Mental health officials are starting to ask the question: Which people being treated for severe mental illness must continue receiving care, and who can be left on their own?

As the money in York and Adams counties runs out because Pennsylvania does not have a budget, they ponder where to cut:

--- Crisis Intervention Services, which helps place people in the midst of a breakdown?

--- Inpatient treatment, trying to move them into recovery?

--- Outpatient services, visits to the psychiatrist and filled prescriptions?

--- Housing, the key to stability?

The state provides the majority of the money for York-Adams Mental Health/Mental Retardation. As Gov. Ed Rendell and the legislature battle over a budget that was due July 1, the two counties have yet to receive a check.

To date, MH/MR has not received $6.1 million in first-quarter funding the county had anticipated, said county administrator Chuck Noll. Normally, most of that money would have passed on to contracted service providers.

Some, such as Bell Socialization Services, have already gone without payments from the county. Soon, the county will have to cease paying others, said Bev Mackereth, York County's human service director.

So far, those providers have been able to continue services.

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Bell, for example, is surviving on money from its July bills, executive director Ivan Hileman said. If the county doesn't pay future bills, he said, Bell will likely have to stop some kind of services.

"I don't know what will happen," Hileman said. "A lot of people are in housing and group homes. You can't just close them."

State Rep. Stan Saylor, R-Windsor Township, said the budget impasse might drag on until December, by which point almost all providers would be out of funding.

When a budget is signed, all sides agree it will almost certainly include a 2 percent cut from last year. Legislators are saying the 2010 and 2011 budgets will be equally spare, if not worse.

This comes at a time when those in the mental health community -- state and county officials, advocates, those living with severe mental illness and their families -- say not enough resources have been dedicated to providing care for the mentally ill as treatment has moved from large state hospitals to smaller, community facilities.

When the money's gone

If providers say they can no longer work without pay, York and Adams counties, which work together for mental health services, will have a choice, Mackereth said: They can take out a loan or discontinue services.

"We don't have the money to cover it," York County Commissioner Chris Reilly said. "The state has mandated programs, and it's not living up to its obligations. I say we discontinue the programs until they do."

The county would have to make sure it wasn't endangering those "who have the greatest dependence on the county," Reilly said, but some would have to go without. He said it would be up to MH/MR to decide what programs would continue.

R. Glenn Snyder, Adams County commissioner, agreed.

"If we can't find the money," he said, "the services will have to cease."

Neither county has a reserve fund, and a loan could get complicated.

By law, both counties would have to repay a loan by Dec. 31 to balance their budgets. Once Rendell signs a state budget, the county will not be paid for six weeks, Mackereth said. The county would be left with a huge deficit if Saylor's predicted timetable proves correct.

One tap, many problems

The York Chapter of the National Alliance for Mental Health receives all of its money from the state, via the county.

It was expecting a two percent budget cut for the fiscal year, executive director Rose Alberghini said. To deal with that, she said, NAMI expected to use its first payment from the county to provide services until a Sept. 26 fundraiser.

Because of the six-week delay, if the governor were to sign a budget today, the money from that fundraiser would be the first to reach NAMI's coffers since July.

The two full-time staffers are working without pay, but Alberghini -- one of them -- said she wonders how much longer they can do that. They have rent to pay, she said. An electric bills.

"We have classes coming up," Alberghini said. "We have people calling every day. We have support groups almost every day. What are they going to do?"

Like NAMI, Bell Socialization Services has no reserve fund. Bell's monthly budget is about $1 million dollars, about $450,000 of which is dedicated to mental health services. With no money coming in, Hileman said, it won't be long before it has to start laying people off.

"We can't borrow that kind of money (to support full operations)," he said.

WellSpan, which operates the psychiatric wing at York Hospital, is in a better position, since it is a more diverse organization, behavioral health director Allen Miller said.

"We'll do as much as we can for as long as we can," Miller said.

Some money does still exist.

Medicare eligible patients can continue treatment because HealthChoices funding is ongoing, said Joan Erney, the Deputy Secretary of the state's Office of Mental Health and Substance Abuse Services.

But that still leaves many people -- both those in crisis and those trying to make their way back -- potentially on their own.

"It's not as if these people go away," Erney said. "They'll still need services. They'll be in the emergency room or in jail or in real trouble."

Worse next year?

While the governor and legislators wrangle over this year's budget, the next two years look bleak as well.

Some officials -- including representatives Eugene DePasquale, D-West Manchester Township -- say funding will likely remain stagnant for mental health services.

"It's clearly going to be a challenge to maintain current funding levels," DePasquale said.

Stimulus money for other programs will dry up. Pension costs are expected to rise. Revenues won't pick up until the economy rebounds.

DePasquale said officials will need to find more creative ways to be efficient. Perhaps that is regionalizing services or making cooperative purchases. Those are conversations that need to happen, he said.

In 2006, the state closed Harrisburg State Hospital, where those with severe mental illness from York and Adams counties had been treated for decades, and built new facilities in the community to promote recovery.

Now, some are bracing for the day when the state asks the two counties to pay for them.

"I fully anticipate that," Reilly said, adding that he thought opening three facilities around the county was a good idea.

Brinda Penyak, deputy director of the County Commissioners Association of Pennsylvania, said counties might have to step in and help pay for mental health services, which for some, will likely mean tax increases.

Erney disagreed. The funding formulas have not changed, she said, and she does not anticipate they will.

* * *

The problem for today is the problem for tomorrow, advocates say.

When the economy, and state revenues, recover, mental health allocations will likely return to their previous levels.

But what happens, they ask, to those living with severe mental illness until then?