Street Asylum

This is the second of two parts on the crisis in health care. Last week's installment was about government's search for solutions.

You can try to befriend Juan, but he knows what you did; he knows how you and everyone else in Seattle signed "the paper" stating that you would agree to help the Seattle police persecute him. The Cuban refugee is somewhat of an iconic figure in town. He stands on the corner of Sixth Avenue and Pine Street day after day and shouts at cars and buses about how the Seattle police are communists and, in fact, how everyone in Seattle is communist. "Seattle police bully-bully," is how he starts his cyclical tirade. He has a sign that explains parts of his message with religious overtones: The Frye Apartments and Seattle police not only are communists, but "devil communists" and Satan.

Juan has been protesting on that corner ever since police evicted him from the federally subsidized Frye Apartments for failing to pay rent a few years ago. Now he sleeps in the Municipal Building shelter at night. He is missing his top teeth, which he claims the police threw in the garbage. When asked why he doesn't get new ones, he pulls an imaginary knife across his throat. The police will follow him and get him when he's put under, you see. He takes breaks in the Nordstrom foyer off Pine, where he sometimes eats lunch. You must be careful, he explains: "People can put something in your food." Why Sixth and Pine? The buildings on at least three of the corners are where people go to sign "the paper" agreeing to give Juan trouble—Nordstrom, Pacific Place, and Old Navy.

Thoughts of persecution are typical of the mentally ill homeless population, says Graydon Andrus, the clinical programs manager at the Downtown Emergency Service Center (DESC). The nature of their illness—distrust of institutions, especially government-funded ones—makes it extremely difficult for them to get help.

The DESC has an outreach program called HOST, whose case managers identify people like Juan who are mentally ill and homeless, build relationships, and encourage them to get help. The outreach workers help with applications to get Medicaid and other benefits, an overwhelming process for a sick person living on the streets. But HOST is one of many mental-health-care programs that are being hit by federal and local budget cuts. HOST is funded with a combination of dollars from ACCESS, a federal project, and Medicaid money through the King County Regional Support Network. In the past two years, Andrus says, HOST has lost $300,000 in funding. Its budget is now $800,000, compared to $1.1 million in 2000. In the face of these cuts, they try to focus efforts on people who are the most ill. "The service gap keeps growing," says Andrus.

It is common knowledge that there is a crisis in health care at just about every level of the system, but it is particularly acute for the vulnerable population at the bottom of the social and economic ladder. One of the hardest-hit services in Seattle is mental-health care for those with no means. According to Dr. Richard Kovar of Country Doctor Community Clinic on Capitol Hill, there has been a sharp upswing in the uninsured and homeless in King County and, "worst of all, a sharp increase in the mentally ill."

The numbers of low-income or homeless mentally ill people have increased, doctors say, and many can no longer get treatment in mental-health clinics. The major reason is that they need to be enrolled in a certain subset of Medicaid. If not, they are not covered at most mental-health clinics. Prospective clients must not only have so-called Medicaid Title XIX, but Medicaid CNP (Categorically Needy Person) or GAX (General Assistance Expedited). Social workers say it can take up to 12 to 14 months to establish the right kind of Medicaid. Physicians determine who is eligible: patients with a chronic mental disability that makes them ineligible for work. Among other factors, they look for extreme disorganization, bad hygiene, an inability to take care of basic needs such as shelter and food, and limited social skills.

Kovar says the increase in the mentally ill population on the streets is due also to the push to deinstitutionalize care, an influx of people from out of state, and the rising cost of medicine.

Many mental-health clinics used to have reserve funding to take on non-Medicaid clients, but budget cuts in the past couple of years have severely diminished most agencies' ability to provide mental-health care for those who don't have Medicaid coverage. In 1995, 30 percent of the Downtown Emergency Service Center's budget was reserved for non-Medicaid clients. Today, DESC Executive Director Bill Hobson says, less than 2 percent of the budget is designated for non-Medicaid clients. Frank Jose, the executive director of Washington Advocates for the Mentally Ill, says that since 2000, the amount of time social workers can spend with people who are not on Medicaid in the mental-health system in King County has declined by 84 percent, and the actual number of people served on average per month has dropped by 36 percent. He cited figures from the Mental Health, Chemical Abuse & Dependency Services Division of King County. "Fewer people are being served, and even those people are getting less service," says Jose.