Recent state cuts to adult mental health services are chipping away at a safety net more than a decade in the making, putting the public at risk and leaving clients without help, providers and several lawmakers say.

But state officials counter that the cuts have been "informed," and added there is no evidence that the public is at greater risk.

The warning from advocates comes as mental health service providers are laying off employees and cutting back on services amid the economic crisis, and as they're highlighting the case of Tittleman Fauatea as a chilling wake-up call.

Fauatea, 25, who has a history of mental illness, has been indicted in the stabbing death late last month of Wai'anae High School teacher Asa Yamashita.

At a joint hearing of the Senate Health and Human Services committees Friday to discuss mental health services, providers said the stabbing is a stark example of what can happen when someone with a mental illness falls through the cracks. When there are more cracks to fall through, they said, the possibility of something terrible happening increases — and that should concern everyone.

"It's really, really scary," said Alex Santiago, executive director of PHOCUSED, a consortium of nonprofits. "And I'm kind of at the point of, are we being pennywise and pound-foolish. Is it not the mission of the Department of Health to prevent the occurrence of these horrific episodes?"

Mental health advocates also say there are other ripple effects of a weakened safety net. If more mentally ill people aren't getting the services they need, advocates said, that could mean more stress on hospital emergency rooms, prisons and homeless shelters. It could also mean more problems for families.

But state Department of Health officials say the situation is not so dire: Though they acknowledge that the reductions of services are painful, they also point out that total spending on mental health services has ballooned over the past several years — from $85.8 million in fiscal year 2003 to more than $174 million five years later — and that the number of people receiving services has never been higher.

State officials could not provide the total expenditures so far this year, but said the Adult Mental Health Division had spent about $106 million from June 30 to Dec. 31, 2008. The division faces a shortfall of $10 million to $15 million this fiscal year — even after making a host of cuts during the year — including a round of scalebacks intended to save about $25 million (which it is expected to do).

Legislative budget drafts for the coming fiscal year show more cuts to expenditures for the state Adult Mental Health Division, though the governor's biennium request for the division proposes funding for AMHD remain steady.

Michelle Hill, AMHD acting chief, said the reductions this year are not "limiting to a degree that would cause harm." She added, during the hearing, "I would like to say the cuts we have made were made in an informed way. We are trying to make sure our consumers' needs are met within resources we have."

FINANCIAL BIND

Providers say that although they understand the state's financial bind, they believe mental health services should be a top priority given its potential public safety impact. They also say paying for mental health services in the community is cheaper than paying for hospital stays or for funding homeless services.

Providers pointed out the average cost for services to a community-based mental health client is about $745 a month. Keeping that person in a hospital after a psychotic episode can cost $745 a day -or more, state officials said.

State Sen. David Ige, D-16th (Pearl City, 'Aiea), chairman of the Senate Health Committee, said he thinks the mental health cuts are concerning.

"The changes are so significant and being implemented so fast. The concern is that it's too much, too quickly and the clients are the ones not being served," he said.

Ige noted that the state used to provide the vast bulk of mental health services. Now, private mental health organizations provide about half of all state-funded mental services in the Islands, while the state covers the rest.

State Sen. Clarence Nishihara, D-18th (Waipahu, Crestview, Pearl City), called on the governor to restore funding to AMHD — or at least stop the cuts.

"I think at some level, the governor herself has to step in and say these services are important enough to say don't cut any more," he said.

State Sen. Suzanne Chun Oakland, D-13th (Kalihi, Nu'uanu), chairwoman of the Senate Human Service Committee, also said AMHD should be looking at the economic stimulus package for other possible streams of funding to shore up its deficit.

"All of you see the deterioration of the (mental health) system going on before our eyes," she said. "There is a real possibility there will not be enough money and some of these providers will have to close their doors."

MAINLAND CONCERN

Cuts to mental health services appear to also have gotten the attention of experts on the Mainland. A National Alliance on Mental Illness state-by-state report issued last week gave Hawai'i a C for its mental health care system — the same grade it has received since 2006. But the report said the state is at a crossroads, and could be at risk of losing years' worth of positive gains.

"Due to budget shortfalls, the state has frozen all hirings despite many unfilled positions. Lack of access to public-sector mental health professionals, especially psychiatrists and nurses, has reached crisis proportions in many parts of the Islands," the report said, adding that Hawai'i's mental health safety net is vastly improved from its "dismal days in the 1980s and early 1990s," but that the mental health system is "at risk of sliding backward" because of cuts.

About 16,000 people in the Islands get mental health services through organizations that have contracts with the state. That's more than triple the number who were receiving services in fiscal year 2003, figures show.

Much of that growth was thanks to public outcries in the 1990s over the condition of the mental health system. After a 1991 lawsuit was filed by the U.S. Justice Department's civil rights branch over conditions at the Hawai'i State Hospital, the state entered into a consent decree that kicked off 15 years of federal oversight over its delivery of mental health services and treatment.

Problems were still glaring as recently as 2001, when a scathing court-ordered report slammed management of the state hospital and Judge Kevin Chang was chosen as a "special master" to oversee the hospital's improvement.

Federal oversight ended in 2006.

Providers say the improvements made during the consent decree were not just aimed at bettering conditions at the state hospital, but at ensuring that those who were able to live outside an institution could. The emphasis on keeping people in communities bolstered programs to provide case management, specialized housing, crisis intervention, counseling and other services.

All that, advocates say, built a safety net that quickly became a model for other states. The safety net, they say, is designed to get care to the underserved and make sure that those under care are caught so that if they deteriorate they can receive hospitalization, more services or more medication monitoring.

Now, advocates say, that safety net is in danger.

"It cost a lot of people (time and energy) being involved to develop the mental health system that we have in this state," said Tina McLaughlin, chief executive officer of CARE Hawaii, which provides a variety of adult mental health services, including crisis intervention and case management.

"The problem is that it was dismantled without thought."

LESS HELP FOR PEOPLE

Marya Grambs, Mental Health America of Hawai'i executive director, said cuts to services will decrease the amount of help getting to people. But it doesn't mean fewer people are in need of help. She added the Fauatea case illustrates why the mental health system is vital to preserve, even during tough times.

Fauatea, the suspect in Yamashita's stabbing, has a long history of mental illness, according to court documents, and had been hospitalized repeatedly and diagnosed as a schizophrenic. Yamashita's killing Feb. 27 came three months after Fauatea was taken from the state hospital to serve a six-day sentence.

At the Senate hearing Friday, Sen. Will Espero, D-20th ('Ewa Beach, Waipahu), questioned Hill about the death and asked whether it has "given the administration some reason to appropriate more funds back into this program."

He added, "People are dying at the hands of this population. We're talking about life-and-death situations now, which can affect every one of us."

Hill would not talk about specifics of the case, but said the division monitors crises involving its clients. She could not provide data on those so-called "sentinel events," which can include suicide attempts and crimes.

But she said a reduction in services does not necessarily mean people are going to become more violent or "any less capable of living in the community."

The hearing followed a string of bad news for mental health service providers. Last week, providers were told that AMHD had run out of money for a slew of contracted services — ranging from case management to crisis outreach — and in many cases won't be able to pay organizations for their work until the new fiscal year starts in July.

Some service providers say the four-month lag in payments could put them out of business or force them to lay off more workers and cut programs. It could also leave thousands of clients without some critical services, providers said.

Also last week, Kahi Mohala Behavior Health in 'Ewa Beach announced it would lay off about 30 people after AMHD cut in half to 16 the number of beds it contracts at the nonprofit psychiatric hospital for overflow patients from the Hawai'i State Hospital. The state said the cost-saving measure is possible because there is more space at the state hospital than in the past.

There are about 160 patients at the hospital right now.

That's down from 183 in fiscal year 2007.

AMHD started its cuts in January, when it capped reimbursable case management hours per client at 3.5 hours a month (from three hours a day), reduced programs and cut services to those with private insurance. The case management cap can be increased on a case-by-case basis, officials said.