Each of us is going through a version of it right now: What do I really need? What can I live without? We are reevaluating our daily cup of coffee, the weekly ticket to the movies, next month’s trip to New York. For the most part, our cutbacks will affect ourselves, our spouse, our children. Grandma who goes unvisited. The coffee shop we used to visit. But the ripple is local.
When the Commonwealth of Virginia starts making cuts, however, that ripple gets a hell of a lot larger. And, particularly for poorer Virginians, we’re talking about more than movie tickets.
With a $3.7 billion shortfall and no political will to raise taxes, many things that once seemed essential now have to be deemed otherwise. These are some of the things that Governor Tim Kaine says Virginia can no longer afford: state-funded school construction; as many assistant principals and guidance counselors and reading specialists in our schools; 15 percent of funding for colleges and universities; as long prison terms for nonviolent felons; new roads; and pay raises for state employees.
We can learn to live without many of those things we used to think we’d need. But when the state rolls away unique safety nets—well, perhaps the only upside is a macabre form of entertainment as we watch how long the high wire act can go on.
One of the most troubling aspects of Tim Kaine’s budget proposal is that we do without any state-run emergency mental health beds for those under 18. Both child advocates and mental health watchdogs say this is a terrible idea that will crowd hospitals, correctional facilities and, some worry, morgues with teens who, with proper care, could return to mainstream society. The Charlottesville area sends 30 to 40 kids a year to the Commonwealth Center for Children and Adolescents (CCCA) in Staunton, and it’s unclear where they would go otherwise.
If the state closes the Staunton center and a smaller unit in Southwest Virginia, it will at best save $7.6 million a year—0.2 percent of the current deficit. What we stand to lose, however, is the last line of treatment for the state’s most disturbed teens. And the open question is: How much will that ultimately cost us?
Perched on a prominent rise that overlooks both I-81 and the commercial strip of Route 250 that leads into the heart of Staunton, the Commonwealth Center for Children and Adolescents is a crossbreed that combines the DNA of an elementary school, a dormitory and a prison.
The well-scrubbed corridors are decorated with student artwork. Strange guttural cries emanate from an unseen room. The courtyard, like any you might find outside an average school cafeteria, is barred. Getting out of a gymnasium door requires a keycard and a punch code. It is a 48-bed institution, a relatively modern one built only 10 years ago, and it provides the calmness, the sterility and the security necessary for the labor of rehabilitating the off-kilter minds of Virginia’s most disturbed children.
This is what the Commonwealth Center for Children and Adolescents does: It treats the kids who are so messed up in the head that their parents and psychologists and social workers think they could seriously hurt themselves or others.
Not all of the 605 children and adolescents admitted to the Commonwealth Center last year threatened or engaged in severe violence to themselves or others, but most of them did, and all of them had nowhere better to go. And steadily for the last 10 years, more and more Virginia children have been forced into the Commonwealth Center.
Stringent privacy laws keep us from knowing the horrifying specifics of what these children did, but it’s clear that these aren’t kids whose bad jokes got taken too seriously by a bunch of prissy adults. Typically, these are children who acted extremely violently or said they would kill themselves or their classmates or their mothers, who were admitted to a hospital, and whose parents and doctors still considered them unsettled enough to commit some horrid act.
Moreover, they’re kids who private psychiatric hospitals won’t take for one reason or another. Maybe the kid is too violent. Maybe he has a felony on his record. Maybe he’s without insurance. Maybe he has insurance, but the policy won’t cover additional time in a hospital even though doctors and parents say the kid needs to be in a hospital. In any of these instances, the kid goes to the Commonwealth Center—a place that isn’t allowed to say “no” to anybody.
“I think they do superior work,” says Buzz Barnette, head of emergency services at Region Ten, the mental health community service board (CSB) that serves Charlottesville and Albemarle. “They’re really about as good as it gets in Virginia.”
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Jeffrey Aaron, forensic coordinator and clinical director of an adolescent unit at the Commonwealth Center, says that resources just aren’t there locally to deal with the kids treated at CCCA. “I would love for this hospital to close because there’s no need for it.”
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“We see these kids who come in and they’re just really struggling in these oppressive environments,” says Jeffrey Aaron, forensic coordinator and clinical director of an adolescent unit at CCCA. “Then they come here and they do extremely well. Now, they’re struggling, so ‘extremely well’ doesn’t mean that they go out of here and go to Harvard. It might mean that they come out of here and they feel like, ‘Wow, this was a really good experience, people cared about me.’”
That doesn’t mean that children spend a long time at the Commonwealth Center—the median stay is about three weeks, and some are as short as a few days depending on staff evaluations. The Commonwealth Center isn’t the old sort of institution that gobbled up an autistic kid, misdiagnosed him, and kept him in a straitjacket until his hair turned gray.
“They’re not necessarily here for long, and you’d think this isn’t where they want to be,” Aaron notes. “A lot of kids don’t want to leave and a lot of kids who leave continue to call back just to check in. ‘I’m doing O.K., I just wanted to let you know that I graduated high school,’ ‘I just wanted to let you know I’m still alive.’”
As Aaron leads a tour of the Commonwealth Center, he is scrupulous in keeping out any specifics of the children treated there—their individual names, of course, but also their individual drawings and school projects and room decorations and particular circumstances. Anything that could tag them publicly and come back to haunt them as they try to put their psychoses behind them.
The Center’s layout is split between a residential wing and a school wing. On the residential side, pods are set up like suites in a college dorm, with bedrooms off a main living area with sofas and a TV. Each bedroom has a window facing the outside.
On the other wing, children go to school, which is run by the City of Staunton School System. The classes are small, usually only up to six students at a time. Sandy Powell has been teaching there for about 10 years and teaches elementary students.
“They’re really good kids,” says Powell. “You just look for the good. Some of them have just been dealt a bad rap in life.”
With so few students, Powell can devote more of her attention to each kid. It means that many children find pleasure in school, often for the first time in their lives.
“We make it positive,” Powell says. “We plant the seed that school is fun.”
That doesn’t mean that the work there is always a delight. Christmas eve, during a shift change, CCCA workers had to call in the Staunton police, who tasered a patient, according to the Staunton News Leader. Rick Gibson worked at the facility until he suffered a herniated disk while trying to subdue a patient trying to attack another worker.
“I’m a testament to the fact that these kids are not the same type of kids that are treated at other private community-based agencies,” says Gibson. Rather than grow bitter, however, Gibson has been one of the most active in trying to keep the Center open, writing frequently to politicians, newspapers and the mental health commissioner. (His wife still works at CCCA.) “I believe this is an injustice to the children of Virginia who desperately need these facilities.”
The Commonwealth Center would not be on the chopping block if the state, like us, hadn’t been living beyond its means. While we were shopping to spite Al-Qaeda and blowing through that stack of cheddar from the mortgage refinance, state coffers were awash in additional sales tax revenue. Like us, Virginia made its budget thinking the good times were here to stay. And because we were both wrong, the state now it has to trim its budget of both fat and muscle.
Virginia composes budgets every two years, and last year the governor and lawmakers put together a $77 billion biennial budget. But state coffers didn’t fill as expected this year, leaving a $3.7 billion hole. That’s only about a 4 percent reduction, but since most of the 2008-2009 fiscal year is already over, that means that proportionally it hits next year much harder.
The first announcement of drastic cuts came in August, at which point Kaine said that the shortfall would be about $1 billion. He had state agencies submit revised two-year spending plans with 5, 10 and 15 percent cuts.
“Some agencies may get cut 20 percent and some may get cut 2 percent, and some we may decide we need to add a little,” said Kaine on a radio call-in show in September. “I end up not making decisions across the board and the reason is [that] not everything is equally important.”
Among those going through the excruciating exercise was James Reinhard, commissioner of the Department of Mental Health, Mental Retardation and Substance Abuse Services.
“With the 5 and 10 percent cuts, we could make plans for other kinds of reductions, but 15 percent was the magnitude that we had to look at the closures,” explains Reinhard. “Any time you take cuts in a system like this, it’s painful.”
Considering that only two years ago, 32 people on a college campus were slaughtered by a mentally deranged shooter who slipped through the cracks of the state mental health system, you might think that the Commonwealth Center would get special consideration. But the Virginia Tech tragedy, which spurred $41.7 million in additional mental health funding as part of the budget last year, actually made matters worse for the Commonwealth Center. Politically, Kaine couldn’t take out all the extra funding that he had negotiated for the community service boards, so by keeping CSB cuts at only 5 percent, it put extra pressure on the other portions of Reinhard’s budget to get to the 15 percent overall cuts that he needed.
So Reinhard proposed closing CCCA, which receives $8.3 million in state funding, and the 16-bed child and adolescent unit at Southwestern Virginia Mental Health Institute in Marion, Virginia, which receives $1.4 million. Once costs to cover the uninsured at private hospitals were factored in, the savings came to $7.6 million annually.
“We felt that as important as that facility is, it had 1) less occupancy than full occupancy, and number 2), we did feel like there was capacity in the community for a majority of people who were being served,” Reinhard says. “And so it was really the lesser of other painful choices that we had.”
In December, facing a budget deficient that had grown from $1 billion to $2.9 billion and after having laid off 570 state employees, Governor Kaine accepted Reinhard’s proposal.
From the moment that choice was announced, however, Reinhard had a lot of explaining to do. On the morning of December 17, about 30 minutes after Governor Kaine publicly announced the particulars of his $2.9 billion budget reduction plan, the state commissioner sent an e-mail to the 128 employees at the Commonwealth Center.
“In sending this email, I hoped to let you know about specifics of the Governor’s plan before you heard about it from other sources or in the media,” read Reinhard’s message. “Part of the plan includes the closure of two facilities and one unit. One of those facilities is CCCA, set to close by June 30, 2009.”
It hastily outlined plans for the patients served and the employees of CCCA, but particularly puzzling was its dictate that both CCCA and the South West center “stop taking admissions immediately.” What were they supposed to do with the patients who would show up for admission that day?
“By that night, it was clear that there was nowhere else for kids to go,” says Aaron. “We heard panic outside of here [from CSBs], ‘What are we going to do with our kids?’”
Reinhard quickly rescinded the order against taking new admissions. “That was a matter of breaking new ground in an area that quite frankly we haven’t done before,” says Reinhard. “We realized that it wasn’t necessary in terms of the time frame, that we did have time to make transition plans for stepping down the process of admissions. So it wasn’t that urgent.”
But the e-mail set a tone of panic about the closure that didn’t let up by the time a public hearing on the matter was held January 7. Parents, child advocates, reporters and CCCA staff packed the gym at the Commonwealth Center to let Reinhard and Marilyn Tavenner, secretary of state Health and Human Services, know just what a terrible mistake they were making.
Several mothers shared stories of being turned out of slews of private facilities before finding quality treatment for their children at the Commonwealth Center. A criminal justice provider from Roanoke worried that adolescents needing treatment would instead languish in jail and recalled cutting down a teenager who had hung himself. Reinhard and Tavenner didn’t win friends by showing a PowerPoint with out-of-date information that underrepresented the daily census at CCCA by 19 percent—average occupancy had been part of Reinhard’s justification for the closure.
“You’re robbing Peter to pay Paul,” said Betsy Strawderman, an employee of the community service board that serves Prince William County. “I can assure you that every one of those children needed to be at the Commonwealth Center.”
Despite the opposition, Reinhard stuck to his way of explaining the closure forced by Kaine: People should be treated closer to home rather than in large state institutions.
Already, that’s been going on both in adult and in children’s mental health care. Ten years ago, Virginia had 180 beds devoted to children with severe head cases. Now, it’s trying to close the only 64 beds it has left.
“It is part of a larger piece of our system transformation, which includes whenever possible recognizing that keeping kids in the community is oftentimes better,” says Reinhard. “Long-term stays in institutions is not the best way to go.”
Both practically and philosophically, that has been the trend in mental health care since the 1970s, and almost universally, experts say that—in general—it’s a good thing.
“Everybody is in favor of increasing community-based care,” says Aaron. “We are in favor of that. I would love for this hospital to close because there’s no need for it.”
But community service boards don’t see the Commonwealth Center as a big residential institution as much as an emergency hospital. In the terminology of mental health care, it’s an “acute” care center as opposed to a “residential” care center.
“That facility is not a part of the problem of over-utilizing residential programs. It gets kids in, stabilizes them, and gets them out fast,” says Neta Davis, who is the director of children’s services at Region Ten. She contrasts it favorably to group homes and residential facilities that keep children for as long as 10 months. “From our perspective, [CCCA] is part of the solution, not necessarily part of the problem.”
Though Reinhard explains the closure as a way of deinstitutionalizing services, his plan doesn’t allocate more money for local community service boards to deal with these most difficult patients locally—instead, it sets aside $2.1 million to pay private mental health acute care centers to handle the kids currently served by the state-run facilities. The plan is about privatizing services—not making them more local.
But already CSBs have to look for placement in private hospitals before referring children to the Commonwealth Center. For Charlottesville, Commonwealth Center is the closest facility, but despite that, Region Ten has to first see if it can ship children to Poplar Springs in Petersburg or Virginia Baptist in Lynchburg before it can refer them to CCCA.
Critics can’t see how $2.1 million will be enough to compensate private hospitals for taking kids they currently won’t serve.
“Private facilities do not want these high-risk cases,” says Dewey Cornell, a UVA education professor and an expert on school violence. “There are plenty of less seriously troubled young people that they can provide treatment for, but no one wants to have these kinds of youths. They are dangerous to maintain, they are disruptive, they are stressful for staff, they may have a negative impact on the other patients in the facility, and so if you’re running a private psychiatric facility, you don’t want to burden yourself with an extremely difficult, high-risk patient that’s going to jeopardize the health of your facility and the wellbeing of the other patients.”
Reinhard acknowledges that private acute care beds won’t always be closer than Staunton but says that part of the plan, particularly in the long term, is to “emphasize [community service] boards’ responsibilities so that the use of those beds is not necessarily just a one-for-one transfer.”
“We want to continue to move the system and ultimately, hopefully when the revenues improve, continue to put resources in the community services board for them to provide those services in the community,” says Reinhard.
Aaron doesn’t see how that fits with cost savings, however. “Community-based care will cost more money,” Aaron says. “We benefit from an economy of scale. We’re one facility, we serve the state, we have an intensive level of expertise and an ability to do treatment that would be diluted or cost more if it were replicated in lots of places.”
For Cornell, CCCA is a safety net that just can’t be replaced. “I agree that we should return services to the community as much as possible,” says Cornell. “But there are cases that are so serious that community-based placement is not a reasonable option. And there are cases that are so serious that private residential treatment centers are unwilling to provide treatment. And in those cases, we absolutely have to have a public fallback position to protect the public in the most serious and high-risk cases, and we are down to essentially one major facility in Staunton and a smaller facility to serve Southwest Virginia. And if we go down to zero, we have no safety net.”
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Kate Duvall, an attorney with the Charlottesville-based group JustChildren, has kept close tabs on the closure and is highly critical of Reinhard’s plan. “The priority seems to be closing these centers, and not improving community-based services.”
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Kate Duvall, an attorney at the Charlottesville-based child advocacy group JustChildren, points to a 2006 report that showed that demand for the Commonwealth Center rising and a dearth of available beds in the private sector.
“If they weren’t there two years ago, we aren’t aware of why we are there now,” says Duvall. “The priority seems to be closing these centers, and not improving community-based services.”
Reinhard says it’s unfair to ask experts who don’t have to deal with the practicality of a limited budget. “It’s a different question that a policymaker has to answer than an expert,” he says. “In an ideal situation, with unlimited resources, I think any expert would say that that would be ideal to have this resource available.”
When it comes to the state budget, what matters is not whether you convince experts—it’s whether you convince state legislators. And state legislators—neither in the house nor the senate—weren’t convinced by his plan.
“There’s a lot of concern about whether the kids will be getting the services they need,” said Delegate Steve Landes, whose district is adjacent to CCCA and includes parts of western Albemarle County, at a February 2 House subcommittee hearing. “Unfortunately, from your presentation today, at least from this legislator’s standpoint, you haven’t given me a lot of confidence that we’re at the point to implement a plan as you have laid it out.”
Though Kaine draws up the budget, it goes through heavy vetting in the General Assembly. Most of the line-item changes happen in subcommittee, and the proposed closures in the mental health system dominated the deliberations of both the House and Senate subcommittees on Health and Human Services. After hearings and deliberations, both Senate and House proposed keeping CCCA open, though the House allowed for the closure of the 16-bed unit in Southwest Virginia while the Senate recommended a 50 percent cut to both facilities.
But then the federal government swooped to the rescue. Last week, heartened by the $789 billion stimulus package expected to kick $4 billion to Virginia, the Senate ratcheted funding to both CCCA and the Southwest unit back to 100 percent. Its budget also calls for the state “to develop a plan to understand the needs of the individuals served at these facilities, the capacity of the community to serve them, and the appropriate role of the state in providing treatment services to this population.”
Aaron is relieved by the news—and hopes that the controversy does lead to more locally based care. “The resources aren’t there now,” says Aaron. “But it would be nice if there needed to be less reliant on a place like the Commonwealth Center because those services were available in the community.”
The fate of the Commonwealth Center remains in the balance until House and Senate agree on a final budget, and even then, Governor Kaine still has a line-item veto at his disposal. Like so many others dependent on state funding, from drug courts to public radio, CCCA employees will have to sweat it out until the budget is signed into law in April.
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“I know that there are organizations and individuals out there saying this is a bad idea,” says James Reinhard, commissioner of the state department of mental health. “It’s not quite a fair question to ask an expert whether or not this is a good idea or not, because it has to do with the context of budget reduction and allocation of scarce resources.”
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And even then, it won’t be out of the woods. Reinhard says that his department isn’t intent on closing the Commonwealth Center, but he says it might come back up in the future.
“We will always have limited resources within our system,” he says. “So I think we will always want to ask ourselves, is this the best use of our resources. I think that we’ll always ask that of any of our facilities, or anything that we do—is this best practices, is this best use of our dollars.”
Of course, we can’t really know if we need the Commonwealth Center or not until it’s too late. When you unhook the safety nets, you don’t ensure that someone will fall. It just makes it that much worse when someone does.
“Prevention is invisible,” says Cornell. “When something bad doesn’t happen, you think you have no need for the folks who are busy engaged in prevention activities. The more successful people are, the less you think you need the services.”
But then when things go wrong, they can go really wrong.
“You know, in the case of the Virginia Tech shooting we did identify that this young man was dangerous and that he needed treatment,” Cornell notes, “but there really was no active provision for following up with him and making sure that he did receive court-mandated treatment, and that he did not continue to be dangerous. And we paid for that. And so it’s really ironic and painful that we seem to be going down the same road on an institutional, statewide basis.”
For Aaron, it isn’t ironic—just worrisome.
“It’s a small amount of money,” he says of the $7.6 million. “If we save a little bit of that now, are we going to spend more locking up kids who wouldn’t otherwise be locked up—and, in whatever form, dealing with the aftermath of inadequate treatment, whether that be harm to those kids or harm to other people, or lost productivity, more benignly but still very problematically.
“I think there’s a great risk that we’ll spend a lot more in the long run.”
