Author: Will Humble

SB1813 Hearing Monday in the House Health Committee

Arizona’s behavioral health system includes an unusual rule that most people have never heard about: only 55 residents of Maricopa County can be admitted to the civil side of the Arizona State Hospital at any one time.

The limit dates back to 1995 and came out of the Arnold v. Sarn litigation that reshaped Arizona’s behavioral health system through the 1995 Stipulation Agreement. At the time, the goal was to reduce reliance on institutional care and move the system toward community-based services.

The 55-bed treatment cap isn’t written in Arizona statute. It exists only because of stipulation agreements stemming from the Arnold v. Sarn case that were later incorporated into the 2014 settlement that finally closed the litigation.

Today, however, the cap has become a major bottleneck in Arizona’s behavioral health system and no longer serves a useful purpose.

It’s important to understand what the cap does and does not apply to.

The limit doesn’t apply to patients sent to the Arizona State Hospital through the criminal courts (the forensic side of the hospital). It applies only to civil patients—people with severe mental illness who meet Arizona’s legal standard for court-ordered treatment because they are a danger to themselves, a danger to others, persistently or acutely disabled, and require the type of care that only a psychiatric hospital can provide.

How the Civil Unit Admission Process Works

Typically, a person experiencing a severe mental health crisis is evaluated in a hospital emergency department or crisis facility. If clinicians believe the person meets Arizona’s legal standard for involuntary treatment, the county attorney files a civil commitment petition.

A judge can then order treatment after hearing the evidence—even if the patient doesn’t want the help.

At that point, the system first tries to provide care in the least restrictive setting, usually a community behavioral health facility funded through AHCCCS or while the person lives with family or a behavioral health group home.

Only when those options can’t meet the person’s needs (and when the patient needs the intensive psychiatric services that only a state hospital can provide) does the system pursue admission to the Arizona State Hospital.

That’s where a bottleneck develops.

Because of the 55-bed cap created by the 1995 Arnold v. Sarn Stipulation Agreement and carried forward in the 2014 Settlement Agreement, Maricopa County residents end up waiting for admission even after a court decides they need the level of care provided at ASH. Actually – most of them can’t get in at all and get stuck in places that can’t meet their needs.

Again… nothing in state law requires the 55-person cap. Yet admission can still be blocked simply because the patient lives in Maricopa County.

Why the Cap Creates Systemwide Problems

The consequences ripple across the entire behavioral health system.

Patients can become stuck in emergency departments, crisis units, or community facilities that are not designed for long-term, high-acuity psychiatric care.

That delays treatment for people who are often in the most severe phase of their illness and forces them to receive care in settings that are not best for what they need.

Removing the cap would also allow ASH to re-commission unused space in the Ironwood and maybe even Palo Verde buildings once staff are hired and trained, creating more treatment capacity…  potentially adding more than twenty badly needed treatment slots.

A Partial Solution

SB1813 (which will be heard in the House Health Committee on Monday) addresses the source of the bottleneck.

Why lawmakers may lift the 55-bed cap for Maricopa County residents at the Arizona State Hospital

If SB1813 passes, the 55-bed cap would be eliminated directly in state law. No agreement between the original parties is needed to remove the current 55 treatment capacity cap. Why? Because the Legislature has the authority to make that change when there is a compelling community need and when the fix is narrowly tailored.

Once SB1813 is enacted, ADHS & AHCCCS could return to court with an amendment to the Settlement Agreement consistent with the new state law. Courts routinely approve such changes when circumstances have evolved… especially when statutes have changed.

A Personal Note

When the 2014 settlement agreement was finalized, I was Director of the Arizona Department of Health Services and signed the agreement on behalf of the state.

At the time, I disagreed with the plaintiffs’ insistence on keeping the 55-bed cap for Maricopa County residents, but I signed the settlement anyway.

The broader agreement set up objective performance measures and finally resolved a lawsuit that had lasted more than three decades.

In that context, the compromise made sense.

Today, however, the cap has become an unnecessary bottleneck in the civil commitment system and is increasingly unfair to Maricopa County residents.

Policies that no longer serve their purpose should be revisited—and this is one of them.

The Bottom Line

• Arizona’s behavioral health system should admit patients to the Arizona State Hospital based on clinical need and medical judgment, not what county they live in.
• SB1813 moves us toward that goal by ending an outdated policy that is a system bottleneck & barrier to care.
• The 55-bed cap may have made sense decades ago in the context of a specific lawsuit and a different behavioral health system. Today, it’s simply getting in the way of the system working better.
• The Arnold v. Sarn Settlement Agreement wouldn’t be at risk if SB1813 passes because courts routinely approve settlement agreement changes when circumstances change… especially when the legislature amends state law.
• Even if SB1813 passes & ASH increases capacity by staffing up the vacant Ironwood floors, there will still be grossly inadequate high-end treatment capacity in Arizona – but at least things would be marginally better.

______________________________________

Our message to the House Health Committee:

Hi…

I’m writing to urge you to support SB1813 when it comes before your health committee next week.

SB1813 addresses a long-standing bottleneck in Arizona’s behavioral health system: the 55-bed cap for Maricopa County residents admitted to the civil units of the Arizona State Hospital. This limit is not in statute. It stems from a decades-old provision in the Arnold v. Sarn settlement agreement and no longer reflects the needs of Arizona’s largest county or today’s behavioral health system.

The result is simple and troubling: admission to ASH is constrained not by clinical need, but by a patient’s county of residence. SB1813 corrects that problem by requiring that admission decisions be based on clinical criteria rather than geography.

Some opponents have suggested that passing SB1813 would “reopen the Arnold case.” That claim is inaccurate and often motivated by a core opposition to psychiatric treatment in secure environments. The Legislature has clear authority to address pressing community needs through statute—especially when the solution is narrowly tailored, as it is here. SB1813 simply establishes in state law that access to treatment at ASH should be determined by medical need.

If SB1813 becomes law, the ADHS/AHCCCS could then return to court to seek a modification of the settlement agreement so that it aligns with the new statute. Courts routinely approve such updates when circumstances change or when legislatures revise the governing law.

In short, SB1813 doesn’t undermine the goals of the original settlement. Instead, it updates an outdated operational constraint that is now harming patients and creating unnecessary pressure throughout Arizona’s behavioral health system.

For individuals with the most severe mental illnesses who require secure hospital treatment, the current 55-person limit is simply no longer workable for Maricopa County. Clinical need—not geography—should guide access to care.

I respectfully urge you to vote YES on SB1813 when it is heard in committee.

Here’s my blog post with more information about the bill, why it’s needed, and why the Arnold scare tactics are inaccurate: Bill Spotlight: SB1813 – Ending the 55-Bed Cap for Maricopa County Residents at the Arizona State Hospital – AZ Public Health Association

Thanks for your consideration…

will