After a call for police assistance with a mentally ill man at a Tucson gas station turned deadly, resulting in the deaths of the responding sheriff’s deputy, the man, and a cab driver who stopped to assist, local leaders began work in 2005 on a better way to respond to people in crisis.
But seven months before the crisis center opened its doors, another tragedy involving a suspended community college student unfolded. The 22-year-old in that 2011 incident, later diagnosed with paranoid schizophrenia, opened fire on 19 people in a supermarket parking lot, killing six and critically injuring then-Congresswoman Gabrielle Giffords.
Before Giffords’ shooting, the Arizona mental health system, over time, had undergone a budget cut of $108.4 million between 2009 and 2011, resulting in far reduced services. Texas underwent something similar in 2003 when lawmakers cut the community mental health funding by $100 million due to economic concerns. This affected how many mental health services were readily available to the public in both states.
The 2005 incident that spurred action in Tucson occurred after a man in the midst of a mental health crisis had been dropped off by police at an emergency room and was released within hours. He walked to a nearby convenience store and began interfering with customers. A Pima County deputy was called out, and the man became combative, running into the adjacent highway as he was being handcuffed. The deputy and a cab driver attempting to help the officer followed. All three were killed by oncoming traffic.
In 2009, two years before Tucson’s Crisis Response Center opened, Connections Health Solutions was created and assumed ownership of the Phoenix Urgent Psychiatric Center. In 2014, they assumed management of the Tucson facility and helped turn both into two of the nation’s largest and most studied crisis response centers.
Today, Tucson’s center now treats 12,000 adults and 2,400 youth annually. Services include 24/7 walk-in urgent care, 23-hour observation, short-term inpatient services for adults, and a police drop-off point.
“Now, with every single call that an officer goes on, they know no matter what condition the person might be in, there is a crisis center that will say ‘yes’ to taking them in,” Winsky said. “This is how a culture changes.”
Politically, Texas and Arizona have long leaned conservative and residents in both states have elected Republican presidents for years.
But despite its GOP bona fides, Arizona took the leap in 2013 and joined the majority of states that have since chosen to expand Medicaid coverage to more low-income residents. Texas is one of a handful of states that has refused to expand Medicaid coverage to all low-income adults who could qualify. If Texas did expand Medicaid, it would bring more than $5 billion in new federal dollars to the state and another 1 million Texans would qualify for health insurance coverage.
The impact of that expanded Medicaid coverage in Arizona was certainly noticeable to Margie Balfour, a former Texan who worked in mental health at Parkland Hospital in Dallas, who moved to Arizona to help run the crisis center in Tucson.
“All I saw was these Medicaid-funded programs, and it took me by surprise,” said Balfour, now the chief of quality and clinical innovation for the Arizona-based Connections Health Solutions and an associate professor of psychiatry at the University of Arizona.
In 2015, Arizona began providing services for residents with serious mental illness in counties other than Maricopa County under three regional behavioral health authorities. A year later, the Division of Behavioral Health Services moved from the Arizona Department of Health Services to the Arizona Health Care Cost Containment System, which administers the state’s Medicaid program.
“Most states have a Medicaid department and a separate department for mental health. The Behavioral Health Department gets federal block grants, and others get Medicaid funding, and you hope it trickles down,” she said. “Arizona has combined them, and it all runs through AHCCCS.”
This funding model allows crisis centers to take on anyone, knowing that one of the three revenue streams will cover the cost.
“It’s a pay upfront model,” she said. “You are paying people to be available at 2 in the morning and to be on standby. Then, the accounting on the backend is done to see which stream will be used for the services.”
It also allows for immediate treatment, meaning a person can be dropped off at a crisis center, stabilized, and receive medication within 24 hours.
“We can do groups and peer therapy and detox protocols. Our case managers are on the phone with clinics and hospitals with the goal to get them back into the community,” Balfour said. “After 23 hours, we reassess, and most go back to the community after that time without ever seeing a jail or hospital.”
Texas is on the right path regarding the “no wrong door” model, but Balfour believes it could be done easier and quicker if lawmakers chose Medicaid expansion.
“Ultimately, Texas needs to expand Medicaid,” Balfour said. “Look at the work done in Arizona by Republican governors and legislators. A true fiscal responsibility to the people means it only makes sense to accept Medicaid because if not, you are just leaving money on the table.”