This is the first of a three-part series running each Saturday in the Clinton Herald looking at mental health issues in the state of Iowa and Clinton County.

CLINTON — Humans learn in early childhood to brush off the stings and scrapes and bruises and bumps that accompany everyday living. But all the band-aids and bactine in the world can’t heal the stings and scrapes and bruises and bumps that can affect the mind.

Relief can be difficult to find in Iowa. A bevy of issues await those who attempt to seek medical care. Inter-county disputes over who foots the bill, a lack of access to quality care, a shortage of medical professionals, and the lack of crisis care for mental health emergencies all serve to muddy up an already murky situation.


For many Iowans, getting proper treatment for mental health issues is a struggle. A struggle that can be exacerbated by the circuitous route afflicted persons must navigate in order to determine who pays for it.

Currently, Iowa utilizes an area of legal settlement system to finance mental health issues. Roger Munns, a spokesman for the Iowa Department of Human Services (IDHS) says the system isn’t just broken, it’s non-sensical.

“It’s an archaic system of determining who should be responsible for your care,” Munns said. “That’s one of the things we hope to change.

“Nobody understands (why we use the system),” he added.

Under the legal settlement system, the county in which a person is diagnosed with a mental illness or intellectual disability is responsible for handling the care of that individual. Even if the mentally ill person were to move to another county, the county of the initial diagnosis is still responsible for the patient’s care plan. For example, if a person were to receive treatment for a mental illness in Jackson County and then relocate to Clinton, they would still have to seek funding from Jackson County for services.

Iowa Sen. Pam Jochum, a longtime mental healthcare advocate, said that this system can lead to counterproductive disagreements.

“We spend an awful lot of time arguing over ...who’s going to pay for what,” Jochum said.

She said that one of the biggest issues with the legal settlement system is the inconsistent level of care acrosss the state.

“Right now we have 99 different systems,” Jochum said. “Where you live determines the level of services in your community.”

She said that counties with stronger property tax bases may offer better services than those without. Conversely, counties with larger populations and therefore larger numbers of the mentally ill, may be stretched too thin to provide a consistent level of care.

Maragaret Stout, executive director of the National Alliance for the Mentally Ill (NAMI) Iowa, said sort of inconsistent care can have severe side effects.

“An unfortunate number of people don’t get care and end up in the criminal justice system,” Stout said.

Jails, not hospitals, have become the primary institutions for the mentally ill, according to Stout. Self-medicating with drugs and alcohol is a common occurrence among the untreated, which often leads to incarceration.


Compounding the problem is the shortage of mental health care professionals in the area.

According to the Health Resources Services Administration (HRSA) in a 2009 study, Iowa ranks 47th in the nation in pyschiatrists per capita and 46th for psychologists.

For every 100,000 people in Iowa, there are 7.2 psychiatrists. This compares to 15.8 nationally. Furthermore, the mental health care professionals are almost exclusively located in urban areas, leaving rural Iowans without immediate access to care. According to the HRSA study, only 32 of 99 counties in Iowa have at least one psychiatrist.

“No matter where you live in Iowa, you should have equal access,” said Stout. “Without enough professionals, you can’t get evaluated quickly to move through the system and get support.”

She said that mental health care professionals, even those produced from state institutions, don’t stay in Iowa to practice.

In the end, Stout believes, it comes down to money.

“We need to figure out some way to get (mental health care professionals) an incentive to stay,” she said.

Even if an Iowan can locate a qualified health care professional, access in crisis situations is almost non-existant.

According to a study funded by the Iowa League of Women Voters, the number of psychiatric beds available at Iowa hospitals has declined dramatically. In 1955, there were 340 psychiatric beds per 100,000 residents. In 2005, that number had decreased to 17 per 100,000.

Stout said that there is also a lack of trained mental health crisis personnel. Cities like Seattle have mobile intervention teams, and law enforcement officers are trained to handle situations involving mentally ill individuals. While Stout said cities like Des Moines has attempted to implement similar systems, Iowa is largely devoid of mental health crisis care.


While far from ideal, Iowa’s mental health care system may not be beyond repair. One of the few items the historically partisan legislature agreed on in 2011 was the need for mental health care reform. Legislation passed calls for the creation of an interim committee to hopefully help overhaul care for mentally ill Iowans by 2013.

“The legislature has approved setting up study groups that will improve delivery of mental health services in Iowa,” said Sen. Joe Bolkcom (D-Iowa City), a member of the subcommittee that reviewed the mental health bill. “The goal is to try and make sure that families have access to quality services in all parts of the state.”

One of the main objectives for lawmakers is to refine or eliminate the concept of legal settlement, making health care more of a state or regional service, and ease the burden on counties and create a more uniform system.

Bolkcom said the interim committee will be attempting to establish core services that should be available everywhere. Regional administration centers will, ideally, eliminate discrepancies in quality of care between counties.

However, the issue of money remains.

“A number of things we need to do improve the system have a price tag,” Bolkcom said.  “We’ve not made progress because we haven’t had the  money.”

Jochum said that the interim committee will hopefully be able to address these issues. Unlike traditional interim committees, which meet to develop and eventually propose suggestions for legislation, the mental health committee is expected to actually write the legislation itself. Jochum said this eliminates a step and helps expedite the process.

“(The committee) should produce some good work,” Jochum said, but added that continued cooperation is essential.  “We have to have agreement between two chambers and a governor to make anything happen.”

Other priorities for the committee will include determining how to best take advantage of the federal health insurance plan set to take effect in 2014, creating jail diversion programs and improving care for brain injury victims.

Stout said she hopes for the best, but has seen similar ideas come and go before.

“They’ve attempted to fix it from time to time,” she said, referring to the legal settlement issue, “but it’s still botched up.”

She said the money issue will continue to be a roadblock for Iowa mental health care.

“Some folks see it as saving money, others see it as bad care,” Stout said. “It depends on what side of the fence you’re on.

“Personally, I see it as bad care,” she added.

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