A PIERCE County judge’s decision last week to delay a fix for the epidemic of psychiatric boarding is a fresh reminder that the Legislature — not the courts — is the venue for ending this too-common practice.
Psychiatric boarding refers to the warehousing of acutely mentally ill patients in emergency rooms because there simply aren’t psychiatric hospital beds. As documented in an unusual hearing in Pierce County Superior Court in March, patients can linger in a bureaucratic netherworld for days or weeks, involuntarily detained because of acute illness, yet getting little or no appropriate treatment because there’s no place for them to go.
A recent Seattle Times story showed that the rate of boarding had more than doubled since 2010, rising to 4,566 this past year. On any given day in King County, dozens of patients are boarded.
With these abysmal facts, judges have stepped in. Pierce County Superior Court Judge Kathryn Nelson in July ruled that boarding violated state and federal law, but stayed her opinion, pending an appeal. This week, she issued a second six-month stay, giving the appeals court more time.
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This case represents a ticking time bomb for the state. Nelson’s opinion applies just to Pierce County, but it could easily be pressed elsewhere. It is not far-fetched to imagine courts requiring Washington to spend tens of millions of dollars on new inpatient psychiatric beds.
Worse for the state are the moral questions. Involuntarily detaining an acutely ill person, yet failing to ensure treatment, is a violation of the state’s social contract to care for the most vulnerable in society, let alone a violation of law.
The cause of psychiatric boarding is clear. Society demands acutely mentally ill people be off the streets, for their safety and others. The state has broadened criteria for involuntarily detaining people eight times since 1998, most recently last year.
Yet 250 psychiatric beds statewide have been cut in recent years, and community resources to stave off hospitalization were seriously eroded during the Great Recession.
The Legislature partially responded last session, paying for a new 16-bed facility in Pierce County and new roving treatment teams in King County. But these steps were a response to the most recent expansion of involuntary commitment laws — not to an ongoing epidemic of boarding years in the making.
This issue cannot be resolved by policy tweaks or reforms. It requires money. The Legislature’s decision to expand Medicaid via the Affordable Care Act may help some. But it is not a full solution. An antiquated federal funding rule, known as the Institutions for Mental Disease exclusion, prohibits Medicaid from paying for care in psychiatric hospitals larger than 16 beds, which are most common in King County. This means the state must put in its own money as well.
There are many demands on state funds, primarily for education. Balancing those is an unenviable task. But the fiscal and moral cost of psychiatric boarding should be heeded.
If your loved one needed crisis mental-health care, how would you feel if he or she instead was strapped to a gurney, without appropriate care, until the state got around to helping?
Better yet, ask your legislator.