Missouri has just eight outpatient beds for people charged with crimes who have been ordered to undergo mental health treatment so their cases can move forward.
Those beds are full. So are the state's 440 psychiatric hospital beds that serve Missourians ruled incompetent to stand trial because of a mental illness or cognitive disability.
There were 524 Missourians as of last week waiting for one of those spots who require treatment and services from the Department of Mental Health. Of those, 446 are in jails throughout the state — incarcerated indefinitely without being convicted of their alleged crimes.
Another 78 are out on bond, their cases stalled until a court can decide if treatment has restored them to competency.
Lawmakers confronted the scale of that backlog Tuesday during a House Budget Committee hearing, as they examined the growing strain on the state's mental health system for people charged with crimes.
"It sure looks like this is a crisis," said Republican state Rep. Greg Sharpe of Ewing.
State Rep. Betsy Fogle of Springfield, ranking Democrat on the committee, said persistent, growing numbers of Missourians stuck in jail without trial puts the state "in scary territory."
"We're forcing someone to be held in a jail without providing them the pathway of getting out, whether or not they were guilty…of that crime," Fogle said.
The Independent has documented the growing waitlist for mental health services for more than three years. The statewide average number of people on the waitlist in January was 518, an increase from 505 in December, according to data shared by the department with The Independent.
The waitlist has more than doubled in size since July 2023.
A federal lawsuit filed in November alleges that the department has illegally denied timely competency evaluations and restoration treatment to Missourians with mental health and cognitive disabilities who stand accused of crimes.
As Mental Health Director Valerie Huhn shared initiatives the department is pursuing to slow the growth of the waitlist, lawmakers said the state isn't doing enough.
Gov. Mike Kehoe's proposed budget for fiscal year 2027 recommends $6.1 million to expand the state's current outpatient competency restoration capacity from eight beds, which are in a group home operated by University Health in Kansas City, to 50. About $3 million would come from the state's general revenue, while almost $3.2 million would be federal funding.
Fogle said the proposal is "too incremental."
"Even with this additional funding, even if we're able to move 50 individuals off the waitlist," Fogle said, "…I'm still concerned that we're going to come back here next year and the year after and see significant wait lists."
The department in the last two years has launched four jail-based competency programs in St. Louis city and county, as well as Jackson and Clay counties. These programs, which were authorized by a 2023 state law, can serve up to 40 people at a time.
Huhn told lawmakers the department is looking for a location to replace the Clay County Sheriff's Office, which is terminating its agreement with the department after the pilot failed to decrease its backlog.
A hospital expected to open in Kansas City in 2029 or 2030 will have 150 beds — 100 for competency restoration and 50 for long-term care.
Forensic mobile teams of clinicians that visit jails to provide medications to people awaiting services have also seen successes, Huhn said. In fiscal year 2025, 166 people attained competency due to the work of those teams, according to the department's appropriations book.
Kehoe's proposed budget recommends a $15,000 cut to those teams in fiscal year 2027.
Huhn added that the department uses "any open bed" in its facilities to provide competency restoration treatment, including in its full-time habilitation centers housing Missourians with acute developmental disabilities.
Disability advocates and families worry that proposed funding reductions for services that help people with disabilities stay safely in their homes will push some into these institutions.
Republican state Rep. Mike Steinmeyer of Sugar Creek said there's a need to find novel responses to what is "not a new problem."
"We can't just keep coming back year after year, saying the same things," he said. "I'm looking at the backlogs growing, and our budgets are growing. We're going to have to be innovative."
'Doesn't scratch the surface'
Republican state Rep. John Black of Marshfield, the co-chair of the subcommittee covering health, mental health and social services, said Kehoe's proposed budget for the department doesn't reflect broader bed shortages throughout the department's facilities.
"This $6 million, it seems to me, probably doesn't scratch the surface of what happens in the entire process," Black said, "particularly with regard to those persons that are determined [permanently incompetent] to stand trial."
Not everyone who undergoes competency restoration treatment is deemed by a court to be competent to move forward with their trial. Patients who are ruled permanently incompetent to stand trial continue to live in state-run hospitals — sometimes for years — before they can be approved to be conditionally released.
Huhn said the department has beds in St. Joseph, Farmington and St. Louis where this long-term care can take place.
People who are ruled permanently incompetent to stand trial go to other state-run hospitals for long-term placement when there are beds available. If there are no open beds, they remain in the facilities where they were undergoing competency restoration treatment until a spot opens up.
Dr. Jeanette Simmons, deputy director of the department's Division of Behavioral Health, said that when someone receiving outpatient treatment is ruled permanently incompetent to stand trial, the provider contracted to provide that treatment would try to find them long-term placement.
Black asked Simmons what would happen if the provider didn't have an open bed.
"I think you just told me you only have these eight beds available, and even if incompetency is determined…you don't have a place for them to go for sure right now," Black said. "They might be stuck taking up one of those eight beds."
Simmons said that was accurate, and that the same goes for state-run hospitals providing competency restoration treatment.
No guarantees
Lawmakers asked what changes to Kehoe's proposed budget would be helpful, but representatives of the department hesitated to make suggestions.
Fogle asked Nora Bock, director of the department's Division of Behavioral Health, if the department needs more funding for its forensic mobile teams.
"If we appropriate more dollars on this line, will we see that wait list of 524 reduced?" Fogle asked. "Do you need more money on this line?"
Bock described the teams as "an integral part of our multi-pronged effort" and "a game-changer."
But she stopped short of asking for additional money.
"We would increase our opportunity to reach more people who are on the list," Bock said.
Republican state Rep. Darin Chappell of Rogersville, the subcommittee chair, said his understanding was that there would be no guarantee that those individuals would be allowed to proceed with their trials.
"There's no guarantee for some individuals that they'll ever reach that," Chappell said. "They may end up being on a wait list for long-term mental health care."
Huhn said this was correct.
This story was originally published by the Missouri Independent, part of the States Newsroom.
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