As the country faces an economic crisis that has not been seen since the Great Depression, our state is in the midst of determining ways to manage the budget. Idaho Medicaid is facing a deficit somewhere around $92 million, yet that could change as new data is received. Proposals have been made to eliminate entire Medicaid programs, including community-based services for adults with developmental or mental health disabilities.

Currently, less than 8 percent of all health spending is attributed to behavioral health spending. While this may seem like a good place to make cuts, we must take into account the domino effect of doing so. People who live with conditions affecting their behavioral health are at a much higher risk of physical illness and disability than others. Medicaid recipients with behavioral health disorders are less likely to seek preventive care for physical concerns that may arise and are 30-60 percent more likely to suffer from preventable conditions such as pulmonary disorders, hypertension, diabetes and heart disease.

A report by the United Hospital Fund found that "Mental health beneficiaries spending on physical health services was 32 percent higher than comparable spending for non-mental health beneficiaries." A study by the New York Community Trust found that 60 percent of all Medicaid spending in New York is for 10 percent of the beneficiaries and that most did not get adequate health care until their physical conditions became critical.

These findings indicate that eliminating vital community-based programs to our most vulnerable citizens will only serve to increase Medicaid costs. While our Legislature has asked for suggestions as to how to cut costs, some continue to be unwilling or uninterested in taking these suggestions to heart. Prior to the statewide Medicaid Matters rallies held on Feb. 19 more than 15,000 signatures had been obtained on petitions in support of increased beer, wine and tobacco taxes as a way of increasing revenue to save programs from elimination.

What other options are there? Plenty have been suggested by provider networks and advocates. It's clear our behavioral health care system needs restructuring, the question is, how to go about this without completely dismantling the current system? There is clear consensus that early intervention with this population would reduce health care spending by averting health crises. Those in the field know that those at highest risk must be identified BEFORE they are in crisis. Not only is aggressive outreach necessary to identify and engage these individuals. When individuals are not identified until they arrive at emergency rooms, as frequently happens, there needs to be an avenue to link them to community-based services/supports immediately.

Our current system includes services such as Psychosocial Rehabilitation (PSR), a community-based skill building program designed to teach persons with severe and persistent mental illness coping skills and strategies to avoid higher cost services. PSR provides only a part of the overall continuum of care. Persons living with mental illness across the state have shared stories with legislators of how PSR services have helped them remain in their homes, achieve educational and vocational goals, and become active members of their communities.

PSR is a program that instills HOPE and promotes RECOVERY for more than 6,000 people in Idaho. Many of these Idaho citizens are now living in fear that the supports that have helped them manage the symptoms of their mental illness will be lost with nothing there to replace them. Many of these adults have been living with mental illness most of their lives. They find themselves alienated and stigmatized due to the devastating effects of mental illness, and a lack of education and support for their families and the community at large.

PSR is voluntary, and those electing to receive this service have the ability to determine what they want, when they want it and how they want it, thus empowering them to guide their journey of recovery based on what it means to them, not to you, me or anyone else. Without this service, these individuals face having their right to choose taken away.

Idaho Medicaid put into rule in 2009 that all qualified PSR providers, not already licensed in Idaho as a social worker or counselor, obtain the Certified Psychiatric Rehabilitation Practitioner (CPRP) credential. This was a bold and controversial move. While the PSR program was simultaneously facing cuts and future funding uncertain, there was much concern over the additional required credential and the associated cost.

The United States Psychiatric Rehabilitation Association (USPRA) administers the CPRP program. In 1975, the U.S. Psychiatric Rehabilitation Association and its members developed and defined the practice of psychosocial/psychiatric rehabilitation, establishing these services as integral to community-based treatment and leading the recovery movement. Established PSR providers in Idaho are feverishly working to get the training and work experience to apply for and take the exam before the January 1, 2012 deadline. Many have already acquired the CPRP credential and scores more are preparing to sit for the exam. The national pass rate of the CPRP exam is around 70 percent, yet the Idaho pass rate is above 80 percent. That says something about the quality of the workforce and the integrity of the program. Still, we can all agree improvements can be made.

Eliminating community-based services, such as PSR that serve some of Idaho's most vulnerable citizens is not the answer to the budget crisis. If implemented, it won't take long to experience the devastation of the cost shift to other Medicaid and non-Medicaid programs. We will effectively rewind to the days when people with mental illness were institutionalized. If community-based services are eliminated, we will all miss out on the opportunity to experience and learn from these individuals who have so much wisdom and talent to share. We will be throwing them away as if they mean nothing.

Jodi Smith, CPRP, LPC, is chair of the Idaho Psychiatric Rehabilitation Association (state chapter of USPRA) and a Coeur d'Alene resident.