Susan Gerard has spent the past 20 years molding and monitoring the state’s health care system. Her expertise has led to positions as the chair of the House and Senate health committees, director of the Arizona Department of Health Services and, most recently, as a member of the board of directors for the Maricopa County Special Health District.
Possibly the largest project she has taken on in her career began in 2005, when Gerard set out to reshape the state’s behavioral health care system. Gerard has since left DHS, but the problems in behavioral health have remained.
Gerard did launch many reform measures as director, including efforts in Maricopa County to divorce the oversight of the system from actual care. But, Gerard said, one barrier always got in the way of real reform: the 1981 class-action lawsuit Arnold v. Sarn.
The lawsuit guaranteed every citizen in Maricopa County the right to mental health care and simultaneously ruined the kind of care they could receive, Gerard said.
You are with the county now, right?
Yes, I ran for office again. I was asked to run for the Maricopa County Special Health District. Years ago, the county wanted to get rid of the county hospital and all the clinics so they started a hospital district. There are five board members, and we are all elected.
You don’t sound very happy that you won.
Well, when you haven’t run for like six or eight years and you have to do it again, it is a lot of work. In fact, it is even more work when it is a little campaign because you don’t have other people helping you. When I used to run for the Legislature, I had a treasurer and a campaign manager. This time, I did it all myself. It was a lot of hard work.
Is there much awareness of the position in the community?
No, no. Every time you talk to people you had to explain what it was. The only people who really care are the health care people, like the doctors and nurses. It was hard to get much interest. Plus, it is so far down the ballot. I won because I have more name ID than the other person. That is probably about it.
What exactly is it that you oversee?
Maricopa County is the only county that has a county hospital. Plus, there are about 11 community health care clinics around the county and an inpatient mental health facility. We are the same as, say, the board at Banner Hospital or any other hospital. It is just that we have to be elected.
As an individual political entity, have you been spared from the effects of the legislative cuts?
We have been affected big time. And it is such a moving target. The big thing that is going to affect us is the AHCCCS (Arizona Health Care Cost Containment System) rates to hospitals. First they froze the rates, then they reduced them by 5 percent, and now they are looking at another 5 percent. The other thing that affects us is the cuts to KidsCare and KidsCare Parents. We obviously serve an awful lot of kids and parents, and this will mean more people will turn up in emergency rooms or our clinics.
The real big question mark, though, is with Desert Vista (the county’s mental health care facility). That is where the court-ordered treatment is. If a judge sends someone to you, you have to take the case, whether there is a payer source or not. You can’t say no to a judge.
They have already cut funds for the non-Title 19 members who are not seriously mentally ill. The budget that was just passed makes another cut to the non-Title 19 seriously mentally ill. That could have a big impact. If you bring someone in for an evaluation and you find out they need treatment, there is no money for the treatment. You can’t just let someone out. It could be a big, big expense to us and a public-safety problem.
Does the district have any sources of income that could be used to offset the costs?
We have some taxing authority. It maxes out at about $53 million a year. This year we are at about $49 million, so I think we are going to go up to the $53 million for the coming years. But that is as much as we can do.
We do also have the ability to bond for capital to build a hospital or something else, but that won’t do anything to fund operations.
If the governor approves the latest legislative proposal, would you have to close clinics?
Potentially. Our clinics are running in the red. We understand that we are a charity hospital, and there are going to be some places that make money and some that don’t. But it is not like when it was a part of the county. Back then, if they ran out of money, they just went to the county and said they were in the red. There is no sugar daddy anymore to get the money. We are going to have to make some tough decisions.
And you know, about 20 to 25 percent of our patients could not pay. That has gone up to 40 percent because of the economy. You can’t operate with that kind of loss.
Can you cost-shift onto privately insured individuals like private hospitals do?
It would be an option, but we don’t get a lot of commercial insurance. We get other AHCCCS health plans. But, again, they’re making cuts there too. We just don’t have that many people to cost-shift onto. We are going to have to make our facilities attractive enough so we can get more privately insured people or private insurance contracts, which could offset providing charity care. But who wants to go to a county hospital that is 40 years old and has four people to a room?
Why not get rid of the county hospital entirely and invest the money in the private hospitals?
All the other hospitals actually support the county hospital because they know they don’t have the capacity to cover the additional ER and trauma patients. If you think it is bad waiting in the ER at St. Joe’s for eight hours, just wait until it is 12 hours because we don’t have the county hospital. And we are the only burn unit in the Southwest.
We also have the only neo-natal clinic in the state. We are not serving only Maricopa County.
I do potentially see that that is something we will have to look at, though, if the funding gets worse.
Let’s look back to your time with the health department. When you first started, you said your goal was to transform what the behavioral health care system looks like. What changes were made?
The major change to the system between now and then is the new contract that does not allow the current RHBA (Regional Behavioral Health Authority) in Maricopa County to provide direct services. A lot of the providers and advocates put the RHBA in a conflict of interest if they were providing services as well as paying for the services. There were concerns that it allowed them to make more money. Magellan is in the process of turning over all the clinics to the providers now.
Do you think this is a shift in the right direction?
I think it will be once it gets done. In the meantime, it is going to be difficult.
Have there been any major changes outside of Maricopa County?
No. The behavioral health systems operate entirely different outside of Maricopa County because of Arnold v. Sarn.
Has the lawsuit been beneficial for the county?
I think it hurts it terribly. I think the lawsuit no longer serves any beneficial purpose to the mentally ill of the state.
Well for starters, you just have to look at how old the statute is. You have people judging the system on criteria that no longer exists in mental health. When this lawsuit started, mental health care was about caretaking. It was very paternalistic.
Now, the whole focus is on recovery. Our goal is to make people well enough that they can go to school and have a job and do meaningful activities. The focus has totally changed, but the system can’t because of the lawsuit.
Providers of care, the professionals, are also a big barrier to making this happen. They went to school and they learned the paternalistic thing, and they don’t want to change the way they do things. We are going to have to re-train all the staff to be focused on recovery.
Everyone is just clinging to whatever it was in the past.
Did you think the lawsuit was a bad idea at the time it was filed and you were in the Legislature?
It wasn’t really a subject I was really watching. We all kind of had our areas of expertise. When Sue Grace was there, mental health was her baby. Then, all of a sudden, I had to learn mental health after Sue Grace left. I really hadn’t been that into it.
The big thing, though, was that people saw it as a way to get more money into the system. Back then there was no question there was not enough money in the system. It was a good thing back then.
Was that the common opinion at the Legislature at the time?
It was a totally different world at the Legislature back then. I mean, you still had so many people who didn’t understand the Medicaid system. I guess nothing has really changed now that I think about it.
But I actually remember talking to legislators back then about Medicaid who would tell me “We don’t have Medicaid. We have AHCCCS.”
Well, that is Medicaid. That is how bad it was. There were very, very few people who were aware of how health care operated in the state.
Is there any way to modernize the lawsuit?
Yeah, there are ways to amend the lawsuit and change it, but that requires a judge to be open to it. It has become quite apparent during the time I was there that the judge was not interested in making any changes. She always sided with the plaintiff’s attorneys and the court monitor. The lawsuit just needs to end.
How do we do that?
We are never, ever, ever, ever going to meet the exit criteria set by the court right now. It is never going to happen, ever. If you used the tool the court monitor uses to judge the system’s success in whichever state is considered to have the best mental health care system in the country, they would fail.
I think the only way that would give us any chance to get out of the lawsuit is to repeal the existing law. I threw myself on a sword year after year against this. But what I think needs to happen now is that we repeal the existing law and put in that same piece of legislation what you want the system to look like. It would be a long road to go that way, but I see that as the only way.
How would you construct the new system?
If we were to adequately fund the department, I don’t think we would need the RBHAs. But that is a huge ‘if.’ I think we could just have providers and skip the clinics, which suck up a lot of money.