School closures, remote work, isolation. Inflation, wildfires, a heat wave. It’s all adding up: Washingtonians’ mental well-being has been profoundly disrupted since the pandemic landed here two years ago. And just when normalcy seemed near, omicron arrived.
This legislative session, lawmakers are faced with tackling a mental health system fraying at its seams.
The mental health workforce is leaving the profession in droves as wages stagnate and burnout takes hold. Community-based providers who treat low-income folks say a lack of resources has forced them to turn patients away. From Spokane to Tacoma, kids across the state are increasingly reporting symptoms of depression — and visiting emergency departments for suicidal ideation and suicide attempts, according to data from the state’s children’s hospitals. Meanwhile, families and adults say they’re facing long wait lists as they attempt to secure outpatient appointments or an inpatient bed.
As part of Gov. Jay Inslee’s proposal that would add $4.2 billion in new spending to the $59 billion biennial budget approved last year, officials are eyeing ways to plug holes in a mental and behavioral health care system that’s historically resided alongside — not within — the traditional medical system. Across the state, providers and community-based organizations are working to integrate mental health care and substance use treatment into primary care and other settings, like schools, to help expand access where it’s lacking.
“There’s a lot happening, big asks, and some of it is trying to figure out how, in a supplemental year, how we take advantage of additional revenue that’s essentially one-time money,” said State Rep. Lisa Callan, D-Issaquah, co-chair of the Children and Youth Behavioral Health Work Group, which advises the legislature on issues related to children’s behavioral health.
This summer, Washington is also launching a statewide 988 hotline establishing a three-digit shortcut for the National Suicide Prevention Lifeline, in line with a federal law that seeks to do the same nationally. Instead of having police respond to a mental health emergency, residents could call the hotline and connect to trained counselors who provide resources and follow-up services. Washington has been among the first states to prepare for the new network, currently taxing wireless service providers to fund the rollout. So far, $17 million is expected to come in with an additional $46 million coming starting January 2023 when fees rise. Still, funding remains an issue.
“When we start looking at our costs, we realize they’re higher than we anticipated,” said State Rep. Tina Orwall, D-SeaTac, one of the sponsors of the 2021 bill that created the hotline. “You also have to add the texting and chat lines, which are really important for youth,” Orwall said.
Federal grants may be an option for supplemental funding, Orwall added, but at this time there are no follow-up bills with that goal in mind. The 988 hotline is scheduled to go live this July.
Intervening early
For years, mental health advocates have pointed out that the behavioral health system is reactive rather than preventive, forcing people with mental illness to wait until they’re really sick before they can access services. Having heard this concern before, proposals from Sen. Manka Dhingra, D-Redmond, include a bill that opens the door to mandatory assisted outpatient treatment, requiring a person to get care like medication or therapy before a mental health crisis escalates and hospitalization is needed.
“We want to be able to help people before they hit rock bottom,” said Dhingra, formerly the chair and founder of the Senate Behavioral Health Subcommittee.
If successful, the measure would also allow certain individuals like emergency room doctors, behavioral health directors, and employees at correctional facilities who develop release plans to petition the court for treatment in the least restrictive setting but up to civil commitment, a role typically only allowed for designated crisis responders. County prosecutors would be tasked with administrative follow-up and ensuring people complete their treatment plans.
“I have heard (prosecutors’) hesitancy because this is work that they haven’t traditionally done,” Dhingra said. “My response to them is very clear: this population, they are dealing with anyway. They’re dealing with them when they are hospitalized, dealing with them if they get charged with a crime, either as a misdemeanor or felony.”
Groups like Mothers of the Mentally Ill support the bill, though the greatest challenges may come after the bill’s passage: Workforce shortages could make it harder for patients to access outpatient treatment quickly.
Other bills to watch:
- Senate Bill 5655 would force the three state hospitals in Washington to establish and maintain space for patients for short term (14-day) detention and civil commitment. The goal would be to get treatment for people with a history of violence who may otherwise be denied care at another facility.
- SB 5736 would extend coverage for partial hospitalization and intensive outpatient services for children on the Medicaid state plan if they are under 18 starting in 2023.
Boosting the workforce
In October 2021, more than half of the state’s community behavioral health centers, which largely serve low-income people enrolled in Medicaid, reported they had to turn away clients because they lacked the workforce to care for them. At the time, the average clinician vacancy rate across those centers was 26% — meaning more than a quarter of open staff positions hadn’t been filled. Just three months later, that rate is now 30-60%, said Ann Christian, CEO of the Washington Council for Behavioral Health, which advocates on behalf of behavioral health agencies and collected the October data.
“The workforce crisis is absolutely the most pressing concern and it affects everything else, whether we’re talking about children’s behavioral health or successful implementation of the 988 line,” she said. “We have to start there.”
Some staff are leaving because they’re overworked, burned out, or retiring, said Susan Skillman, senior deputy director at UW’s Center for Health Workforce Studies. But many are finding jobs with higher pay. Community-based care salaries are $20,000-$35,000 less than those offered by providers who see more patients with commercial insurance, Christian said.
To help stem the shortage, Inslee is proposing a 4.5% increase to the amount community behavioral health agencies receive when they bill Medicaid; the Washington Council for Behavioral Health is lobbying for a 7% increase. Inslee’s budget would also add an additional $50 million in one-time funding for such providers, but Christian said agencies may hesitate to use temporary funds to improve compensation packages.
Adding positions with lower training requirements could also bolster the behavioral health workforce. For example, state Rep. Lauren Davis, D-Shoreline, is sponsoring a bill that would establish a certified peer specialist credential. This would allow a person with personal experience with substance use or mental health conditions to complete training and work in behavioral health settings, aiding others in their recovery and serving as an advocate.
While peer specialists already exist, they currently only serve Medicaid recipients at community behavioral health agencies like Valley Cities or the Downtown Emergency Service Center. This bill would allow people with commercial insurance to also access peer specialists.
“There are so many people that really could offer their time and talents that have lived experience,” Orwall said. “We know they’re highly effective. And we know there’s no shortage.”
The peer support movement has been a growing force where people directly impacted share their knowledge with the community and aid in others’ recovery; research shows the model has successful outcomes and it would be one way to fill gaps in the current workforce.
Other bills to watch:
- House Bill 1863 would create a license giving psychologists the ability to prescribe psychiatric prescription drugs. A 2017 report from Skillman and her colleagues suggests Washington has too few mental health professionals who are willing or able to prescribe medications; this measure is aimed at improving access.
- SB 5638 would allow people applying to become a social worker associate, mental health counselor associate, or marriage and family therapist associate to work while their license application is being processed.
Caring for kids
Citing high emergency room visits and admissions for mental health concerns, Inslee declared a statewide youth mental health crisis in March 2021. By December, the U.S. Surgeon General warned such a crisis was affecting youth nationwide.
On the table this session — so far — are a handful of big budget items and a slew of legislative proposals aiming to bulk up the state’s pediatric treatment options and better integrate children’s mental health services into primary care and schools.
Inslee’s supplemental budget proposal would add $15 million in new spending on the Children’s Long-term Inpatient Program, known as CLIP, which is the most intensive inpatient service available to children and involves lengthy residential stays. The proposed budget would also use federal dollars to add an additional $15 million to the CLIP program, plus $12 million to expand or establish crisis stabilization facilities for children. Washington currently has 84 CLIP beds, far too few to serve the 1.1 million children who live here, say many mental health advocates, clinicians and parents.
Under Inslee’s proposal, more than $1 million in combined federal and state dollars would support staff at a new 18-bed residential facility, and nearly $6 million would be geared toward helping families secure temporary help while they’re on waitlists for inpatient or long-term care.
Meanwhile, lawmakers are proposing a series of policies to add funding for school-based health staff and make certain intensive outpatient services available to youth from low-income families. A bipartisan bill, for instance, would make pediatric partial hospitalization programs — or “day treatment” — reimbursable through Medicaid; the state currently only pays for such programs for adults.
If officials agree to investments in all corners — schools, primary care, mental health centers and alternatives to hospitalization — “I would be over the moon,” said Sarah Rafton, executive director of the Washington Chapter of the American Academy of Pediatrics. “I’m just worried that because of how health care is financed in this country, we’re not going to help the kids until they show up at the hospital door.”
Other bills to watch:
- HB 1905 would create a rapid response team that helps connect youth at risk of homelessness with housing and other services before they exit publicly-funded care. Inslee is proposing $6 million in funding to support these efforts.
- HB 1890 would instruct the Children and Youth Behavioral Health Work Group to develop a strategic plan that examines the availability of youth mental health services statewide, and how access could be improved.
- HB 1664 would add school health staff by increasing the ratio of school nurses to students over three years. Inslee’s budget proposes $184 million to increase the number of nurses, social workers, counselors, and psychologists who work in schools.
Fixing 1310
Top of mind for legislators this short session is what to do about the consequences of HB 1310, a measure that went into effect last summer with the intention of curbing law enforcement’s use of force. Many mental health advocates say that backfired, as some police officers stopped supporting behavioral health staff during mental health crises, citing concerns over the new standard. That meant fewer people received treatment while social workers were left on their own. Now, around a dozen new bills set out to clarify the law’s language.
“That cannot happen soon enough,” said Orwall, who has signed on as a sponsor for HB 1735, one of the bills that’s expected to gather momentum from legislators. Rep. Jesse Johnson, D-Federal Way, the original co-sponsor of HB 1310, drafted this fix.
The new bill authorizes officers to use physical force if they are helping detain an individual for involuntary treatment or evaluation. It also defines what de-escalation tactics can be used before resorting to physical or deadly force and emphasizes the responsibility of law enforcement to respond to calls for help from mental health workers and the general public.
“We still expect law enforcement officers to be guardians of our community,” Dhingra said.
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