Sometimes, a little bit can go a long way.
Since the 1998-99 fiscal year, Pennsylvania's funding for mental health has decreased from 3.22 percent of the total state budget to approximately 2.4 percent.
While a decrease of less than 1 percent may seem slight, the impact at the local level has been anything but.
When state cuts are coupled with federal and local level spending cuts, the cumulative effects have resulted in a shift to where those with mental illness are ultimately ending up.
For many, where they're ending up is the criminal justice system, and the costs are high.
"We have people who are now going through the criminal justice system who should not be in the criminal justice system," Warren County District Attorney Ross McKeirnan said. "But I can't just cut them loose into the community."
"We closed the state hospitals and we ended up opening state prisons to handle the folks who were in the mental health system," Warren County Adult Probation Director Carl McKee agreed. "The state has a square peg and no square hole."
To understand how this happened, it's important to look at the economics behind the shift.
The state is investing more real dollars in mental health than were being spent a decade and a half ago. However, adjustments for inflation gives a clearer picture.
Cumulative total inflation between 1998 and the end of 2012 was 42.08 percent. This means for every $1 something cost then, it costs $1.48 now.
In the 1998-99 budget, the state mental health services appropriation was $579,339,000. The governor's 2013-14 proposed budget would appropriate $689,380,000. Adjusting for inflation, it would take $823,124,850 to provide funding equal to 1998-99 spending levels. That means while mental health spending as a percentage of budget has only gone down approximately 1 percent, the actual difference in the buying power of that funding has gone down more than 16 percent.
Additionally, since 1997, the number of people served by the state hospital system has declined by 60 percent according to the 2012 annual report on the system.
"With the deinstitutionalization of the state hospital system, there was a lot of money out into the community system," Forest-Warren Human Services Director Mary Kushner said. "When they cut, it's county match for most of it and the (county) commissioners don't fund it because the county doesn't have it. So we lose it. They commit crimes and they end up in the criminal justice system. Law enforcement get cuts, too. You don't want your taxes raised and then they try do things (to cut costs)."
"The jail has become, sort of, state hospital south," McKee said. "We're warehousing."
This isn't a new trend or a cheap one.
According to a 2006 U.S. Department of Justice special report, prior to the financial crisis, in 2005, 45 percent of federal inmates, 56 percent of state inmates and 64 percent of local-level jail inmates had a recognized mental health problem. By comparison, in Pennsylvania, the general population has a recognized mental health problem rate of only 17.7 percent.
In 1999, Pennsylvania appropriated $859,334,000 to fund state correctional institutions. Had spending kept pace with inflation, that figure would have risen to $1,220,941,750. By 2012, the actual spending had risen to $1,629,099,000, more than $400 million more than indicated by adjusting for inflation.
At the state level, the cost per inmate has risen from approximately $11,447 in 1980 to more than $32,000 per inmate, according to a 2011 auditor general's report. Adjusting for inflation alone, the per-inmate cost in 2012 would have been $16,123.70, or, a little over half what the increase actually was.
In inflation-adjusted dollars, mental health funding is down approximately $130 million since 1998, while spending on corrections has increased by more than three times as much. Meanwhile, on a per-inmate basis, costs have essentially doubled. The change is, in part, due to increased spending on mental health services.
Cost increases are being felt at the local level as well.
In 2010, the state shuttered the forensic unit at Warren State Hospital. Those in need of forensic psychiatric evaluation are now sent to Torrance State Hospital, approximately 125 miles away.
"Anyone who comes through the DA's office who needs an exam, you have to ship them down to Torrance," Kushner said. "That's a burden on the community for cost."
"It's very cumbersome to get someone who needs a check up from the neck up and they have to go to Torrance," McKeirnan said. "These people are also very much a burden on our local Warren County Prison. They're not really set up to deal with them."
Steve Smith, deputy warden at the Warren County Jail, said the jail currently has "five or six" inmates at Torrance for evaluation and as many additionally with confirmed mental health diagnoses. Of the total jail population, "probably at least 70 percent," have mental health issues, according to Smith.
"Our numbers have been about $3,400 per month for medications," Smith said. "Recently, they've been more like $4,500."
"Looking at the drug costs there (the jail), they changed the formulary because the county couldn't afford the drugs," Kushner pointed out. "At one point the drugs would be $10,000 per month. You look at the community, they couldn't afford that as taxpayers."
"Nationally, the largest mental health system is the California prison system, unfortunately," Smith said. "You need to protect society, but at what cost? It cuts one end of the budget, but at what cost to the other end?"