A Survey of County Boards' Views of Funding for Mental Retardation Versus Funding for Mental Illness

State and local funding for services to persons with mental illness and to persons with mental retardation varies. In a study of resource allocation by states, Braddock (1) found that state size, wealth, federal aid, civil rights activity, and consumer advocacy accounted for 50 percent of the variance in spending on services for mental retardation but that these factors did not account for any appreciable variance in spending on community mental health services. In examining the impact of local advocacy on county spending, Reilly (2) found that local area boards possessed a large amount of control in developing policies, budgets, and program priorities for services to persons with mental illness and persons with developmental disabilities.

In Iowa, a rural state with 99 counties, services for persons with mental retardation and mental illness are primarily funded by the county. Although services for persons with mental retardation are mandated by the state, services for persons with mental illness are not, which results in a widely divergent spending pattern between community mental health and mental retardation services in Iowa. This pattern was described by Braddock (1), who found that Iowa ranked 18th in state spending for mental retardation, at $1.60 per $1,000 of annual personal income, but ranked last (51st) in state spending for mental health services, at $.06 per $1,000.

In the study reported here, members of county boards of supervisors in Iowa were interviewed about their attitudes toward services for persons with mental illness and mental retardation. Their beliefs about services for persons with mental retardation and with mental illness were compared. It was hoped that findings would provide insight into the complicated relationship between advocacy, state policy, and local funding that might be useful to persons in other states with county-based systems of funding.

Methods

Opinions held by members of county boards of supervisors about services for persons with mental illness and mental retardation were assessed in a telephone survey. The survey instrument was developed by the author with input from the Iowa State Association of Counties, the Alliance for the Mentally Ill, the Iowa Department of Human Services, and the Iowa Coalition, a consumer group. It was felt by those groups to have acceptable face validity.

The chairpersons of county boards in all Iowa counties were asked to participate in a telephone interview lasting approximately 15 minutes. The chairpersons agreed to be interviewed themselves or identified a board member or other county official to be interviewed. Interviews were conducted between September and November 1995.

Results

Interviews were completed with representatives of 98 of the 99 Iowa counties. One county declined to participate because of concern about potential liability. Ninety-seven of the 98 respondents were board members, and one was the county auditor. Sixty-seven were board chairpersons.

Nearly all respondents (80 percent) reported that they believed that mental illness is treatable, whereas mental retardation is not, and that mentally ill persons can become well with appropriate treatment or services. Respondents were asked to identify the population of persons with mental illness on whom county funding should be focused. Forty-nine percent indicated that the priority group should be persons who are not severely ill or who are ill for brief periods of time. Only 16 percent said that the priority group should be persons with serious and chronic mental illness.

Respondents were more likely to express the belief that residential care is more appropriate for persons with mental retardation than for persons with mental illness (46 percent versus 1 percent), although 70 percent of respondents felt that the focus of services for persons in both groups should be to allow them to live in their own homes or apartments. However, when asked if the best treatment would be for persons to live in a residential facility if it was affordable, 47 percent indicated that such a facility would be the treatment of choice for those with mental retardation but not for those with mental illness. Twenty-four percent felt that a residential facility was equally appropriate for both groups, and 28 percent felt it was not the best treatment for either group.

Respondents were asked whether services should focus on prevention of disturbance and of danger to the community. A much larger proportion of respondents felt that such a focus was more appropriate for mentally ill persons than for persons with mental retardation (41 percent versus 4 percent). However, 33 percent of respondents felt that this focus was equally important for both groups.

Respondents were asked their opinion about the most appropriate treatment focus for both groups. For mental illness, an overwhelming majority (78 percent) felt that the best services were those that reduced the symptoms of mental illness. Opinions about the best treatment for persons with mental retardation were more variable. One-third of respondents cited more training and education; 29 percent, support to live independently; 23 percent, residential care; 11 percent, assistance in finding and securing gainful employment; and 1 percent, minimization of the risk of danger or disturbance to the community.

When asked about redistribution of county funding for mental retardation and mental illness, 47 percent felt that the current distribution was appropriate. Respondents were asked to identify three service areas in which more money should be spent if additional money that could be spent on any service area were available to the county. Most often identified as the first priority was public safety (22 percent); the second most-cited area was roads and transportation (20 percent). Mental illness and mental retardation were ranked as one of the top three priorities by 47 percent and 49 percent of respondents. However, when asked if financing for services for persons with mental illness should be a responsibility of county government, 73 percent of respondents said that it should not, 14 percent of respondents said that it should, and 11 percent were undecided.

Discussion and conclusions

The survey results suggest that counties are generally more willing to fund residential, supportive, and vocational services for persons with mental retardation than for persons with mental illness. This greater willingness is consistent with the finding that most counties do not regard persons with serious and chronic mental illness as the first priority for funding mental health services.

It is not clear why the state mandates services for one vulnerable group and not others. However, it appears that the more important issue at the county level is not whether services for either group should be funded, but whether funding should be the responsibility of county government. Previous studies of state (1) and local (2) funding suggest that variation in funding is associated with variability in advocacy. Thus greater advocacy for mental illness may be one strategy that can be used to increase funding for mental illness. However, this strategy may have the undesirable consequence of enlarging the discrepancy between counties in service funding and availability.

Acknowledgment

Financial support for this study was provided by the Iowa Department of Human Services.

Dr. Rohland is assistant professor of psychiatry in the department of psychiatry at the University of Iowa College of Medicine, Psychiatry Research-MEB, Room 1-400, Iowa City, Iowa 52242.