Late one night in 2022, Ming’s 33-year-old daughter was talking about hurting herself again. Unlike other times she was in crisis, he said, “She actually came up to me and said, ‘I need you to take me to the emergency room.’ ”
It was one of four times his daughter ended up in the ER over suicidal thoughts in the past 12 months. Three of those visits involved a full emergency response from police, EMTs and an ambulance. Ming’s daughter, who has been hospitalized for psychiatric needs at least 20 times, sometimes resorts to more extreme, even dangerous, cries for help.
“She doesn’t know how else to get that help,” said Ming, who lives with his family in Greenwood and requested to use only his first name to protect his daughter’s privacy. “When we told her the proposal to create these crisis stabilization centers, she said, ‘That’s exactly what I need.’”
In a special election April 25, voters will decide whether to fund five new 24/7 crisis centers, which would be among the first of their kind in King County. If the measure passes, the proposed tax levy on King County homeowners is expected to raise more than $1.2 billion over nine years.
The levy splits the county into four regions, with one crisis center planned in each. A fifth center would serve youths. People in need of substance use treatment, or in any kind of emotional or behavioral health crisis, could seek care at the centers or be connected to a detox program or sobering center. The walk-in crisis centers are voluntary but law enforcement and first responders are also expected to drop people off, and in the process, divert them from jails and emergency departments. The proposal is also expected to add back at least 111 residential mental health beds for people with serious mental illnesses; the number of such beds is half what it was in the 1990s.
The money is primarily aimed at crisis care, which is only one piece of a broader mental health system that has historically been under-resourced and fragmented in Washington. Some have raised concerns about the scope of the proposal and whether a major investment in crisis care comes at the expense of funding other corners of the system, including early outpatient care to prevent people from reaching crisis, or longer-term housing for people who need permanent support.
There is no organized opposition to the levy. An opposition statement in the election’s voter’s guide argues that if the crisis centers are essential, money can be found within existing funds.
Still, King County leaders are pitching the centers as a crucial link, at a moment in King County and Washington when local and state leaders are striving to build a connected crisis system.
The national 988 crisis care line rolled out last spring, but to date, crisis line counselors haven’t had a place — besides emergency rooms — to refer people in need. The Downtown Emergency Service Center’s Crisis Solutions Center offers crisis care but requires a referral from police, a mobile crisis team or mental health professional.
“We’re trying to build essentially a parallel system,” said Leo Flor, King County’s director of community and human services. “Who do you call? 988. Who responds? The mobile crisis team or perhaps a co-responder model. Where do they go? The crisis care center.”
Had a crisis center been available to Ming’s daughter, he believes she could have avoided languishing in ER rooms during past moments of crisis. “It would have been better to be taken somewhere that was specialized in mental health care,” he said. “Where she could potentially stay for a week or two, just to get settled down and maybe get her meds stabilized again, and just break the cycle that she currently is in.”
‘No wrong door’
The new system King County seeks to build is based on a model from Arizona that’s often described as a “no-wrong door” approach. Last May, almost 50 people involved in Washington’s behavioral health system, including state legislators and agency heads, traveled south to learn more about how Maricopa County built this system.
One of the key takeaways was simple: Let in everyone who seeks care. Whether they’re diagnosed with a mental illness, substance use disorder, or an intellectual or developmental disability, all people get access to services in the same place.
Kent Mayor Dana Ralph, among the coalition that visited Arizona, said she witnessed a seamless handoff of a 16-year-old boy in crisis from a law enforcement officer to an employee at the facility. “The whole exchange took under five minutes. It was absolutely amazing to watch.”
Right now in Washington, people have to navigate a labyrinth of behavioral health programs siloed across several local and state departments. If the crisis centers are built, the goal is that people could start at a crisis center instead, and then be rerouted to the best services. Together, the King County centers would be expected to serve 50,000 people per year.
Each center would consist of three parts: A behavioral health urgent care clinic that offers screening and triage to appropriate services, an observation unit where people could stay for up to 23 hours, and a short-term stabilization unit where people could stay for up to 14 days before being discharged or referred elsewhere.
Designated crisis responders (professionals tasked with evaluating whether someone meets the threshold for involuntary commitment) would be based at each crisis facility. Officials say the goal of the proposed levy is to reduce the number of people falling into a deep crisis requiring involuntary hospitalization by providing care earlier, though most upstream parts of the behavioral health system wouldn’t receive additional support through the levy.
Minor medical needs would ideally be treated on site, Flor said, to avoid additional transportation between crisis centers and hospitals.
Residents could visit any of the facilities, regardless of where they live in the county. The centers can bill private insurance, Medicaid, or provide care using levy money in cases where someone does not have insurance.
Nuts and bolts
The levy would be set at 14.5 cents per $1,000 of assessed home value. In Seattle, a homeowner with a property valued at the median of $760,000 could expect to pay about $133 more in their property taxes in 2024. Across King County, where average home values are slightly lower than in the city, the median payment for a property owner would be about $121.
The first two facilities would be slated to open in 2026, and the final facility would be expected to open in 2030. However, immediate investments in supportive housing programs and money toward existing mental health facilities in King County could begin in 2024 and 2025.
Hiring enough staff is a challenge for many behavioral health facilities; the field has seen a drop in providers due to burnout, low wages and steep education debt. The county says it would attract staff by offering wages for crisis center workers that are about 20% higher than what typical behavioral health workers earn now. The promise of higher wages could mean the crisis centers would draw workers away from existing behavioral health clinics, but Flor said there’s no good alternative: keeping workers’ wages low could cause people to leave the field altogether.
Some of the levy funds, with County Council approval, would also go toward apprenticeship programs and the costs of credentialing for prospective workers, to boost the pipeline of new staff.
Realistically, there are few ways to pay for all the crisis centers’ services long-term unless the state changes the kinds of care that are reimbursable through Medicaid.
County officials say they expect about 20% of crisis center operations costs to be covered by Medicaid, with levy dollars making up the rest. Expanding the services Medicaid covers, Flor said, could make the centers financially sustainable long-term.
In early April, lawmakers passed a measure that officially enshrines walk-in crisis centers as licensed health facilities in Washington. Adding that kind of licensure could make it easier to expand Medicaid coverage for crisis care, he added.
“There’s still plenty for the state to do,” said Flor. “This is a part of the solution. It is not the entire solution.”
The fate of the levy will be decided with several questions left unanswered, such as the centers’ locations, where people could be referred once they discharge and how levy-supported programs would be sustained in the long run. Some of these details might be ironed out in an implementation plan the county would create, should the levy pass.
To decide where each crisis center would be located, cities and providers would work together to craft proposals, county officials say.
In North King County, a coalition of five cities offers a model for such a proposal. The cities — Bothell, Kenmore, Kirkland, Lake Forest Park and Shoreline — are planning to open the county’s first walk-in mental health clinic in 2024, a plan they seeded before the levy proposal was announced. Connections Health Solutions, an Arizona-based provider, has been chosen to run the center in Kirkland; together, they’ve secured Department of Commerce money to build the facility. Kirkland Mayor Penny Sweet said she wants the county to include this facility among the five centers.
Although the levy ordinance is bound to specific purposes — to build crisis centers, first and foremost — the exact breakdown of how the levy money would be spent is ultimately up to the Metropolitan King County Council. For instance, cities might apply for DOC grants to support certain crisis center construction costs, which could leave dollars on the table to fund other aspects of the levy’s priorities.
How the crisis centers and other proposed programs would be funded past the nine-year life of the levy is unknown.
Some critics argue that cities could pursue state funding to build crisis centers instead of relying on county-raised tax dollars.
Over the past few years, for example, the state’s Department of Commerce has awarded at least a dozen grants totaling more than $50 million in construction funds for crisis stabilization projects across the state.
“If that’s happening by the state, why are we going after more money to build centers? And then, even if that’s not enough money, it seems like the costs are way higher than expected,” said Amnon Shoenfeld, a former director of King County’s behavioral health division, referring to estimated costs of the levy-backed centers. County officials estimate that $185 million in levy dollars would go toward crisis center construction or building rehabilitation costs, or roughly $37 million per facility.
The process of securing sites could be lengthy: Land and real estate are expensive, and cities could face resistance from neighbors. Homeowners opposed to other mental health facilities have attempted to block projects in Snohomish, Lewis and Clark counties.
“This is for your next-door neighbor, your child, your mother, anyone in need of behavioral health support,” countered Auburn Mayor Nancy Backus. “This can’t be one of those NIMBY things.”
Officials acknowledge that adding crisis care would only stem part of the significant need for more mental health care in King County. The county lacks enough affordable housing and both inpatient and outpatient providers, for example, which means some people who visit crisis centers could be discharged back into homelessness or without a referral for additional care.
People like Ming’s daughter need a range of services to stay stable, he said. She’s diagnosed with schizoaffective disorder and fetal alcohol spectrum disorder, and also experiences anxiety, depression and PTSD. She’s visited the ER at least 50 times for self-harm and other psychiatric concerns.
Crisis care will help, Ming said. But his daughter is rarely given enough services to truly get well: She’s been discharged swiftly from inpatient stays and turned away from other important supports such as permanent supportive housing programs, he said.
“Even when she does get an inpatient bed, it’s rarely for more than two weeks,” which is about as long as she could ever expect to stay at a crisis center, he said. “It’s just long enough for her to stabilize somewhat, but not actually heal.”
The Ballmer Group, which funds The Seattle Times Mental Health Project, has contributed to the levy campaign. Times editors and reporters operate independently of our funders and maintain full editorial control over our journalism.