Because of antipsychotic medications, Alex’s sleepy, drawling voice lingers on consonants. But his mind is lucid when he talks about his struggles with mental illnessbouts of depression and alcohol-fueled mania that derailed his history studies at New York’s prestigious Vassar College more than a decade ago.

“I went from being a very successful businessman to just painting houses,” Alex says. (INDY Week is not using his last name to protect his privacy.)

The 37-year-old Chapel Hill native has been diagnosed with depression, bipolar disorder and, recently, schizoaffective disordercharacterized by extreme moods, paranoia and delusions. He’s heard voices that command, accuse and insult him. Other times, the voices tell him to kill himself.

Alex, who regularly undergoes therapy at UNC’s Schizophrenia Treatment and Evaluation Program in Carrboro, is one of four people living at a group home on Chapel Hill’s Homestead Road. Here, people with mental illness or disabilities receive daily assistance with living. For Alex, that includes taking medications and staying off booze. For others, it may include help bathing, eating or dressing.

Group homes, Alex says, are integral to caring for people who need supervision and assistance to cope with their illness or disability.

These homes are just one small cog in North Carolina’s sprawling, messy systema system catapulted to the forefront in recent years by a two-year federal investigation into the state’s institutionalization practices.

Mental health reform will be among the first major issues faced by Republican leadership and the newly inaugurated Gov. Pat McCrory when state leaders reconvene Jan. 30. The immediate task for lawmakers is to find the cashand the political willto assist thousands of residents with mental illness who otherwise will be expelled from group homes and adult-care facilities.

Typically limited to six residents, group homes are smaller than adult-care facilities, which were once reserved for the elderly or people with disabilities. But in recent decades, these facilities have been flooded by people with mental illness, who have nowhere else to go.

“North Carolina has got such a mess on its hands,” says Jenny Gadd, the UNC-Chapel Hill master’s student who manages Alex’s group home. “It may be the final hour, and hopefully a solution will be found.”

Last year, lawmakers excluded group homes from $39.7 million set aside to stabilize foundering adult-care homes as they lose Medicaid fundingmoney eliminated by penny-pinching state and federal leaders.

In the final weeks of her term, former Gov. Bev Perdue allotted $1 million in stopgap funding through the end of January in order to keep some 1,400 group-home residents in their homes. Now the General Assembly must decide quickly whether to extend the stopgap funds into February or open up last year’s $39.7 million pot to group homes, says Rep. Verla Insko, D-Orange.

“It’s a perfect storm,” Insko says. “And it’s going to cost money.”

The expense of mental health reform cannot be avoided. In 2012, state health officials negotiated a settlement with the federal government, obligating the state, if not its lawmakers, to an estimated $287 million investment in job training, treatment and housing for people with mental illnesses over eight years. State statute bars legislators from imposing funding requirements on future lawmakers, meaning an independent assessor will have to determine if North Carolina complies with the settlement deal. If the state reneges, it risks a lawsuit from the U.S. Department of Justice.

The DOJ investigation, prompted by a Disability Rights North Carolina complaint, found North Carolina institutionalizes too many of its residents with mental illness, rather than promoting community programs that encourage independence. Disability advocates and the feds said the state violated the Americans with Disabilities Act by forcing individuals to enter institutions to access mental health services.

Insko estimates 6,000 North Carolinians will need a place to live as a result of last year’s DOJ settlement. She says North Carolina must find funds by July 1, the start of the new fiscal year. Otherwise, the state will pay more in jail or hospital costs as the lost Medicaid funds force people out of group homes and adult-care facilities.

Gadd says Medicaid funds make up roughly 30 percent, or about $60,000 annually, of the budget in her two group homes, amounting to three staff workers or a year’s worth of food.

She adds that, without group homes, thousands will lose the intensive daily services they need. Other available services aren’t able to handle the additional caseload.

“It doesn’t matter how great your case manager is or your therapist is,” Gadd says. “If you’re living under a bridge, chances are you aren’t going to get better.”

The DOJ settlement comes as decade-long reforms shift mental health treatment from local governments to private, regional agencies called managed care organizations. MCOs are tasked with efficiently meting out public funds for mental health services. The MCO approach worries critics who speculate that the dwindling state funding for mental healthslashed last year by $20 million, or about 8 percentwill force agencies to focus more on saving money than providing top-flight care.

Lawmakers must assess the MCOs to determine if their budget-spurred parsimony is depriving people of necessary services, according to Corye Dunn, public policy director for Disability Rights North Carolina.

“I’ve seen the pendulum when [MCOs] start,” Dunn says. “They may start out wanting to be the ones who do the best job of providing care, and then budgets get tight, lots of red ink, and they swing back the other way.”

Dunn adds that lawmakers must brainstorm comprehensive solutions to the state’s mental health problems. “Take the good work happening to implement the DOJ settlement and use it,” she says. “Make an array of mental health services that make sense and keep people out of hospitals.”

Alex agrees. Fix the system, he says, because he needs the system.

“I would probably kill myself if I lived alone,” he says. “Or drink all the time, to be honest with you.”

This article appeared in print with the headline “Mind over money.”