On the Edge

Judi Maikoff worked for 25 years as a registered nurse, until she could no longer nurse herself through a bipolar disorder. She spent several chaotic years after that, careening from paralyzing depressions to giddy, exhausting highs.

Then Maikoff found an anti-psychotic drug called Abilify.

“I was able to live my life normally,” she says, “get things done and just live in a happy fashion.”

Those days of normalcy ended in July, when budget cuts enacted by Arizona Legislature meant that Judi and thousands like her would no longer receive assistance for brand-name drugs such as Abilify.

The drug costs $565 a month. Maikoff only gets around $900 monthly from Social Security disability. Without help, she can’t buy Abilify on her own.

So she’s been forced to switch to a generic drug called risperidone. The change has not been a good one. “I’ve been having a reaction to it, physical reactions, and mental, too,” she says. “I started to feel that I just couldn’t move forward in life, that I didn’t want to do anything.”

Then there were the thoughts of suicide.

Unfortunately, Maikoff isn’t alone. Nearly 4,000 people in Southern Arizona—including about 3,500 in Pima County—who relied on state assistance to pay for brand-name psychiatric medications and other mental-health services are now largely on their own. As a result, advocates for the mentally ill fear more of them will end up in expensive emergency rooms—and on the fringes of society.

That impact was noted by Dr. Laura Nelson last spring, during an interview on the Phoenix PBS affiliate KAET Channel 8. Nelson is deputy director of the state Division of Behavioral Health Services. She described reductions exceeding 50 percent “in the state general-fund dollars that went to support individuals who don’t qualify for Medicaid, including adults with serious mental illness.”

Among other things, it means most folks will be pushed from brand-name drugs to generics. And that could spell disaster.

“There are quite a few newer atypical, anti-psychotic medications that are used to treat things like schizophrenia and bipolar disorder that aren’t available in a generic form yet,” Nelson said. “Now, there are still some other alternative medications that can treat some of those same symptoms, but everybody responds to medications differently, so it’s nice to have a variety of options.”

In this part of the state, overall management of the mental-health system falls to the Community Partnership of Southern Arizona. Neal Cash is the CEO, and he says the cuts “have a very real impact on us, our providers, and the folks we serve. It’s been a rough few months.”

According to Cash, $40 million to $50 million was slashed from mental-health services statewide. About 20 percent of it came from the five-county area—Graham, Greenlee, Santa Cruz, Cochise and Pima—served by his organization.

Since people affected by the cuts don’t qualify for Medicaid under Arizona’s Health Care Cost Containment System, there’s really no place for them to go. And it’s not just about medications. Up until July 1, says Cash, folks in his system were receiving services that paralleled Medicaid, “everything from inpatient services and residential (treatment) to case management and therapy—the kinds of things that people need to recover.”

Not all of this budget-pinching can be blamed on the economy. Instead, Cash points to endless tax cuts that have incrementally starved the system. “The result is that there’s been insufficient funding to pay for that kind of benefits package,” he says. “Clearly we have seen insufficient revenue to cover the things that I think are important to very many people in this state. Whether we’re talking about mental-health services or education, there are a variety of things we find ourselves struggling with, and a lot of it has to do with the lack of adequate revenues.”

According to statistics compiled by Arizona Budget Coalition, a group that urges alternatives to tax cuts, Arizona has passed tax-reduction legislation nearly every year since 1989. “Considering inflation and population growth,” says a coalition report from January, “revenue in the current fiscal year is nearly $2.6 billion less than it would have been had the long series of tax cuts not taken place.”

But according to Paul Boyer, a spokesman for Arizona House Republicans, state revenues have actually increased over the past few years, by percentages that exceed population growth. However, the result has not been a balanced budget, he says, so reductions must come from somewhere. “We’ve cut the structural imbalance, but it’s still over $1 billion. And until we actually get our revenues in line with our expenditures, we’re going to continue to have budget problems.”

But to H. Clarke Romans, balancing budgets on the backs of people like Maikoff is misguided. Romans heads Southern Arizona’s branch of the National Alliance on Mental Illness, and he considers people such as Maikoff to be victims of a legislative bait-and-switch.

Roman notes that the mentally ill were pushed right to the edge of the budgetary precipice—but not quite over it. “We’re talking about people with a serious mental illness who, by the way, are protected by the Americans With Disabilities Act,” he says. “Cynically, I believe they were not entirely dis-enrolled (from state mental-health services) to avoid violation of that law. But they lost their case-management services, supportive housing, transportation, support groups and every other service—except that they could still get a prescription from a doctor for a non-brand-name medication.”

Since then, situations he long dreaded have begun taking shape. “We’ve been feeling the impact, but now we’re feeling it even more,” he says. “I’ve talked to at least three people in the last 72 hours who were on a brand-name medication. Because these people were in the public mental-health system, the doctors had tried every other (prescription) alternative before finally trying that brand-name. A lot of the people who are most dramatically impacted are people who didn’t do well on the other meds, but have done well on these brand-name ones.”

People like Judi Maikoff, who’s been forced off the very drug that offered her a decent life. Now she’s stuck with pills that only make matters worse. “I don’t want to get into my car or drive to certain places,” she says. “It’s the difference of being off the Abilify, which was working, and being on the risperidone, which isn’t working.”

These days, Maikoff sometimes holes up in her place and just cries. It is no way to live.

This article appears in Jul 29 – Aug 4, 2010.