Fight for health

One morning in January, a former mechanic named Steve Winward walked into the offices of Spokane Mental Health, laid his left arm on the receptionist’s desk, and drew a shaving razor across the blue veins of his wrist. ■ Then he asked the horrified receptionist: “Now do you think I’m serious?”

The 54-year-old mechanic had spent months filling out forms, making appointments and undergoing counseling for severe depression. On Jan. 20, with his medical bills piling up and his frustration with public mental health care piqued, Winward retreated from the office to his car, blood running down his forearms, and repeatedly slashed his wrists as police broke his car windows and restrained him.

Today, Winward faces a singular obstacle in his recovery: For the past three years he has been in the crosshairs of the federal government’s fight to slow the spiraling costs of Medicaid, the state-federal program for poor Americans.

Winward belongs to a segment of the mental health population known as “non-Medicaid clients” because he has failed to qualify for the health program. He and his wife of 29 years have too much money to receive free mental health care from the government, but not enough to afford private insurance.

He’s not alone.

More than 5,500 patients like Winward lost access to the public mental health system in Washington as a result of federal cuts, according to a review of state data. In Spokane County, about 800 people lost outpatient care from 2003 to 2005.

Some likely qualified for other programs, such as Medicare, or purchased private insurance. Others may have become eligible for Medicaid as their resources dwindled.

But state officials cannot say how many found other sources of help because no one tracked them.

“If you’re not insured, you’re not in anybody’s database,” said Ann Christian, CEO of the Washington Community Mental Health Council, a professional trade association of community mental health providers. “If you’re not in a database, you kind of become invisible.”

While data has been sparse, anecdotes are plentiful.

Mental health patients arrived at family clinics with empty medication bags. Jail costs grew so steadily that the Legislature forced mental health officials to fund new programs for the incarcerated. In the final year of the three-year period, suicides in Spokane County spiked to an all-time high.

As Steve Winward collapsed, so did his finances. With an annual income of $21,000, the couple’s medical bills were shifted to credit cards, and his debt grew to more than $20,000.

Still, Medicaid officials said he did not qualify for public health care because he wasn’t impoverished.

Documents from the Department of Social and Health Services, which were attached to his letter of rejection, showed Winward had $162.74 in his savings account at the time. He had an additional $2,602.44 in his checking account.

“I’m not here to bleed the system,” Winward said, sitting in his middle-class home in a suburb north of Spokane. “All I want to do is get well and go back to work.”

Gifted with his hands, but troubled by his mind

For nearly 30 years, Steve Winward crawled under the carriages of sedans, vans and trucks.

The money was good, and he loved being a mechanic. He and his wife paid into the Social Security system, bought a home, and even set aside a little money for stocks. Each month, he paid $234 for private insurance.

Winward had suffered with depression for years; on average, he slept two hours a night, waking every 30 minutes for cigarettes to calm his nerves.

His mental health problems have deep family roots. His father suffered from depression, and Winward and his siblings – several of whom have attempted suicide – drifted through the state’s foster care system.

Among other diagnoses, doctors believe Winward may have bipolar disorder, and obsessive compulsive and narcissistic disorders.

“All my psychologists said I’ve probably had most of my problems since I was about 10 years old,” Winward said. “Back then, they just said you had an attitude problem.”

He dropped out of high school and got kicked out of the military. He had trouble socializing with others.

But in the garage, working with his hands, Winward found his calling.

Two years ago, everything changed. He and his wife sold their home and moved to a subdivision in north Spokane. In the months that followed, a cloud of depression enveloped him.

“It destroyed me,” Winward said. “It all came apart. I remember my wife was on a stepladder in the kitchen. I walked up to her and just started crying, and I couldn’t stop.”

He spent more than a week at Sacred Heart’s psychiatric unit. He was released and then readmitted. He underwent shock treatments. During the next two years, his medical bills grew as he was unable to work. County counseling programs that could have served him no longer accepted non-Medicaid patients.

His wife, Sherri, a hairdresser, did not have health insurance through her job.

Winward briefly qualified for Medicaid, but then lost the coverage – despite the fact that his household income had dropped sharply. Even when he was covered by the program, his bills mounted.

For people whose income and assets are slightly above the federal limit, Medicaid requires that they pay for some expenses before the government picks up the remainder of the bill – much like a deductible on an insurance policy. Last year, Winward’s Medicaid spend-down was $8,518.38.

Once his medical costs topped that, the government program would help with his bills.

“They don’t want you to have anything,” Winward said. “They want you to be flat busted.”

Each day, Winward took Effexor, Seroquel, Valium and a host of other drugs. By the time he lost his Medicaid coverage, the cost for private insurance for his counseling and medication was well out of reach.

His depression threatened everything he had worked for: his marriage, his financial security, his suburban home with a fish tank and two Basset hounds.

On January 20, when Winward learned that he did not have an appointment with his doctor, he became suicidal. He slashed his wrists in the office, and then in his car, as cops broke through his window and shot him with a stun gun.

“I thought, ‘You guys aren’t doing me any favors,’ ” said Winward, who spent a week at a psychiatric hospital after the suicide attempt. “I just wanted them to leave me alone and let me go.”

As feds cut, local expenses rise

For every $10 spent on public mental health in Washington state, the federal government once chipped in $9. Today, its share has dropped to about $7.40.

For a $600 million system, that means the cost to state and local governments runs into the tens of millions of dollars.

Originally outlined in the 1997 Balanced Budget Act, the federal cost-savings weren’t enacted until the Bush administration came into office. When the cuts reached local governments, officials scrambled to stabilize an already-fragile mental health system.

The state Legislature stepped in with $80 million to stem the cuts. But some officials complained about how the money was distributed, as well as the restrictions the state put on spending it.

Three years ago, Spokane County began shedding hundreds of clients who were no longer eligible for services. But no one tracked where they went or what happened to them.

Immediately after the cuts, the county paid a local nonprofit $17,000 to help those people find new coverage, but it did not give the nonprofit a list of names. In the end, the nonprofit Health Improvement Project counseled only about one in eight people who had lost coverage.

A little-known state program, Healthcare for Workers with Disabilities, offered hope. But even though thousands of people in Washington appeared to qualify for the program, all requests were routed through an office in Omak that housed a single employee.

Applications mounted, and six months after the cuts, only 14 people from Spokane had been enrolled.

Meanwhile, cost-savings in Spokane County failed to materialize. The county’s cost for outpatient services – for consumers who did not require hospitalization but needed ongoing treatment – grew from $21.9 million to $32.9 million in the three-year period.

Without support services once offered by Medicaid, patients became sicker, requiring a greater number of lengthy and expensive hospitalizations, according to reports from the state’s Mental Health Division.

In Spokane County, hundreds of patients apparently shifted from outpatient programs to psychiatric wards, according to data provided by county officials.

The inpatient psychiatric care cost taxpayers an average of $440 a day – about two to three times what it would have cost if they had been treated with outpatient care such as counseling, according to a state analysis. That figure does not include the economic losses from missed work days, or the financial toll on police and fire.

The care not only costs more; it’s less effective, mental health experts say.

“It’s the bare minimum of a public health response,” said Christian, with the statewide mental health council. “But it’s not a humane way to take care of people.”

Once released from psychiatric hospitals, but without access to Medicaid’s support services, uninsured patients were more likely to have to be readmitted, according to a state report.

In King County, more than half the patients sent to a state psychiatric hospital did not have Medicaid.

“We have evidence to suggest that the non-Medicaid population is being served in the state institutions and in the county jails,” said Amnon Shoenfeld, director of King County’s mental health services. “But we don’t know exactly. And that’s a problem.”

Spokane County’s behavioral health triage center absorbed much of the crisis, with apparent success. In a little over a year, the center served about 3,000 people; only about one out of every 15 patients had to be hospitalized in the two weeks after their release.

Last fall, that safety net was removed.

In the midst of a huge budget deficit, the county cut millions from its mental health budget, laid off dozens of counselors and shuttered the crisis triage center.

Trying to get well, struggling to pay bills

In a sparse room at Eastern State Hospital this winter, Steve Winward began to pray.

“It was like the clouds just parted, and I came up out of this dark hole,” said Winward, a devout Mormon. “I never would be where I am today if it wasn’t for my faith.”

Winward sat for several lengthy interviews with The Spokesman-Review, discussing his most personal health information. He consented to the interviews, he said, in the hope that his story would highlight the dilemma faced by those caught in the gap between public and private mental health care.

In Washington state, that gap has proved fatal.

In 2004, a severely depressed man from Monroe, Wash., who had been unable to find mental health treatment for his bipolar grandson, shot the boy in front of the city’s police station. He then turned the gun on himself.

While Winward himself has found some hope, problems remain. He receives $944 a month in federal disability. Currently his prescriptions tally about $700 a month, he said.

After a mandatory two-year wait, Winward will qualify this spring for Medicare, the program for elderly adults or those whose disabilities are so profound they are unable to work. To qualify for Medicare, he had to be on federal disability for two years.

The coverage is not as comprehensive as Medicaid but will allow Winward to see a psychologist. Once on the federal program, his prescription bill will be about $150 a month, he said.

He plans to slowly chip away at $20,000 in medical bills, or, if more problems occur, consider opting for bankruptcy.

The bills cause him constant worry. To soothe himself, he plays the gospel songs of Elvis Presley, or the Mormon Tabernacle Choir.

“The suicidal thoughts will never be gone,” he said, sitting in his living room. “I just have to have faith that God is going to step in and help me out.”