Florida’s problems with mental health system flagged decades ago

Thousands of people struggle to access mental health services in Florida. The treatment system is disjointed and complex. Some residents bounce between providers and are prescribed different medications, with clinicians unaware of what happened. Jails and prisons have become de facto homes for many who need care.

These problems and more were identified in a scathing report released earlier this year by the Commission on Mental Health and Substance Abuse, a 19-person panel that Florida lawmakers created to push for reforms of the state’s patchwork of behavioral health services for uninsured people and low-income families.

What’s most troubling about the group’s findings? They aren’t new.

More than 20 years ago, the Florida Legislature set up a commission with the same name to examine the same issues and publish recommendations on how to improve mental health care in the publicly funded system.

The echoes between the two groups — over two decades apart — are unmistakable.

“It comes down to how much investment, financially, legislators are willing to put into building a system that works,” said Caren Howard, director of policy and advocacy at the nonprofit Mental Health America.

The 1999 Commission on Mental Health and Substance Abuse, launched when Jeb Bush was governor, then called the state’s treatment system “complex, fragmented, uncoordinated and often ineffective.”

The group found that jails and prisons were Florida’s “largest mental hospitals” after “deinstitutionalization” began — the 20th century movement to shutter state psychiatric facilities and treat people instead through community services.

The commission’s 2001 report also blasted Florida agencies for not sharing patient data with one another and being unable to track whether those with severe mental illnesses like schizophrenia were truly getting needed help.

“A lot of the things that we’re finding now, they found back then,” said Charlotte County Sheriff Bill Prummell, a member of the latest commission who served as the chairperson for about 18 months.

The similarities raise questions about whether his group’s work will also end up on a shelf, collecting dust, as Florida lawmakers continue to wrestle with the same challenges again and again.

“Are they really going to take us seriously?” Prummell asked. “Or are we just going to be another one of these commissions or committees that (make) recommendations and they fall upon deaf ears?”

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A bleak picture

The Florida Council for Community Mental Health urged state lawmakers to launch the 1999 commission, said Robert Constantine, former president of the Tallahassee nonprofit, now known as the Florida Behavioral Health Association.

The goal was to get the Legislature and what is now the Department of Children and Families to focus more on mental health and substance use, said Constantine, who is retired and lives in St. Petersburg. The system, he said, was chronically underfunded.

After hosting public meetings across the state, the group released a 74-page report in 2001 that painted a bleak picture.

Although programs that got money from the Department of Children and Families and services covered by Medicaid were seen as the state’s behavioral health system, people were also being treated in jails, prisons, juvenile justice facilities, schools and other locations.

No single state agency oversaw the entire system, which was fragmented and confusing to navigate. There wasn’t a centralized database to track how residents were cycling through it, according to the report. Agencies failed to share information about who was in their programs.

Florida officials couldn’t evaluate what treatment strategies worked — and whether they were funding useful services — on a systemwide basis.

“No one is measuring overall outcomes,” the 23-member commission said.

People with mental illnesses had also swamped the state’s jails and prisons. They struggled to access early treatment in the community to stop them from spiraling into crisis. They lacked affordable follow-up care, such as help with finding housing, the group said.

The commission urged a slate of reforms, including expanding jail diversion programs like mental health courts to place those with serious ailments into community-based treatment instead of keeping them behind bars.

But the group’s key recommendation was to set up a “coordinating council” in the governor’s office to lead the system and develop a strategy for care.

The council’s aim would have been to improve Florida agencies’ sharing of patient data so state officials could get a full view of the system and assess whether programs were effective. The council was also to review budget requests to check if leaders in Tallahassee were paying attention to behavioral health issues.

But that never happened.

Dropping the ball

David Shern, chairperson of the 1999 group and former dean of the University of South Florida’s Louis de la Parte Florida Mental Health Institute, said he thinks Bush’s office dropped the ball.

The Republican governor, known for his spending cuts, didn’t want to add staff to his office, so the coordinating council was never created, said Shern, who lives east of Riverview in Hillsborough County.

That’s “where the plan really fell apart,” he said.

Instead, lawmakers established a work group in the Department of Children and Families to review how Florida could improve its behavioral health system and submit a report to Bush, among other leaders.

The work group disbanded in 2003. That same year, the Legislature created a not-for-profit corporation to oversee the system, but it was dissolved in 2011, according to state business records. When the Tampa Bay Times recently asked for the work group’s report, Laura Walthall, a spokesperson for the Department of Children and Families, said it couldn’t be found. Bush didn’t respond to emailed questions.

Former state Rep. Sandra Murman, however, said that what happened is just a reality of bureaucracy.

“It’s the same with all commissions,” said Murman, a Tampa Republican who was part of the 1999 group. “The life cycle of any big report that comes out is probably about five years.”

Lawmakers leave Tallahassee because of term limits. Agency heads step down. New officials get elected. Priorities shift.

“They come in with their agenda, and you won’t see social services ever at the top,” she said of legislative leaders.

But some state lawmakers focused on mental illness in the wake of the 2018 mass shooting that left 17 students and staff members dead at Marjory Stoneman Douglas High School in Parkland. Amid mounting public demand for more drastic gun control measures, such as an assault weapons ban, the Republican-controlled Legislature instead approved more limited restrictions, like Florida’s “red flag” law, along with steps unrelated to gun control, allocating about $400 million for mental health and school safety initiatives.

Before the massacre, Parkland shooter Nikolas Cruz received mental health services through several public and private providers, splitting the future gunman’s medical history, according to a 2019 report from the Marjory Stoneman Douglas High School Public Safety Commission.

“No single health professional or entity had the entire ‘story’ regarding Cruz’s mental health and family issues, due, in part, to an absence of communication between providers and a lack of disclosure by the Cruz family,” the report said.

The vast majority of people with a mental illness are not violent, according to the nonprofit National Council for Mental Wellbeing in Washington, D.C. And they are more likely to be victims of violent crime than perpetrators.

In 2020, a grand jury investigating school safety issues related to the shooting called Florida’s mental health care system “a mess.”

“Deficiencies in funding, leadership and services,” the grand jury said, “tend to turn up everywhere like bad pennies.”

The panel said it didn’t have enough time to conduct a full review of the system and urged state lawmakers to set up a commission to do so.

The latest commission, created in 2021, reported that the system remains splintered and suffers from “enormous gaps in treatment.” And there’s still no centralized database on patients.

The group, just like its predecessor over two decades ago, has suggested that Florida create more jail diversion programs and that state agencies share patient data. The commission has pitched new ideas, too, like a pilot in which one agency manages all public behavioral health funding in a geographic area, including state money and local dollars, so providers can focus more on care and less on complicated billing processes.

“This isn’t going away, and if we don’t address it, it’s going to get worse,” Prummell told a House subcommittee last month.

Solutions to Florida’s problems are not headline grabbers, which makes it tough to generate political support, said Holly Bullard, chief strategy and development officer at the Florida Policy Institute, an Orlando nonprofit.

“Building good government, it can get technical,” she said, “and sometimes it’s hard to communicate the importance of it.”

Will anything change?

There’s been some progress in Florida’s mental health care system since 2001, said Jay Reeve, the new chairperson of the latest commission and chief executive officer of the Apalachee Center, a behavioral health provider in Tallahassee.

The system is more responsive to regional issues, partly because of state contracts with seven “managing entities” — nonprofits that oversee safety-net services for the uninsured, he said.

There’s also been an increase in initiatives like mobile response teams, which help people in mental health emergencies, and crisis intervention training for police officers, in which they get trained on de-escalation techniques and psychiatric diagnoses so they know when to get residents into treatment instead of arresting them, Reeve said.

The Department of Children and Families used to spend about $500 million per year on community-based behavioral health services such as outpatient treatment, case management and crisis stabilization units, the 1999 commission reported. Now, its budget for such care is $1.1 billion.

Pockets of innovation exist at the local level, too, like in Palm Beach County, where an initiative called BeWellPBC aims to boost the area’s mental health care workforce, among other things, said Shern, a senior associate in the department of mental health at the Johns Hopkins Bloomberg School of Public Health.

But challenges remain.

Nearly 3 million Florida adults have a mental illness, according to Mental Health America, a national advocacy group just outside of Washington, D.C. That’s about 17% of the state’s population of those 18 and up. An estimated 225,000 youth experienced at least one major depressive episode in the past year, the nonprofit reported in October.

In 2020, Florida ranked last among states for its per capita mental health care funding, the Parkland grand jury said. In 2021, the Miami-Dade County jail system was the largest psychiatric institution in the state, according to the 11th Judicial Circuit. And last year, Mental Health America said Florida ranked 46th in the U.S. for access to care. Only Arizona, Kansas, Georgia, Alabama and Texas were worse off, according to the nonprofit, which based its rankings on access to insurance, treatment and special education, along with the cost and quality of insurance and the number of mental health providers.

“As long as you keep things siloed, accountability is easier to dodge,” said Ann Berner, a member of the 2021 commission and chief executive officer of Southeast Florida Behavioral Health Network, a managing entity.

Political will is needed to enact major reforms, Shern said. So is follow-up on the commission’s work, said Murman, who lives in Tampa and works at Shumaker Advisors Florida, a lobbying firm.

“In this case, it probably is something that has to be revived every five years to really make an impact,” she said.

Rep. Christine Hunschofsky, a Parkland Democrat on the 2021 commission, said there’s bipartisan support to improve the system.

But during the current legislative session, the Times on March 13 could find only one House bill and a matching Senate bill based on the commission’s 35-page interim report: a proposal to study Medicaid expansion for some young adults ages 26 and under. (Republican leaders in Florida have refused to expand the federal-state health care program under the Affordable Care Act, which became law in 2010.)

Hunschofsky said she thinks the Legislature will take more action once the commission releases its final report, which is due by Sept. 1.

Gov. Ron DeSantis’ office referred questions to the Department of Children and Families, where officials didn’t answer them.

Senate President Kathleen Passidomo didn’t respond to a voicemail and interview requests made through a spokesperson. Nor could House Speaker Paul Renner be reached for comment.

After more than 20 years, Shern is frustrated.

“It’s time to move on these issues,” he said. “We’ve spent literally decades thinking about them, talking about them.”

This article was produced in partnership with Kaiser Health News, a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). The Foundation for a Healthy St. Petersburg also provided funding for this story.