Crisis Care Centers Levy Aims to Fill Gaps in King County's Behavioral Health System

Crisis Care Centers Levy Fact Sheet

Building Behavioral Health | Yes on King County Proposition 1

“King County Council votes to put tax funding crisis centers on April ballot” by Michelle Baruchman from The Seattle Times

“King County measure would put $1.25 bn over a decade toward behavioral health crises” by Guy Oron from Real Change News

“To Help Kids Like Mine, Pass the King County Crisis Care Centers Levy” by Brittany Miles for PubliCola

“King County proposes moving people from Seattle, Kent jails to Des Moines site” by David Gutman and Sydney Brownstone from The Seattle Times

“ACLU sues King County over Seattle jail conditions” by Sydney Brownstone from The Seattle Times

[00:00:00] Crystal Fincher: Welcome to Hacks & Wonks. I'm Crystal Fincher, and I'm a political consultant and your host. On this show, we talk with policy wonks and political hacks to gather insight into local politics and policy in Washington state through the lens of those doing the work with behind-the-scenes perspectives on what's happening, why it's happening, and what you can do about it. Be sure to subscribe to the podcast to get the full versions of our Friday almost-live shows and our midweek show delivered to your podcast feed. If you like us, the most helpful thing you can do is leave a review wherever you listen to Hacks & Wonks. Full transcripts and resources referenced in the show are always available at officialhacksandwonks.com and in our episode notes.

So today I'm thrilled to welcome King County Executive Dow Constantine to talk about a very important levy that's going to be on all of our ballots this April - the Crisis Care Centers Levy. Welcome, Executive Constantine.

[00:01:08] Executive Dow Constantine: Thanks, Crystal, for having me.

[00:01:09] Crystal Fincher: Absolutely. So what is this levy? What does this do?

[00:01:13] Executive Dow Constantine: So there's a need - an unmet need in our community. We all see it - in our families and with our friends, in the streets, in the justice system. There is no walk-in treatment available for people - either mental health or addiction crisis - collectively behavioral health crisis. Further, we're losing the long-term residential treatment beds that were built, that were set up when the large state hospitals began to shut down in the '70s and '80s. And then we're really losing a lot of workers. Now I know this is a common story across the whole workforce right now, but behavioral health work has long been low-paid and it's always high stress. It demands a lot of you emotionally. And so people are not able to hang in there, especially on the wages that are paid.

So we have a behavioral health levy - the Crisis Care Centers Levy - and it does three things. First, it builds five walk-in clinics - crisis care centers for those in behavioral health crisis - one of them exclusively for youth. The rest would be distributed geographically around the county so that everyone could have access. Second, it begins to rebuild the stock of those residential treatment beds where you can stay indefinitely as you get treatment and begin to chart a path forward in life. And third, it supports the workforce by increasing wages and bringing apprenticeships and training and other supports that people need to dedicate themselves to this important work. Because as we say over and over, it takes people to treat people - buildings and programs are not enough. You have to have the people - educated, dedicated people - to do this work.

[00:02:49] Crystal Fincher: Absolutely, and that's so important. And talking about the need - you summed it up - this is critical for our overall public safety and public health response here. I know I have been in the situation - so many people have been in the situation - where we see someone who's clearly struggling with a behavioral health issue, but it doesn't seem like police are the appropriate response. They're not breaking the law, but they're clearly in crisis. Maybe they're scaring people around them. Maybe they're going through an episode and scared themselves. In a situation like that, how would it work with this new system - instead of someone being diverted to a jail, or calling the police, or using that kind of response?

[00:03:33] Executive Dow Constantine: Right. Right now, people may end up getting arrested and taken for booking - if in their crisis, they act out in a way that is illegal. They can end up being taken to the hospital emergency room - taking themselves, taking others - not the right place for people in behavioral health crisis, but many people end up essentially staying there and boarding - I call it - at the emergency room for long periods of time. They can end up often in the streets, and we've seen this time and again. When people are in crisis, they're no longer able to do the work that's required to stay housed and they can suddenly end up sleeping outside, which of course then just tends to exacerbate the problems that they're struggling with.

We're putting together a system where whether you decide that you need to go in and get help, or perhaps you're picked up for a petty crime and the police determine that what's really going on here is you seem to have a behavioral health challenge, or your family is desperate and needs a place to find you help because they're afraid you're gonna hurt yourself or others - they have a place to take you. And it's a place where for the first day, the first 23 hours, you can begin to get re-centered. They have experts there who can help you get past the immediate crisis, and then move into the other wing of this crisis care facility - where for the next two weeks, you can get diagnosed, understand what kind of treatment's going to be available, begin to plan your path forward. And that's - it's a no wrong front door approach. Anywhere you enter the system, somebody can bring you to this place and you can begin to get the help you need.

I will add one more thing, since you mentioned the criminal legal system. In Maricopa County, Arizona, they have a clinic like this - this is something that local governments are taking up in spots around the country because of the failure of the federal and state governments to step up. In Maricopa County last year, the police dropped off 28,000 people at the crisis care clinic - people who otherwise might have gone to jail or might have ended up out in the streets. And that is a really significant number. And we expect those kinds of numbers here as well.

[00:05:37] Crystal Fincher: Those are huge numbers. And I think most people at this point are looking around in our communities and saying, "Yeah, I can see where there's that kind of need." Will these centers be able to handle that kind of capacity? As you've mentioned, this is a result of longstanding decisions and policies that have gotten us here - neglecting systems or not investing appropriately in systems over decades, really. So we have this large backlog of need, pent up need, and an increasing ongoing need. Will this be appropriate to handle all of the need that exists?

[00:06:14] Executive Dow Constantine: I think it will be appropriate, but probably still insufficient - at least at the beginning. Remember, there's a lot of - as you say - pent up need. There's a lot of unmet need out there. Yes, in the streets. Yes, in the criminal legal system. Yes, in the hospitals. But also in homes across the county, in communities - rich and poor. Folks are struggling everywhere, and a lot of people find that they really have nowhere to turn. Even people of means, even people with insurance, even people with connections don't have a place for their loved one to go. So at the outset, it will not be enough - this is as much as we believe we can do as a county. I will say that two weeks ago, we were able to break ground on a new center in Kirkland that's modeled - it's on the same model. That one was funded by the state with some county money - ahead of this levy. And it's my hope that that will be able to - rather than being one of the five - that will be able to be a sixth clinic. But we're cobbling this together as best we're able - recognizing again that behavioral health challenges do not stop at city or county or state borders, and this should really be a national effort to meet a clear need of the people.

[00:07:22] Crystal Fincher: Yeah, I saw the news of that facility - the groundbreaking on that facility in Kirkland. It looks like all of the surrounding cities are very excited about it and eager to get it going because the need is so great in the area.

[00:07:34] Executive Dow Constantine: Can I just mention something about that? 'Cause we often hear about communities or cities opposing the siting of human service facilities in their jurisdiction. And we're having battles over homeless housing, and battles over all sorts of things. But this seems to be a service that - across the political spectrum - is recognized as needed, as necessary, because everyone has this experience in their personal life. And I have to tell you that as I've been calling around raising support to get this levy passed, everyone I have talked to eventually gets to a personal story. My child, my sibling, my parent, my best friend had this thing happen to them - this crisis - and we didn't know what to do, we didn't know where to turn. Or we finally randomly found a lifeline and were able to get help for them, but that should be available for everyone. So the cities, like Kirkland and those northern cities, are really interested in having this facility sited locally.

[00:08:27] Crystal Fincher: Yeah, and I think - as you talked about in other situations - there have been varying responses to cities being excited or not excited about the location of services or hotels for the homeless. And developing that response and then having sometimes not positive feedback about where things are sited and located. But it seems like, with the five separate centers, that this is something that is gonna be geographically distributed and able to meet the needs of cities around this county. Was that part of the calculation as you were putting this together that went into looking at the variety of centers?

[00:09:05] Executive Dow Constantine: Very much - the need is everywhere. The upsurge in mental health challenges coming out of the COVID crisis is everywhere - it's across the county - fentanyl, and before that the prescription opioid and heroin challenges everywhere. And although it's visible in the homeless population, it's visible in the people who come into contact with the criminal legal system, you cannot find a community where there aren't stories of struggle and suffering - and yes, tragedy - anywhere in this county or in this country. And so this is something that - yeah, again, cities are excited about and we were excited to make sure that this was not just centered in Seattle, but it was going to be able to serve everyone across the county - 2.3 million people.

[00:09:48] Crystal Fincher: Now will this reduce strain? You talked about before - right now these people are winding up on the streets too often. They're also being caught up in the criminal legal system, which - with a behavioral health issue - doesn't really have the tools to address the root causes of behavioral health issues. Emergency rooms, and we hear all throughout our healthcare systems - they're being overburdened and people waiting longer and longer just for general or specialized appointments. Do you anticipate this easing the burden on some of those other systems?

[00:10:20] Executive Dow Constantine: Yes, it has to. And this clearly is a logical and sort of utilitarian response to these overburdening challenges of the hospital system, the justice system, the emergency medical telephone system, and the challenges we're seeing on the streets. But it's not only about that, because there are an awful lot of people who have a behavioral health challenge who don't fall into any of those categories - who've not come into contact with any of those systems, but they also have nowhere to turn. And there is this - again, quiet suffering happening in families and communities everywhere. I will tell you that this is the obvious missing element in a lot of the other work, frustrating work, that we're trying to do. How do we reduce the jail population? A huge percentage of people in jail have either an addiction or a mental health challenge, or very often both. How do we reduce homelessness? A lot of folks who are on the streets don't have a diagnosable challenge, but a very large percentage do. And to be able to get them the help they need so that they can get centered, get clear, and begin to exercise agency over their lives again is absolutely critical to solving this. The hospitals are constantly asking us for help because they are really overburdened. They cannot provide the services they're supposed to provide because so many people, because of a lack of options, are showing up at their door.

There's one crisis care center that is not open access in King County right now - it's run by the Downtown Emergency Service Center. You can be brought there by the police, or you can be brought there from a hospital - checked out of a hospital and checked in there. You cannot self-refer, your family can't bring you, your human services counselor can't bring you. And it doesn't have anywhere near the capacity that either the hospitals or the police would need to be able to deal with the challenge. I talked with an emergency medical worker - a firefighter - last week, and he was saying that just a huge percentage of the calls they receive are ultimately people who are simply in crisis. They're decompensating, as they say in the psychiatric world. They're having either withdrawal or overdose challenge. And these folks need somewhere to take people - they can't just continue to either bring them to the hospital or show up and then leave without providing them help.

[00:12:42] Crystal Fincher: So I think those are excellent points. I actually think you're right on target that it will reduce reliance on hospital system - on so many of our systems - that are overburdened, that we're trying to manage and deal with. We did hear recent news about a lawsuit from the ACLU for King County Jails, a new potential SCORE - Des Moines facility - contract for some spillover capacity with the Seattle Jail, King County Jails there. Do you anticipate this helping to reduce the need for those facilities and the inmates that we're sending to those facilities?

[00:13:19] Executive Dow Constantine: Yeah, yes. First of all, the highest priority is to relieve the suffering - to provide the help regardless of where you're interacting with the systems. But we have this enormous challenge with being required to accept people being booked into jail - ordered into jail by the courts, booked into jail by the cops from different jurisdictions - and we are overwhelmed. We don't have the personnel to be able to do what we agreed to 20 years ago under the Hammer agreement. Now we've been working with the ACLU - we believe we're in compliance with the agreement in the sense that we're doing everything we can to hire and accommodate people. But that has forced us to go out and try to rent more space - and the personnel that comes with it - to move people around in order to be able to comply with their demands.

The fact is that we have about a hundred people in the jail on any given day who are supposed to be in state custody because they've been ordered over for evaluation and restoration of their competency to stand trial. But the state doesn't have the capacity to take them - so they, instead of being out of our jail within a week, as is required by law - some people have been there for 7, 8, 9, 10 months and they're not getting better while they're there, they're not getting the services to restore their competency to stand trial, and they're causing our jail to be overcrowded. And it is just unacceptable. It's also costing us $10 million or more per year to deal with that state failure.

These are all results of the underinvestment in the behavioral health system. And also, if you want to broaden the aperture, underinvestment in the upstream measures that will cause people not to come into contact with the criminal legal system in the first place - including the work we're doing - Best Starts for Kids, diversion programs and other. It is - this is probably the single most obvious glaring void in the system - the lack of crisis care and long-term treatment capacity. And if we do this, I think we're going to be a long way down the road towards solving the problem with the jail system.

[00:15:19] Crystal Fincher: Absolutely. Now you say - rightly - that you have to compensate and make up for the lack of capacity elsewhere, that is costing King County money. But with public health being such a core responsibility of the county, what went into making this a levy as opposed to funding it out of the budget?

[00:15:38] Executive Dow Constantine: Yeah, there's just no money. This would raise $1.25 billion over six years - that dwarfs anything we can do in the tiny sliver of the general fund that is available for discretionary spending. Most of the general fund - three quarters of it - is devoted to criminal legal system work mandated by the State of Washington. So we're left with about a quarter of our discretionary money to use for the elections process, the assessor's office, all the public health work that we do, all of the diversion to move people away from the criminal legal system, sexual assault and domestic violence victims' programs - all of the things that we, collectively as a community, think are important to do instead of using the hammer of the criminal legal system. And yet those are the things that are on the chopping block if we don't have enough funding in the general fund - because they are not required by state law.

[00:16:29] Crystal Fincher: How do you respond to people who say, "Okay, we're required to do some things by state law, but not everything. Maybe we opened up too many jail facilities, and maybe we're jailing too many people. Is there something that we can do with our sizable public safety budget to make some room?"

[00:16:47] Executive Dow Constantine: Yes - first off, we're not in charge of that - the courts order us to hold people and that is our job. The executive doesn't get to by fiat decide that some people leave the jail - the exception being when we had to maintain the jail population at a certain level because of the COVID emergency that I declared. But absent that emergency and the need to prevent overcrowding to prevent the spread of COVID in the jail, I'm outside of my authority to send people home. What we need to do is create these alternatives - starting with making sure that people are getting behavioral health treatment instead of booking at the jail - but also diversion programs, sending people into a setting where they can actually deal with their underlying challenges, and perhaps compensate their victims rather than going through an empty process that doesn't change them or the outcome for the person they victimized. And if we have enough of that capacity, we can begin to get the cops and the courts and the prosecutors and everyone else to start reducing the demand on the jail system.

I've said many times and I say it again - we have to close the downtown Seattle jail. It was opened in the 1980s. It was obsolete in terms of the model on which it was built the day it opened. It's very obsolete now and it is in the wrong place. You've got this jail - hulking jail - on one of the most valuable real estate opportunities in the entire Northwest. There could be hundreds of units of housing for people with varying incomes on that site. And instead there's this jail that adds nothing to the urban fabric and is built on the wrong model to start with - we've got to do better. And building this kind of capacity that we're talking about today is an essential, indispensable element of doing that.

[00:18:28] Crystal Fincher: I see. And so I want to talk a little bit more about - you said this does three things - creating the five new regional crisis care centers, preserving the residential treatment beds that are necessary, and growing the behavioral health workforce pipeline, which is crucial and critical. We can build buildings, but if we can't staff them and don't have the appropriate people to provide the services, it's all for naught. So how does this go about increasing the workforce and preparing the workforce?

[00:18:59] Executive Dow Constantine: So the idea is - first - that all of these human service agencies that receive government funding to provide behavioral health services are very strapped. They get reimbursed based on very unrealistic rates from the state and federal government - rates that often don't reflect the higher cost of living in Seattle and King County. So we will add to that funding to help raise up the floor for people and essentially change the standard for what the industry pays. This is the same thing we're having to do in childcare, for example, and elder care. All of these caring professions have been historically underpaid, historically disproportionately peopled by women and people of color. And they've been really not given the compensation that they need or deserve. And it is a matter of changing expectations. Changing expectations also means raising more money, which is what we're talking about doing here.

It's not just the compensation. It is also the path into this. You shouldn't have to go deeply into debt to be able to enter this profession. You should have some certainty about - once you commit yourself to this, having a job that you can work in. You should be able to progress in the profession if you choose to do that. And so we want to provide apprenticeship programs - we've already begun one with Service Employees International Union 1199 - they represent a lot of these workers. They will have continuing education investment. And then in the implementation plan for this, we'll be looking at the specific conditions, talking with workers about - What is it you really need? Do you need housing subsidy? Is that the thing that's most important? Do you need to be near transportation? What - is it about insurance? What are the things that could cause you to be able to take up this work and be able to do it sustainably?

[00:20:38] Crystal Fincher: And I guess follow-up question is that - that is all absolutely necessary. And these centers, in my opinion, certainly seem like they will help and help to fill this gap that so obviously exists. I have seen people question - okay, we get these centers and someone can get there and stabilize overnight. They can even potentially get a couple weeks of services, but some people are dealing with some significant challenge they're gonna take a while to work through. And so there needs to be some kind of handoff if we're gonna continue care and people are gonna get better. How does that process work, and does that capacity exist? Does this help address that capacity too?

[00:21:17] Executive Dow Constantine: So some people who leave a center will be going home to their family. Some people who leave a center may need to go to just simply affordable housing - housing that has artificially been made affordable. Some people may need to go to long-term residential treatment. And I mentioned that - that's the second leg of this three-legged stool here. Those are the facilities that replaced the big hospitals as they began to close. And although Western State still exists here, it's not what it once was - and there used to be three state mental health hospitals. There were never enough of these community-based facilities built. Most of them are now 40 or more years old and they've never had reinvestment in the infrastructure. And so the little nonprofits that are running them - that are getting by day-to-day on inadequate compensation from the federal and state governments - aren't able to put the new roof on, aren't able to replace the wiring or the plumbing, and they're locking the doors and walking away. So the county, with help from the state, has been scurrying around trying to prop up this house of cards over the last few years to keep as many beds as possible. Still, we've lost a third of our capacity just since 2018 - half of our capacity over the last couple of decades. So this begins - this stops the outflow and then it starts to rebuild the capacity. And the immediate commitment here is to rebuild to the 2018 level, which was about one third, so it'd essentially be adding 50% to the base that we have now.

[00:22:38] Crystal Fincher: Yeah, we gotta stop digging if we're ever gonna climb out of this hole. And 2018 levels are a good start - certainly we saw a lot exacerbated throughout the pandemic and more cracks exposed that were already there and just made worse over that time. But this seems like a good start. Can you talk to me about the timing of this? When would these centers be built and coming online? When will these services be available for the community?

[00:23:03] Executive Dow Constantine: Yeah, so as I say, we advanced funding to get the Kirkland center started even before the levy is presented to voters or passes. Assuming it passes, my understanding is that we would be able to begin collecting this funding on January 1st of next year. We are in a very bad budget situation. The State Legislature has failed to act on the 1% lid on property taxes for the 20th year in a row. And with 8% inflation and a 1% lid, you can imagine that things are pretty dire. But we're gonna be looking for ways to jumpstart this even before the tax receipts start coming in. I am not committed to only building new - if we find a building that will work and that's cheaper and faster, we will go that direction. And that is true for the crisis centers, it's true for the residential treatment facilities. We want to be sensible, we want to act boldly and quickly. And I think still, as with the homeless hotels, one of the major impediments is going to be the ability to hire - that has just been a tremendous challenge in everything we do over the course of the last three years or so. And so we gotta get started on that with Service Employees International 1199 immediately.

[00:24:09] Crystal Fincher: Makes sense. So this looks like it will cost the average King County homeowner about $10 a month, based on the assessment there. As they're considering this and thinking about their various obligations and commitments and bills, what do you say to them as they're pondering this decision - when they get their ballot - to just reinforce why this is worth it?

[00:24:31] Executive Dow Constantine: First off, let's all acknowledge that Washington State has about the worst state tax system in the country. And I once again call upon the Legislature to fix it so that we are able to pay for what is needed with everyone contributing as they are able. Now, as - among the taxes that exist, the property tax is perhaps slightly more progressive than the others, like the sales tax. A person who owns an $800,000 house, which is the median home in King County, would pay about $10 a month. For that homeowner, I would ask - Have you ever had anyone in your life who's experienced a behavioral health challenge, an addiction or mental health challenge? Or in your community, are you seeing the results of the failure to provide service on the streets - in petty crime, et cetera? I think you can make a very clear, rational, unemotional argument that it just makes sense to invest this small amount of money to deal with what is obviously a huge societal problem. Because of that, I've actually taken on the responsibility of co-chairing a National Commission on Mental Health and Wellbeing on behalf of the National Association of Counties - met with the surgeon general and the president a few weeks ago. We're going to be advocating for a renewal of federal commitment to this challenge. And we have a national crisis of mental health and addiction and we just cannot afford to neglect it anymore.

[00:25:55] Crystal Fincher: Absolutely. And with that, we will leave it there. And thank you so much for sharing all of the details about the Crisis Care Centers Levy that will be on our ballots in April - we'll be receiving our ballots here coming up pretty soon, so we're all getting prepared for it. Make sure we share the word just because - this is not when people are used to voting all the time - we really need to make sure that we are all turning out and spreading the word that this is a necessary vote and that these crisis care centers are helpful. Thank you so much, Executive Constantine.

[00:26:27] Executive Dow Constantine: Thank you.

[00:26:27] Crystal Fincher: Thank you for listening to Hacks & Wonks, which is co-produced by Shannon Cheng and Bryce Cannatelli. You can follow Hacks & Wonks on Twitter @HacksWonks. You can catch Hacks & Wonks on iTunes, Spotify, or wherever you get your podcasts - just type "Hacks and Wonks" into the search bar. Be sure to subscribe to the podcast to get the full versions of our Friday almost-live shows and our midweek show delivered to your podcast feed. If you like us, leave a review wherever you listen. You can also get a full transcript of this episode and links to the resources referenced in the show at officialhacksandwonks.com and in the episode notes.

Thanks for tuning in - talk to you next time.