Iowa's most shameful ranking yet

Kali White VanBaale is an Iowa-based novelist, creative writing professor, and mental health care advocate. Find more of her work at (where this essay first appeared) and     

In late January, the Treatment and Advocacy Center released an annual report, “Prevention Over Punishment: Finding the Right Balance of Civil and Forensic State Psychiatric Hospital Beds.” It says in part:

The number of state psychiatric hospital beds for adults with severe mental illness has continued to decline to a historic low of 36,150, or 10.8 per 100,000 population in 2023, with a majority of state hospital beds occupied by people who have been committed to the hospital through the criminal legal system. This strategy of prioritizing admission of forensic patients effectively creates a system where someone must be arrested to access a state hospital bed in many states.

Other key findings:

  • An increasing number of the remaining beds are being utilized for forensic patients, leaving fewer and fewer beds for civil patients.
  • Forensic bed waits remain an issue, with significant and sometimes tragic consequences.
  • Staffing shortages, lack of appropriate discharge facilities and the COVID-19 pandemic have all contributed to the loss of psychiatric beds in the more recent years.

Furthermore, according to the Treatment and Advocacy Center’s research, Iowa ranks 51st in beds per 100,000 population across the U.S. and the District of Columbia.

Read that again.

We still, since 2016, rank dead last, even behind the District of Columbia, for number of acute psychiatric beds per resident.

There are also no state hospitals specifically designed for forensic patients in Iowa. State officials told the center’s researchers that hospitals do have forensic patients, but those numbers in state hospitals aren’t tracked.

When most or all of a state’s beds are used for patients who are involved the criminal legal system, it leaves people with severe mental illness who have no criminal behavior with fewer options for treatment (and logically then increases their chances of criminal behavior as their illness progresses). The shortage of civil beds in particular means civil patients who rely on state hospital for care—those with serious mental illness (SMIs), complex needs, and co-occurring issues like SMI and addiction—may have few options for treatment.

Former Governor Terry Branstad closed two of Iowa’s four in-patient facilities. Stats on the two remaining: the Independence Mental Health Institution has 40 beds for adults and sixteen for children, with a reported 91 percent occupancy rates in 2022 and average length stay of 6.6 months/157 days.

The Cherokee Mental Health Hospital has 24 beds for adults, and twelve for children with a reported 97 percent occupancy rate in 2022, and average length stay of 1.9 months/56 days.

Hospital occupancy rates greater than 85 percent are indicative of bed shortages. Iowa’s state hospitals have occupancy rates of 91 percent and 97 percent, suggesting the current number of state hospital beds is insufficient for addressing community needs in Iowa.

Which feels like an understatement.

A state psychiatric bed (or any psychiatric bed) in 2017 might have saved the lives of Mark, Charla, and Tawni Nicholson, my neighbors murdered by their son/brother in the grips of an SMI and acute psychotic episode, but there wasn’t one available across the entire state when he needed it. And here we are in 2024, and the family would’ve faced the exact same dire situation if it were to happen today.

Besides my relationship with Chase Nicholson, I also have an extended family member suffering from a complex and co-occurring mental illness. He’s homeless in downtown Des Moines as I type this essay. As an adult in his early 20s, he’s completely responsible for navigating the tangled and intricate mental health care system, treatment options, and basic living needs like holding down a job, securing safe and affordable housing, and transportation.

He’s sought treatment and medical care many times, getting admitted to various hospitals around the metro only to be discharged a week or even hours later. He’s tried checking himself into rehab clinics, only to be turned away because he “didn’t meet their criteria” for admission, likely due to his co-occurring mental illness. Which means he continues to flounder on his own, oftentimes too ill or suffering psychosis to even recognize how sick he really is. Because of his complex illness, co-occurring issues, and chronic homelessness, he’s also been in and out of the criminal legal system, which only compounds the problem.

It’s impossible to ignore that with admission to a long-term state facility, he could receive acute care, treatment, life building and coping skills, and ultimately stability, and then transition into therapeutic housing as he reintegrates into society. But here in Iowa, he’s “not sick enough.” And even if he were, like I saw firsthand with Chase, it probably wouldn’t matter because there’s likely not a bed available.

In the eight years since Iowa earned that shameful ranking, the names of the people from high profile cases who’ve died because of it are engraved on my heart:

  • Jackie Dieckmann and Illa Pfeiffer, Council Bluffs, March 2016
  • Mark, Charla, and Tawni Nicholson, Bondurant, April 2017
  • Brian and Michelle Glasz, DeWitt, June 2017
  • Linda Selters, Burlington, October 2017
  • Diana Lensgraf, Muscatine, December 2018
  • Celia Barquín Arozamena, Ames, Sept 2019
  • Rev. Allen Henderson, Fort Dodge, October 2019

All cases committed by an individual with an identified mental illness or SMI, and with family members who reported struggling to get even adequate mental health care for their loved one. Several individuals on that list died at the hands of their seriously ill and grossly under-treated loved one while still fighting to get them help.

Not to mention the thousands of other suffering families whose nonviolent mentally ill loved one struggles without adequate treatment.

Iowa, when are we going to collectively decide this is unacceptable and do something about it?

Top photo is by metamorworks, available via Shutterstock.

About the Author(s)

Kali White VanBaale

  • Thanks for Highlighting . . .

    . . . this important matter in such a thoughtful way.

    I’m a former rural hospital administrator at a healthcare center that invested in both inpatient and outpatient behavioral health services.

    A simple and common sense place to begin is for commercial and government insurers to simply increase payments to clinics and hospitals that seek to meet the needs of their communities.

    It’s a financial significant challenge for rural healthcare providers to maintain these critical services.

    Iowans should not take existing behavioral health services for granted. Increased payment levels are essential.

  • thanks for this

    while I agree that “It’s impossible to ignore that with admission to a long-term state facility, he could receive acute care, treatment, life building and coping skills, and ultimately stability, and then transition into therapeutic housing as he reintegrates into society”
    this is rarely the norm of tx anywhere in the US I worked for years with the NYS office of mental health and also in several states in the midwest, California and the greater Memphis area and very few people get to stay in hospitals long enough even for their meds to really kick before they are shipped off to dubious housing and overtaxed country/city mental health clinics. I’ll have to take a deeper into California’s new proposal but at least it’s at the scale of the kind of overhaul and investment needed: