Nervous advocates worry that Iowa's mental health overhaul could leave some without care

Advocates agree with Gov. Kim Reynolds: Iowa's badly fractured mental health system is in need of a major fix.

But they say new legislation attempting to rework the system lacks the details they need to understand how providers and patients will be affected.

In particular, they're concerned that services and programs already established to help Iowans could be left behind in a massive overhaul.

"Anytime a system changes, we worry most about the people we are serving, our employees and the need to maintain the continuity of care to our clients," said Flora Schmidt, executive director of the Iowa Behavioral Health Association. "At this time, we have more questions than answers as we await the release of the amendments currently being drafted by legislators, HHS and the governor."

The proposal introduced to the Iowa Legislature this year would establish a Behavioral Health Service System that's comprised of seven new "unified districts."

The new districts would combine the 32 local regions in Iowa, which includes 13 Mental Health and Disability Service regions that oversee mental health and disability services and 19 Integrated Provider Networks that manage substance use and problem gambling services.

Both House and Senate versions of the legislation have passed committee vote and are awaiting debate.

More: Kim Reynolds has released her plan to restructure Iowa's mental health systems. Here's what it says:

The legislation being considered by lawmakers creates a basic infrastructure for the plan, which is based on an assessment of the newly aligned Iowa Department of Health and Human Services conducted last year.

Many of the details on its day-to-day functionality of the new system will be determined by state leadership in the coming months. The new system will be fully operational by July 1, 2025, according to the state bill.

Still, its leaves many unanswered questions to the psychiatrists, therapists and other professionals that care for this population, as well as the administrators that oversee the current system.

“We'd like to get our hands on those details and try to share with our members how it's going to specifically impact them. Right now, it's really hard to do that," said Ben Shuberg, CEO of the Iowa Association of Community Providers.

Why do state officials want to consolidate these systems?

State officials have described the current system as "fractured," saying the separation between substance use treatments and mental health services creates gaps for Iowans seeking services for co-occurring conditions.

Because services are determined by each of the 32 local regions, state officials say services are inconsistent across the state. As a result, the ability for Iowans to receive certain types of care often depends on where they live.

The goal of the new system is to create equitable access to all Iowans, state officials say.

"The newly aligned system will be well coordinated with clear access points so Iowans can receive the same behavioral health services across the state no matter where they live," Iowa HHS spokesperson Alex Murphy previously told the Register.

Providers agree a fix is needed for the 'fractured' systems, but wonder what services will remain

The broad strokes of the plan has received cautious support from most involved with Iowa's current system, with many providers agreeing that the effort to create a consistent statewide system is a good move.

"Not only is this better access, it’s less red tape, confusion and ultimately time spent by providers and people served by the system," said Annie Uetz, CEO of Polk County Behavioral Health and Disability Services.

Darci Alt, CEO of Heart of Iowa, an MHDS region that includes Audubon, Dallas and Guthrie counties, agreed separating mental health and substance use services has created challenges for Iowans. Alt said she "wholeheartedly" agrees those services shouldn't be siloed.

Alt said her region is only able to fund services for those with a mental health condition. If someone comes to them solely with a substance use disorder diagnosis, the Heart of Iowa region unable to help them, she said.

“There are things within this bill that lead us to a space that opens the door for us to work with all populations as far as in the behavioral health realm. So I think they really they're moving us forward in that area," Alt said.

However, Alt said she is worried the work the Heart of Iowa region has been able to accomplish may not fit into the new requirements of the new system.

In particular, she pointed to a program that established four co-responder teams at local law enforcement agencies within the region. A mental health professional responds to calls with a police officer in order to help divert people in crisis from jail and into mental health services.

“We have some really cool things going on in the region, and I just don't want to I don't want to lose all the momentum in all of the amazing programs we already have," she said.

The system for children needs to look different, youth services providers say

As the bill has made its way through the Iowa Legislature, some have raised concerns on how children's services will fit into the state's larger plans.

Anne Starr, CEO of Des Moines-based children's behavioral health service provider Orchard Place, said more dollars in Iowa are typically spent on adults, which can often mean adolescents and children are inadvertently left behind.

State officials have previously made a point to prioritize Iowa youth. One of Reynolds' priorities in 2019 was the establishment of a children's mental health system, which required core services for kids and adolescents, such as crisis intervention and community-based services.

However, Starr said many Iowa children still weren't able to access those services because providers "were not adequately funded." She said Medicaid rates had not increased in several years, and many safety net providers serving patients with the highest needs did not see any additional state or state-controlled federal dollars.

“I don’t have anything to object to about the plan, but I wouldn’t have objected to the one we have today. It’s just that it wasn’t funded," Starr said.

As state officials build a new behavioral health system, she said she hopes to better understand what their vision is for children's behavioral health services, and how funding for a new system will include Iowa youth.

“We get so little funding from the mental health region, much less for substance use," Starr said. "So we don’t really know how that’s going to affect it. It can only get better because we get nothing today.”

Increased funding ensures all needs met, help address workforce issues, advocates say

The state's goal of implementing the new behavioral health system by next year is worrisome for many stakeholders and advocates, including Schmidt with the Iowa Behavioral Health Association, who said the timeline is too aggressive "to seamlessly create, design and integrate legacy programs/services within the new structure."

Schmidt also said the new system also needs to ensure it can meet the unique needs of those with substance use disorders. That includes assurances the system will receive enough funding to serve all populations, including children and adolescents, and to stand up residential treatment and prevention services, Schmidt said.

State officials have pointed to an estimated $23 million unspent incentive funds among the regions, stating the new system will ensure those dollars will be used to help meet the growing behavioral health need.

Providers also emphasized the importance of enough funding, particularly for community mental health centers, which serve as safety net providers for patients with the highest needs and who face disparities in accessing services, such as those on Medicaid.

UnityPoint Health's Eyerly Ball is a Des Moines-based provider that serves as a community mental health center for Central Iowa. CEO Cynthia Steidl Bishop said the organization relies on block grants from the state to help pay for its programs, and to provide certain evidence-based trainings for therapists.

Those trainings have been a way for Eyerly Ball to recruit mental health care professionals in the midst of an ongoing workforce shortage felt by many in the industry, Steidl Bishop said.

These evidence-based trainings are expensive, and they can get it through a community mental health center, so they come and work here. It’s a great way to recruit," she said. "Are we going to lose that? It’s harder to recruit at community mental health centers because we see the most difficult clients, and people are willing to come because they know they’re going to get those trainings."

Michaela Ramm covers health care for the Des Moines Register. She can be reached at [email protected], at (319) 339-7354 or on Twitter at @Michaela_Ramm

This article originally appeared on Des Moines Register: Iowa pitches overhaul of behavioral health that worries some advocates