Mental health advocates in Iowa are accustomed to “busting myths” about mental illness, but they say the biggest misconception they’ll have to address during the coming legislative session revolves around funding for behavioral health programs. 

A group of mental health advocates from across the state met in mid-October in downtown Des Moines in an effort to reinvigorate a coalition aimed at “holding legislators’ feet to the fire” to fund the mental health initiatives that were enacted during the last session. 

Although the progress made in getting a Children’s Mental Health System bill passed was a significant accomplishment, legislators have yet to appropriate any money to fund that system. 

The advocates who met recently included hospital administrators and mental health service providers from numerous private and state agencies across the state, along with some of the regional representatives who lead the 14 Mental Health and Disability Services (MHDS) regions in the state. 

Those advocates are adamant that they don’t want priorities for funding children’s mental health to be pitted against adult mental health services they want both adequately funded.  

“What we’re hearing more and more is this rumbling [from legislators saying]: ‘We’ve got plenty of money — it’s just a matter of rearranging it.’” said Peggy Huppert, executive director of NAMI Iowa, the Iowa chapter of the National Alliance on Mental Illness. However, property tax funds can’t be shifted between the designated MHDS regions, and the state as a whole is woefully underfunded in federal Medicaid support, she said. 

Iowa is divided into 14 regional mental health districts, each comprising a handful of counties. The exception is Polk County, which is designated as its own region that’s served by nonprofit agency Polk County Health Services. 

The current stopgap measure that the state’s mental health regions are operating under was enacted by the 87th General Assembly in 2014. Those measures, HF650 and companion bill SF504, followed a statewide redesign of the MHDS system that shifted responsibility for payment for Medicaid services from the counties to the state. It also instituted a statewide cap on the mental health levy from property tax revenues to a per capita rate of $47.28 — a total statewide levy cap of $125.8 million. 

The Mental Health Levy legislation required districts whose counties had surpluses to draw down those surpluses, while counties with levy rates below the per capita cap received equalization payments. 

“Because of the way it’s structured, the legal responsibility [for funding and providing the services] is on the regions,” Huppert said. “And whatever they don’t pay for, the county gets stuck with. It’s an untenable situation as the services grow and the counties grow.”  

Iowa also receives about $3.3 million in federal mental health block grant funding each year through Title 19 (Medicaid) funding. Iowa’s use of the Community Mental Health Services Block Grant is overseen by the Division of Mental Health and Disability Services in accordance with federal regulations, state laws and legislation, and applicable agency rules.

“One of our points is that Medicaid is not paying enough,” Huppert said. Although legislators will point to the fact that 97% of Iowa children have some form of health coverage, families with private coverage often have high co-pays and deductibles, and often workers have few choices of plans from their employers, and some of those plans may not offer mental health coverage at all. 

Liz Cox, CEO of Polk County Health Services, has been systematically meeting one-on-one with legislators, armed with facts and figures, among them an analysis of the impact that the levy cap has had on the Polk County Mental Health and Disability Services Region that her nonprofit serves. 

“There seemed to be a lot of myths going on in the Legislature about what’s going on in the mental health regions,” Cox said. “And so that’s part of what inspired us to just put it down on paper in black and white and red.” 

Under the revised funding formula, “for the past several years, we’ve exceeded our funding capacity and have spent down all of our reserves,” she said. 

Built into the mental health levy cap legislation was a specific mandate for Broadlawns Medical Center in Des Moines to pay $6.3 million a year to Polk County — $2.8 million annually in cash to the county’s MHDS fund and the remaining $3.5 million in in-kind services — in fiscal years 2018, 2019 and 2020.  

When fiscal 2021 begins on July 1, 2020, there is no funding plan for Polk County’s mental health services, and the county will be short by $13.75 million, according to Cox’s analysis. 

For the coming budget year that begins July 1, the mental health districts will have additional requirements to fund education and prevention programs under the Children’s Mental Health legislation. “So we’ve added additional dollars there, but of course, that’s just digging a deeper hole for us because we don’t have adequate funding to cover the existing services,” she said.  

Cox said she believes there’s a perception that Polk County has “some sort of Cadillac level of service,” due to a number of services her agency performs outside of the mental health regions that are not funded with so-called “Fund 10” mental health dollars from the property tax levy. 

“The county has been very generous in providing support for those other [education and prevention] programs through other funding,” she said. 
The lack of funding could mean that many more people with mental illness in Polk County end up going to jail rather than getting services they need, she said.  

“It’s cheaper and with better outcomes long term if we can provide these interventions in the community in a supportive environment where they can have access to their family and friends and the professionals who can help them,” Cox said. “And that costs money. Polk County has the will to cover those costs. What they need is flexibility from the Legislature.” 

Other regional mental health district residents who attended the coalition meeting in Des Moines are similarly trying to fund more services with fewer dollars, while others face declining budgets due to shrinking populations. 

On the eastern side of the state, for instance, Muscatine County is fighting the clock to secure a contract with a new mental health region after one of the regional districts, Southeast Iowa Link, rejected its application for membership. The county had withdrawn from the Eastern Iowa Region in late October after the region cut its $12 million budget by more than 10%, with projections that it will have to cut another $4 million in the next fiscal year. 

Art Wittmack, interim president of the Taxpayers Association of Central Iowa, said it’s apparent that awareness of mental health issues is becoming more prevalent, but answers to the funding puzzle remain elusive. 

“I recently asked Des Moines Police Chief Dana Wingert, ‘What is your major concern right now?’” Wittmack said. Wingert told him it’s mental health and the demands his officers are seeing to respond to mental health crises.
The taxpayers association knows that a more sustainable solution is necessary, but it hasn’t yet determined what the ideal route might be. 

“We have to have a better, more uniform, consistent and sustainable funding stream,” Wittmack said. “It can’t be based on geography — mental health doesn’t stop at county borders, and it doesn’t stop at the regional boundaries.” 

His association has a committee that has been meeting on an ongoing basis to try to come up with some funding recommendations, but he’s doubtful that the time-consuming process will be completed before the Legislature reconvenes. 

“Are we for the 1-cent sales tax? We haven’t come to that [conclusion] yet. However, with the environmental issues that the taxpayers voted for overwhelmingly [to create the 3/8-cent water infrastructure fund], maybe you put two-eighths or a quarter of [the cent] into some form of mental health funding to relieve localities of the property tax burden, and make it even more uniform from region to region.” 

Huppert of NAMI Iowa warns that without consistent funding, private-sector mental health providers can’t be compelled to deliver services. 

“Already there are services such as the Children’s Medicaid waiver in which there are large parts of the state that don’t have [those services] because Medicaid doesn’t pay enough,” she said. “Unless the state provides it directly — and I’m not saying that’s the preferred way — but if we’re going to rely on private providers for these services, we’re going to have to pay them.” 

Huppert said that from the recent Des Moines meeting, “I think there was a consensus that we need to speak together for funding the children’s and adult system, but we didn’t agree on a specific way to do that.” 

Just providing the opportunity for connecting advocates whose paths normally don’t cross was extremely valuable, she said. “There were a lot of people in the room who honestly didn’t know each other. It was really good that they met people who are working in the field, but in a different way. 

“We’ve certainly made strides in the past several years with policies, but that hasn’t translated yet into services,” Huppert said. “We just need to keep pushing ahead.”