Southwest Alabama's safety net for psychiatric care, which was strained to start with, has gotten smaller.

Shock waves have spread from Infirmary Health's announcement in November that it was repurposing its inpatient psychiatric unit. Instead of serving the general adult population, those beds would now be set aside for geriatric patients.

The loss was felt because Mobile Infirmary was the last acute-care hospital in the region to maintain an adult psychiatric inpatient unit. Its move to get out of the business completed a trend that has taken more than a decade to play out.

Mobile County's health officer, Dr. Bernard H. Eichold II, said the move was "another reason to renovate and reopen Searcy Hospital in Mount Vernon," a huge state-owned facility that was closed in 2012. Tuerk Schlesinger, head of AltaPointe Health System, told the Mobile County Commission that the loss of 17 Infirmary beds "left a void, and a void that must be filled to ensure that people who are experiencing mental health crises receive care."

"Closure of Mobile Infirmary's adult unit will result in a community crisis for hospitalization of persons in psychiatric distress," Schlesinger told commissioners. "Local first responders share our concerns."

Speaking after the meeting, Schlesinger took pains to make clear that he doesn't see Infirmary Health as a villain. "I would say they're certainly not the bad guys," he said. The Infirmary stayed in the business "longer than anybody else would," he said.

Schlesinger said the problem goes all the way back to the early '90s. One sad fact of mental illness is that it often leaves sufferers unable to pay for their care, which in turn makes caring for them an expensive proposition. One by one, area hospitals shut down money-losing psych units.

Mobile Infirmary's leadership, responding to questions via e-mail, affirmed that general outline, saying that "the costs associated with operating this unit has far exceeded all revenue sources available for treatment of these patients" and have "negatively impacted the hospital's ability to provide other critical medical services."

"Over the years, the Board of Directors for Mobile Infirmary has often debated the negative financial impact of continuing to operate the adult inpatient psychiatric unit while all other local hospitals discontinued these services," said a statement provided by the Infirmary. "Historically, the Board determined the financial losses associated with keeping the unit open was justifiable and in the best interest of the community. However, with evidence of a growing need to provide additional psychiatric services to the expanding geriatric population, the decision was made to repurpose the adult unit and dedicate these financial resources to serve the over 65 age population."

Schlesinger doesn't dispute the financial challenges. He's well aware of them.

AltaPointe provides a full spectrum of mental health services and initially wasn't in the hospital business at all. But as hospitals eased out of psychiatric care, AltaPointe took measures to fill the gap. The biggest piece of that - though far from the only one -- is EastPointe Hospital, a Daphne facility that AltaPointe purchased for $4.4 million and opened in 2012 after a $10 million renovation. It has 82 beds, 16 for "subacute" care and the other 66 for acute care. But one 16-bed unit is closed because AltaPointe can't afford to operate it.

"We don't want to put this hospital at risk," Schlesigner said. "We already run this facility at a loss."

The financial challenges are compounded by the fact that as a freestanding psychiatric hospital, EastPointe can't receive Medicaid payments. There's a Medicaid rule called the Institutions for Mental Diseases exclusion that applies to residential treatment facilities larger than 16 beds. It applies to patients between ages 21 and 65, which helps explain why care for adults is a different ballgame from care for children and senior citizens.

Schlesinger said that while AltaPointe is happy to be "the safety net for the community," and works with most hospitals in the area, there's a need for psychiatric beds at acute-care hospitals. Many psychiatric patients have serious physical health issues as well. The acute-care hospitals have Emergency Departments and other resources that EastPointe doesn't. "There's a lot of things they have that we don't have," he said.

Underneath all the worry about policies and beds and funding structures, there's the underlying reality of people in crisis.

"The key to good mental health care is getting treatment early and often," said Jimmy Walsh of the National Alliance on Mental Illness' (NAMI) Alabama office.

But as resources wither across the state, patients in crisis aren't getting the help they need up front, which means their problems snowball. "It's going on all over the state," said Walsh. "We're like the California fires. It just keeps getting worse."

"It was just very disturbing that we're losing more beds," said Connie Ewing, a board member of NAMI's Mobile chapter.

"How would you feel if you had a cancer patient and there were no cancer beds?" she asked. "This population I so disenfranchised ... It's just so wrong."

One cornerstone of NAMI's work is trying to reduce the stigma of mental illness. Ewing said it's wrong to think of the mentally ill as violent, or the victims of their own irresponsibility or lack of discipline. "They are sick," she said. "Just because they have something wrong with their brain, that doesn't mean they can control it."

"I tell people, you could be next," said Walsh. Without a safety net, people in crisis end up bouncing in and out of Emergency Departments ill-equipped to handle them, falling into homelessness and neglect, or going to jail, which in turn puts a new strain on state resources. With proper care, he said, they can be stabilized to the point where counseling and other long-term services help them become healthy, productive members of society.

"The system works," he said. "Everybody knows it works."

Fixing the system so it can work for more people is not an easy proposition. Solutions inevitably come down to money, and the prospect of getting more money from the state or federal level isn't rosy.

Schlesinger said he thinks that the area could use another 16 acute care beds, which AltaPointe is prepared to operate. He pegs the cost of a 16-bed unit at around $6 million a year to operate. Typically, there is reimbursement for only 21 percent of patients for inpatient psychiatric services, meaning $4.7 million a year has to come from an outside source, he said.

As Mobile's county commissioners took in Schlesinger's remarks, they seemed to share a real sense of concern - but also a feeling that the problem was too big for the county to address alone. Commissioner Connie Hudson said mental health care funding was something the state legislature would need to address, and that commissioners should raise the issue with the local delegation. "I think we just need help," she said.

The prospect of reopening Searcy certainly wouldn't be cheap, though it is attractive to some.

"We believe the closure of Searcy State Mental Hospital placed a much greater burden on the adult psychiatric unit at Mobile Infirmary," said the Infirmary statement. "There is a population of adult, non-geriatric patients in need of a long-term inpatient facility like Searcy Hospital and we support Dr. Eichold's recommendation of reopening that facility."

Schlesinger, however, maintains that Searcy isn't the answer. It was built primarily to serve patients who'd been involuntarily committed by courts. That's not where the current acute problem lies, he said. The current need is for inpatient beds to serve patients who are voluntarily seeking treatment.

With a scarcity of beds in Mobile, they have to wait, he said. Or they get sent to other parts of the state, depending on where beds are open at any given time: Dothan, Montgomery, even Birmingham.

Walsh said that in January, NAMI and other agencies will hold a summit in Montgomery, to heighten awareness of the problem and explore solutions. He said he expects participants to include county commissioners, city council members and law enforcement representatives, among others.

Personally, he said, he thinks the conversation should be about a shift in funding. It's about priorities, he said, such as spending on new health care facilities rather than new prisons.

It's a question of whether the state wants to invest in preventing a fire, or just keep directing all its resources to fighting fires. But he concedes it's not that simple.

"We've got to do all of this at the same time," he said.