Wake County is holding steady on its commitment to helping people with behavioral health problems, but a growing population and shortfalls in other funding sources means the need keeps growing.

At a four-hour work session Monday, county commissioners and officials including Regina Petteway, director of Wake County Human Services, and District Attorney Lorrin Freeman asked questions about the work that’s getting done and the gaps that need addressing. Wake County’s budget for the new fiscal year includes about $27 million for mental health care, roughly the same as last year.

On hand to address their sometimes sharp questions were the leaders of Alliance Behavioral Health, the managed care organization that oversees services in Wake, Durham, Johnston, and Cumberland counties.

Denise Foreman, assistant to the county manager, gave an overview of how the county moved from relying on Dorothea Dix Hospital and county human services for mental health care, through the closing of Dix and the state mandate to transfer county-led care to publicly funded local management entities and managed care organizations, referred to as LME-MCOs.

Developments that make management difficult include the uncertain future of the Affordable Care Act. There have also been deep cuts in state funding and the coming statewide transformation to managed care of Medicaid, the federally funded program for low-income people and those with disabilities.

All of this means Wake County has to make continuing adjustments to ensure its growing numbers of citizens with behavioral health problems—including mental illness and substance abuse problems—receive adequate care for in hospitals, crisis centers, homeless shelters, and jails.

“Where we are today isn’t where we’ll be in the future,” Foreman said. “We don’t know what that’s going to look like in the future.”

Wake County’s 2017–18 contract with Alliance commits $18.5 million for crisis services at WakeBrook and Holly Hill, $4 million for outpatient and foster care, $1.3 for criminal justice-related services, $1.4 million for community support (including schools), $1 million for housing support and case management, and $385,000 in recovery care for people with substance abuse problems.

Commissioner John Burns and others cited Governor Pat McCrory’s decision not to expand Medicaid to hundreds of thousands more North Carolinians as key to the funding shortfalls that Wake and other counties are experiencing. Federal cuts to Medicaid in the form of block-grant funding may be in the future as President Trump pushes for tax cuts, infrastructure development, and other budget provisions that could drain social services.

Alliance CEO Rob Robinson noted that the organization gets paid on a per-person basis only to treat people on Medicaid but has to find savings in those payments in order to treat about 271,000 people who are uninsured or underinsured.

The LME-MCOs were designed to develop innovative, cost-saving treatment methods, as well as meet current needs, and are allowed to keep a fund balance for that purposes.

“You have one hundred and six million dollars in reserve,” said Commissioner Erv Portman.

“That’s Medicaid savings,” Robinson said. “We use that to support the underinsured and uninsured.”

Alliance officials described a series of treatment methods with a common goal of addressing behavioral health problems before people reach a state where they wind up in hospital emergency departments. These therapies, based on evidence that they work, include licensed independent practitioners offering outpatient care, parent-child interactive sessions, and paying professionals more to use proven methods.

As they addressed questions such as the delayed opening of a new crisis center, commissioners hit on a common theme: If the care paid for by federal, state, and county sources isn’t enough, how will Wake County know how much would be enough?

“It’s hard to say that we’re doing a good job if we don’t have an idea of what the need is,” Commissioner Jessica Holmes said.

Added Commissioner James West, “What I seem to hear here is that we need an accurate picture of the current reality. What I’m also hearing is that there’s a gap between what there is and what ought to be.”

The expansion of Medicaid would help Wake meet more of the needs of its residents, several participants noted. Alliance has said it would cost more than $180 million annually to care for the county’s uninsured and underinsured people at the level allowed under Medicaid. But there’s a bigger picture, even beyond Wake’s population boom, Foreman said.

“The stronger our system is here, the more people come here,” she said. “You come to Wake County, you come to Mecklenburg, you can come to Durham, because you can’t get these services across the state.”

Alliance receives about $495 million annually to provide care in its four-county area, with about three-quarters coming from Medicaid. Robinson said the organization develops ways to help people in response to specific needs, not by assessing an entire universe of issues.

“When we put something together, we kind of respond to what’s the problem we’re trying to solve and start that way, not the big global question of what the need is,” he said. “We don’t look at the bigger demand across the county because it’s unrealistic to think we are even going to be able to touch that.”