Governor’s bill to restructure mental health, substance abuse care in Iowa moves forward

Mental health providers and advocates praised the governor’s plan to overhaul the state’s behavioral health system during a subcommittee meeting Thursday, though some said they hope to see specific concerns addressed with provisions on disability services and in-patient care.

Lawmakers gave initial approval to House Study Bill 653 on a 2-1 vote. The legislation, one of Iowa Gov. Kim Reynolds’ priorities laid out for the 2024 legislative session, proposes establishing a Behavioral Health Services System (BHSS) in Iowa to provide mental health, substance abuse and other addiction recovery services, while moving the current Mental Health and Disabilities Services (MHDS) system into an advisory role.

The behavioral health system would divide the state into seven districts that would take over the existing 13 mental health and 19 substance abuse regions designated for providing care, as well as put the Iowa Department of Health and Human Services overseeing BHSS and in charge of negotiating contracts with care providers in each district. Disability services currently provided by MHDS would also move to the Iowa HHS’ division of disability and aging services.

Iowa HHS director Kelly Garcia told lawmakers the legislation’s proposed changes came from four years of assessments, agency alignment work and feedback from Iowa communities on how to best address problems in the state’s mental health care system.

“What we see today is a system that is fractured,” Garcia said. “It is fractured, it is not serving Iowans. And so we are taking a really significant step forward to really cure that issue, and doing it in a thoughtful and methodical way, but with some really clear direction and accountability that starts to shore up those gaps that we see.”

Multiple lobbyists representing care providers and mental health advocacy organizations thanked Iowa Gov. Kim Reynolds and Iowa HHS for bringing forward a plan to address the state’s mental and behavioral health needs, and the existing shortages in available care.

In a January Treatment Advocacy Center report, Iowa ranked last in the nation for in-patient psychiatric beds available to treat adults managed by the state. Iowa has 64 state hospital beds available for adults with serious mental illnesses — a rate of two beds per 100,000 residents. The mental health care advocacy group stated that 50 beds per 100,000 residents is the lower limit required to “provide minimally adequate treatment for individuals with severe mental illness.”

Leslie Carpenter with Iowa Mental Health Advocacy, said she supports the overall goal of the project and the merging of mental health and substance abuse services. But she criticized language in the bill calling for a focus on community-based services that “avoid, divert or offset the need for acute in patient services, long-term services provided in large institutional settings, law enforcement involvement and incarceration.”

While she said she supported measures to avoid law enforcement involvement and incarceration, Carpenter said acute inpatient services should not be disincentivized. In-patient and hospital treatment can often help people in the early stages of psychosis, she said, and stop mental illnesses from progressing to more severe problems that will involve the criminal legal system.

“Inpatient and long-term permanent supportive housing that heals, not warehousing, is far preferable to homelessness, incarceration, and graves,” she said. “Inpatient care is not inherently bad. We could be doing it with a lot less trauma, but for those who have the most serious illnesses, it is a vital life saving piece of the continuum of care and needs to be continue to be available.”

Others questioned other specific components of the bill, like the transition period outlined for the system changes. The BHSS districts will be fully operational and ready by July 1, 2025 under the bill, with the current system continuing to operate as-is until that date.

Amy Campbell, representing the Iowa Association of Area Agencies on Aging and the Polk County Board of Supervisors and multiple health care groups, thanked HHS and the governor’s office for their transparency in the proposed changes, but said some questions remain unanswered. For example, Campbell said she does not foresee the transition timeline being an issue for the behavioral health services, but could cause problems for disability services currently provided through the MHDS system.

“I think there’s a lot of concern about the moving of the disability services over (to HHS), and the plan for that is not as well outlined in the bill,” Campbell said. “And that’s a significant population when you talk about job support and work supports that they get for employment. You don’t want to have a hiccup there.”

Campbell also said funding for mental and behavioral health moving forward remains unclear, as the amount being taken out of the system that is currently allocated for disability services.

Rep. Beth Wessel-Kroeschell, D-Ames, said there were many positive changes in the proposal, but declined signing off because she had some unanswered questions. Reps. Joel Fry and Ann Meyer voted to move the bill forward.

Fry, R-Osceola, said the bill is the next step in a years-long effort to improve mental health care in Iowa.

“I’m proud of where we’re at today,” Fry said. “I think we’re doing well. There’s improvements to be made and many opportunities to be getting, but by and large, we are listening to what Iowans are needing and we look forward to how this bill will also help complement the next step of our mental health and disability service system.”

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