After I was elected to the Legislature in 1978, the newly elected freshmen were loaded onto a bus at the Capitol in early December for a week-long tour of state facilities. One of our first stops was the state mental hospital in Pueblo where more than two thousand patients were housed. Colorado’s total population was less than half what it is now. Today, available mental health beds are just a few hundred. Where have all those patients gone? They were released into communities across the state as pharmacology introduced Thorazine and other drugs that can bring aberrant behavior under control.
If you suspect this might be a mismatch between behavioral treatment needs and available resources, you would be right. By default, hospital emergency rooms, municipal and county jails, homeless encampments and drunk tanks have been required to pick up the slack. As de-institutionalization of the mentally ill swept across the country during the 1980s and 1990s, state governments were forced to cobble together mental health services without a guidebook. The “laboratories of democracy” created a variety of structures, ranging from governmental facilities staffed by civil servants to quasi-non-governmental (quangos) agencies ostensibly operating as non-profits. Colorado opted for this latter model.
This community mental health structure has proven problematic for decades. Regional districts are served by the successful bidder in a contracting process that usually produced just a single applicant — the incumbent provider. Academics frequently point to the evolution of “regulatory capture,” where an industry’s relationship with its regulators grows so symbiotic that staff routinely move back and forth between the watchdog agency and key employers within the industry itself. Such charges of cronyism were often leveled by public advocates against the Colorado Oil and Gas Conservation Commission and Colorado drillers. It required a decade to clean this up, arguably to the benefit of all parties.
However chummy that relationship was, it can’t compare with the incestuous links between behavioral health service providers and the Colorado Department of Human Services. The coziness between providers and the state goes well past capture to something approximating collusion. With virtually all their revenue provided by taxpayers, community mental health centers operate under the supervision of boards of directors, usually composed of powerful local business and political leaders. When an Arizona firm, Crisis Access, was selected as winner in 2013-14 these players pulled out all the political stops to overturn that contract award.
Roxanne White, chief of staff to then Gov. John Hickenlooper took the lead in discrediting the original selection process. Soon the initial award was determined to be flawed and a second procurement was ordered. When this reversal was challenged, District Court judge Hub Stern ruled that Crisis Access was likely to prevail. Yet, despite his favorable ruling the Arizona applicants withdrew from the second procurement process and rumors of a confidential, out-of-court settlement circulated. Several Human Services employees believe to this day that a cash fund was tapped to encourage the successful bidder to return to Phoenix with their lips zipped. To no one’s surprise, incumbents succeeded on their second attempt.
There is a great deal of money at stake when winning these contracts. Providers are represented at the Capitol by Mental Health Colorado, which moved quickly to insure there would never again be a risk from competitively bidding mental health care contracts — substituting periodic renegotiation in its place. Statewide, the mental health system is approaching collapse. More than a thousand vacancies exist despite the fact most agencies are sitting on fat surpluses they have been unwilling to tap. Their eyes are focused on the $450 million in additional dollars earmarked in the COVID rescue funding headed to Colorado for strengthening behavioral health services.
Both local hospitals and sheriff’s departments have complained for years that it is nearly impossible to transfer mental health cases arriving at their facilities to community mental health providers, particularly when there is reason to suspect these individuals might be dangerous to themselves or others. Existing contracts permit community centers to dodge this responsibility. Nor do many provide 24-hour access to crisis counseling.
The state auditor’s office recently declared the system a mess, while Michelle Barnes and Kim Bimestefer with the Colorado Department of Health Care Policy and Financing — conduit for the expected federal dollars — recommended a thorough audit of existing programs. For example, Mental Health Denver pays, its Executive Director more than $800,000. What sounds absurd is actually obscene.
The Legislature has authorized the creation of a ‘stand-alone’ behavioral health department. Jared Polis announced his selection last week of Morgan Medlock, chief medical officer for Washington D. C.’s Department of Behavioral Health, to join his Cabinet. The Colorado Behavioral Healthcare Council has supported an accountability audit. Doctor Medlock would be well served by an independent appraisal before she starts “transforming” Colorado’s mental health system.
Miller Hudson is a public affairs consultant and a former Colorado legislator.