Attorney General Jim Hood speaks on Feb. 21, 2018, about pending legislation that could limit the powers of his office.

When Mississippi faces off against the Department of Justice this week in the longstanding battle over the state’s treatment of mentally ill Mississippians, its defense will depend on the office of Attorney General Jim Hood — despite the fact that Hood has been, arguably, one of the biggest critics of the state’s mental health system.

In 2016 the U.S. Department of Justice sued Mississippi, claiming the state warehoused people seeking help in its state-run hospitals and institutions and defied the federal standard of community-oriented care.

Hood quickly latched on, criticizing lawmakers for cutting mental health funding.

“The fact is … it’s all about the money,” Hood said, criticizing the state Legislature to a room of mental health advocates in 2017. “And you have to spend a little bit of money to save money. And you can’t get these folks to understand that because they’re only focused on the next election.”

Two years later, few people are as focused on the next election as Hood, considered the front-runner for Democrats’ nomination for governor. And the lawsuit could provide ammunition against his likely opponent in November, Lt. Gov. Tate Reeves, a Republican who has controlled the purse strings of the state Legislature since 2012, months after the federal government sent Mississippi its first letter telling Mississippi the state was out of compliance with federal standards.

But Hood has toned down his rhetoric going into the trial, which begins June 4 and is projected to last until July. When asked for a comment on the merits of the Department of Justice’s case and whether the state has sufficiently improved since 2016, Hood declined to comment. Instead his office sent Mississippi Today a statement from 2016 in which the attorney general calls the lawsuit “a clarion call to all of us in state leadership to consider how we care for the least among us and how we can make it better” and asks the Legislature to increase its spending on mental health, noting litigation would likely be costly.

According to the attorney general’s office, the state has so far spent over $1.4 million on outside counsel and expert witnesses.

Those outside attorneys have argued in a recent brief that the state is transitioning to community-based care responsibly and that “a mental health service system that has no ‘gaps’ and no ‘unmet needs'” is a system “no State can deliver.”

When asked about improvements over the last three years, the Department of Mental Health also declined to comment, citing the pending litigation. But the agency provided a document that spokesman Adam Moore said “highlights some of the ways community services have been expanded in Mississippi” since 2016. This includes $13.3 million that was shifted from the department’s institutional budget to community programs in 2019.

Mental health advocates on the ground acknowledge these strides but say the face of Mississippi’s mental health system remains largely unchanged.

“We are so far behind. We have a lot of ground to make up for,” said Polly Tribble, executive director of Disability Rights Mississippi. “We have a long way to go to make it acceptable for the people who receive these services.”

The foundation of Mississippi’s lawsuit is a 1999 Supreme Court decision in Olmstead v. L.C. that found the state of Georgia had violated the Americans with Disabilities Act by sequestering people with mental health disorders in institutions, even when therapists had determined these patients would fare better living in their communities. As a result, the Olmstead ruling says states must provide community-based services when appropriate.

The state of Mississippi has twice noted the ineffectiveness of its reliance on institutions. In 2008, a legislative watchdog report concluded that Mississippi was far behind the rest of the country in shifting towards community-based services even though institutional care “represents a much more expensive service delivery model than does community-based care.” In 2014, after budget cuts contributed to the closure of Mississippi State Hospital’s Community Services Division, a second legislative report criticized the department’s decision and recommended the agency develop a comprehensive system for tracking patients and implementing services.

The Department of Justice complaint against Mississippi, filed in 2016, paints its allegations in broad strokes, describing a system in which “individuals with persistent needs cycle through the state hospitals over and over again, to say nothing of admissions to local emergency rooms, private psychiatric hospitals, and jails” because services in the community, it says, are “insufficient.”

Hood has long blamed funding as the root of the problem. In 2017, months after the Department of Justice filed its suit against Mississippi, lawmakers slashed nearly $28 million from the Department of Mental Health’s $600 million budget, a move that eliminated more than 500 jobs within the state hospital system.

And to that end, Hood in 2017 and 2018 often portrayed the lawsuit as a political issue, linking the Department of Mental Health’s budget cuts to the package of corporate tax cuts Reeves championed in 2016.

“They ran out of money because they gave it all away. They gave it to tax cuts to the wealthy,” Hood told Mississippi Today about the origins of the lawsuit in 2017, adding: “The state needs to step up and pay for more on mental health.”

Hood is not alone in assigning blame at the Department of Mental Health. In 2017, shortly after signing one of the biggest cuts to the agency, Gov. Phil Bryant blasted the Department of Mental Health for continuing to rely on its hospitals.

“They’re reinforcing old continuums of mental health care. We’re being sued by the federal government. We should be putting more (resources) into community based care.”

But advocates on the ground say the problems with the state’s mental health system are much more complex than funding for one agency.

Although the Department of Mental Health provides or certifies the majority of the state’s mental health services, the agency is not a party in the lawsuit. Neither is the Division of Medicaid, which pays for many of these services, nor the Department of Rehabilitation Services, which often provides job training and other services to people transitioning out of care.

The Department of Justice has instead sued the state of Mississippi, arguing the state repeatedly lets residents seeking help for mental health fall through the cracks, something several mental health advocates say hasn’t changed, even as the Department of Mental Health has built up resources at its community mental health centers.

“I’m not certain how our system should be funded and what it should take to fund it because until we get it focused on the types of services and support that people most need — and, more importantly, how the system should be structured to provide those supports — I don’t think we have any idea how much money it will take to fund that and where it may need to go,” said Joy Hogge, executive director of Families as Allies.

Excerpts from the scores of depositions conducted by the Department of Justice get at the lack of statewide planning. In one, conducted last summer, nearly two years after the Department of Justice sued the state, an attorney for the Department of Justice asks Steve Allen, deputy executive director for the Department of Mental Health, if he knows what an Olmstead Plan is.

“I guess the definition of it would be a plan of how to create a system to allow people to
live, work, and play in their own community of their choice,” Allen said.

But when asked if Mississippi had created an Olmstead Plan, Allen answered “I’ve never seen one.”

The lack of statewide coordination also becomes apparent when trying to gauge how Mississippi has changed its spending on mental health services since 2016, when the Department of Justice sued the state. Mississippi has no central gatekeeper of information about mental health. Each agency that contributes — the Department of Mental Health, the Division of Medicaid, the Department of Rehab Services — must be contacted individually for funds and, when numbers are available, they arrive with asterisks.

Medicaid, which receives a three-for-one federal match for every dollar spent on mental health in the state, said it tracked spending on community mental services but wasn’t able to immediately provide numbers because the agency has multiple programs that provide these services, according to Matt Westerfield, Medicaid’s director of communications. These range from waiver programs to reimbursements at community mental health centers.

The Department of Mental Health estimated that in fiscal year 2019 it will spend $23 million less on institutional care and $10 million more on services at its community mental health centers than it did three years ago. But agency spokesperson Adam Moore clarified that “these figures do not represent the entire Service Budget allocations (and) are only the amounts allocated for adult mental health services” at those centers and in the community.

“That’s the real problem. We don’t have a way to look at the overall picture of mental health services in our state,” Hogge said. “So how do we coordinate all these incredibly disjointed parts of our mental health system to make them work together to track what outcomes people are getting?”

The new money going toward community care has had an impact on services. Last year the state added $13.3 million to its entire service budget, and this allowed the state to add 42 crisis stabilization beds statewide. It also allowed one of the community mental health centers to open a women’s community transition home in Simpson County and to expedite the evaluation and restoration process in Mississippi State Hospital’s forensics unit.

But these additions also highlight discrepancies. Although crisis stabilization beds have been added, they aren’t yet available at all 14 community mental health centers. Whether people get the services they need — not just beds but services such as indigent care, court liaisons and intensive care managers — still depends on what’s available at that time, in their area, according to Tribble.

“No matter if you live in Marshall County or Forrest County, the services should be the same,” Tribble said. “And they’re not.”

Editor’s note: An earlier version of this story misstated that legislative budget cuts resulted in the closure of Mississippi State Hospital in 2014. However, just the community services division closed not the entire hospital. 

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Larrison Campbell is a Greenville native who reports on politics with an emphasis on public health. She received a bachelor’s from Wesleyan University and a master’s from Columbia University's Graduate School of Journalism.Larrison is a 2018 National Press Foundation fellow in public health, a 2019 Blue Cross Blue Shield Foundation of Massachusetts fellow in health care reporting and a 2019 Center for Health Journalism National Fellow.