This is how Lucy Wilmer wants to remember Bill: the tousled brown hair, the wry grin, the sense that, before he even finishes this joke, he has two more waiting.
"People tell me the world's worse off because Bill is gone," Wilmer says. "It sounds like a platitude, but it isn't. He was just super funny and outgoing, one of the friendliest, quirkiest, most interesting human beings."
Bill, her 38-year-old boyfriend, killed himself in 2008 in Beaufort County, four years after he was diagnosed with bipolar disorder. Like many with that condition, Bill suffered crippling mood swings.
"When he was in a manic state, he didn't feel the need to take any medicine," Wilmer says. "He was going to start 17 businesses. But when the depression started, it was very difficult to get him to do anything, to take his medicine, to go to his doctor's appointments."
It was a struggle until the day he killed himself. But earlier treatment may have made the difference, says Wilmer, now the chairwoman of the consumer council for the state chapter of the National Alliance on Mental Illness, an advisory panel of volunteers who have experienced the ramifications of mental illness. And North Carolina's reformed public mental health system, which is a little more than a decade old, can offer the kind of creative outreach needed for people like Bill, many of whom begin to show symptoms in their 20s.
That's why the architects of the state's push for regional, public mental health authorities say North Carolina's experiment, which has come under legislative attack, must be preserved. The system, designed to simplify, economize and improve the state's confusing network of providers, relies on nine regional groups called local management entities, or LMEs, "one-stop shops" charged with dispensing Medicaid dollars for mental health treatment.
State House and Senate budget writers remain deadlocked in negotiations; one of the outstanding disputes is over Medicaid spending on mental health. Senate leaders want to cut LME funding by roughly $185 million for each year of the biennial budget, calling on the LMEs to fill that hole with reserve cash—money intended for reinvestment in outreach programs targeted toward earlier diagnosis and treatment, says Wilmer.
"If [Bill] had a diagnosis much, much earlier in his life, his life would have been changed to an extraordinary extent," she says. "It may well have prevented his suicide."
Wilmer, like many mental health advocates, says the Senate's proposed funding cuts signal that Republican lawmakers are abandoning the LME system in favor of a privatized system, similar to ones in New Mexico and Arizona, a change that could ultimately be a death blow for a reform process still in its formative years.
"I don't think the LMEs could survive without that money," says Rep. Verla Insko, D-Orange, one of the Legislature's longtime supporters of mental health reform.
The LMEs are key to the state's shaky mental health efforts, advocates say. The organizations answer to a board of directors appointed by state and local elected officials, but they are meant to operate much like a business in streamlining North Carolina's much-harangued system of public mental health care.
It's a system so despised that the U.S. Department of Justice investigated the state following a 2010 complaint that North Carolina institutionalized too many of its mentally ill residents. A 2012 settlement committed North Carolina to spending $287 million over eight years to shuttle institutionalized people into more integrated, community-based treatment options like those favored by LMEs.
Insko is also vice chairwoman of the House's appropriations committee for Health and Human Services. Her committee proposed allocating about $712 million for LMEs this year, a slight bump from the $705 million budgeted last year.
The Senate, however, wants to cut LME spending to about $519 million, forcing the organizations to drain their reserves.
Those reserves are meant to supply flexible, locally tailored services or innovative new practices, Insko says. They're also meant to be a short-term bridge for paying providers when state Medicaid reimbursements come too late, a frequent occurrence in recent budget-strapped years.
The co-chairmen of the chamber's appropriations committee for Health and Human Services—Sens. Louis Pate, Ralph Hise and Tommy Tucker—did not respond to the INDY's interview requests for this story. But when lawmakers rolled out funding cuts for community treatment options in 2013, Pate, a Mount Olive Republican, told the INDY that runaway Medicaid expenses were strangling the state budget. (Medicaid ran a $130 million surplus last year.)
But that's confusing the issue, says Jack Register, executive director of the state NAMI. Much of the consternation over Medicaid costs does not stem from mental health spending, which has been largely stable in recent years, he says. Register credits that fact to LME outreach programs intended to head off expensive trips to the emergency room.
Both Register and Insko believe GOP lawmakers intend to usher in a privatized system, under which treatment decisions would be made by multi-state corporations based on profits.
"You can't make money on Medicaid unless you cut reimbursement rates for providers or cut services," Insko says. "And you can't expect providers to stay in business if they can't get paid."
This article appeared in print with the headline "Of madness and money"