reimbursement rates. Some of the specific challenges that NACo is looking at are addressing the prohibition against behavioral health payment for folks who are in custody awaiting trial. Our jails are full of folks who need mental health or addiction services and can't get them.
Governing: A lot of this falls on counties. Can you talk about the need for support from other actors, whether other levels of government or the private sector?
Constantine: This is kind of a classic example of what has happened over time with devolution of responsibility to more local levels of government. As federal and state governments have over time backed away from funding responsibility, we've been compelled to pick up more of that. We’ve heard stories about states where counties have become the majority funder of mental health services. That's not how it was supposed to be and we're not really set up to do that. But we see the results of the neglect, in our jails, on our streets, in overcrowded hospitals and in our communities, and so we're compelled to respond. What we need is a partnership with our state governments and the federal government to deliver the level of service that is needed today in America, which I think is greater than it has been in a very long time.
Barger: We have to have the states at the table because any federal changes, like an IMD waiver, is going to take state application. (Medicaid doesn’t pay for care in some inpatient settings, known as “institutions for mental disease.”) And so it's not only about educating the federal government. We're working to make sure that all of our county partners educate their state officials about the needs at the state level in order for the federal government to move forward.
Governing: You’re both officials in very large counties. Working with the commission, have you found the picture to be different in smaller communities?
Barger: I would say that whether the county is large or small, we all share the same issues. Fentanyl and other opioids are plaguing both rural and metropolitan areas. It is frightening what's taking place, and we don't have the infrastructure to really address the magnitude of what we're seeing.
Constantine: Mental health challenges are on the rise in large jurisdictions and small, in rural and urban areas. This was true before COVID-19, but very much more so now as we’re exiting from the pandemic. Mental health and addiction, with first the prescription opioids and now fentanyl, is an enormous challenge in our country, and it does not discriminate based on geography or race or income.
Governing: Are you finding any innovative programs in counties that could potentially serve as models?
Barger: In L.A. County, we are investing in a lot of peer-to-peer networking as it relates to outreach on the streets, especially when you look at the number of individuals that are without housing who are mentally ill. Other counties are doing peer-to-peer work to keep people in treatment, because many are not coming in for their appointments at all.
Constantine: In April, we passed a major levy in our county to create a network of crisis care centers, just to receive those who are poor and in a moment of crisis, and then to help them stabilize and get them onto treatment.
That is us, again, stepping up with local funding to do what historically might have been funded through the state or federal government. But we can't wait.
