Argall asked for “cost-effective solutions.” The panelists responded with a complex web of systemic inadequacies, often pointing to preventative measures that would require the kind of fiscal support the majority party has been hesitant to provide through government spending.

“The difficulty is that I can’t offer one straightforward flatline funding solution because the real need is to build up that bottom level prevention base because we all know that that ounce of prevention is worth more than that pound of cure, both for the individuals and fiscally,” explained Melanie Gordon of the County Commissioners Association of Pennsylvania. “So that’s why we’re advocating more for base services, base funding to build those systems up.”

Gordon noted that one of the biggest challenges that providers face, even for those who are insured, is figuring out which program will ultimately pay for treatment. This makes it hard for people with co-occurring disorders to access care.

Although state data does not capture how many of its 1.8 million residents with mental health conditions experience more than one at a time, at least 21.5 million people nationwide do, according to federal data.

Jen McLaughlin, director of Mental Health Services at Community Services Group, said her organization is “concerned” about the future of Medicaid following “frightening” federal cuts, a program that she says already offers very little in the way of reimbursement.

McLaughlin also highlighted an issue Senate Republicans could have a direct and immediate impact on: public transit within the commonwealth. According to the National Conference of State Legislatures, people with disabilities are three times more likely to rely on public transit. For those coming in and out of institutions like state hospitals and prisons, a personal mode of transportation is an even greater challenge.

“Rural Pennsylvania is so greatly lacking in any sort of public transportation and then if you’re lucky enough to be in an area that has public transportation, it is typically woefully inadequate,” said McLaughlin. “Running from, you know, nine o’clock to three o’clock. If you can get an appointment or a job in those hours, you’re okay. So it is a huge crisis for us.”

Argall described the “pendulum swing” of public policy. State institutions of the past posed horrible living conditions for those with mental illness. Today, however, many people in crisis are living on the streets and frequently incarcerated for lack of a better option, leaving them in even worse conditions.

The two prison wardens at the roundtable insisted that jails are not only an inappropriate setting for people in a behavioral crisis but they are dangerous for both individuals and guards.

“I have young officers and they’ve been trained to handle things number one, by use of force, by chemical agents or restraints,” said George Nye of Columbia County Prison.

Nye described an incarcerated woman who arrived at the county prison from Danville State Hospital. In addition to assaulting employees, the woman lodged her finger in a wall, ingested silverware, and was forced to spend 37 days restrained, alone, and in a padded 6×6 cell.

“However, it seems like every time we try to rectify the situation that we have, it’s not a money problem. It’s a logistical problem of what we’re going to do with these individuals,” said Nye. “My fear as the warden and the representative of Columbia County is that one of these individuals are either going to seriously assault one of my correctional officers or die within that facility, and that’s how serious the problem is that we’re dealing with right now.”

“Shifting homeless individuals into long-term institutional settings for humane treatment through the appropriate use of civil commitment will restore public order,” reads the order, which some see as a much-welcomed swing of the pendulum back from deinstitutionalization. Others see it as a measure that effectively criminalizes homelessness.

The deinstitutionalization that many remember sending scores of mentally ill people onto the streets under the Reagan administration came after a movement over decades toward creating community-based mental health resources. That movement culminated in former President Jimmy Carter’s Mental Health Systems Act of 1980, which aimed to revolutionize mental health care in the United States.

It was repealed by Reagan and Senate Republicans within a year through a major budget reconciliation bill, funneling funding and decision-making power to individual states.

Despite the significant overlap of problems described in Trump’s order, data exists that calls into question the conflation of the nation’s homelessness problem with its mental health care crisis. One University of California study found that 90% of the people living on the streets in the state found their way there due to a lack of affordable housing. For many, it was after experiencing the difficulties of homelessness that mental health and substance use disorders were triggered.

Agreeing on a root cause may be essential to agreeing on a cure. If financial and social instability are a root cause, then a whole host of supports are required to lift individuals out or keep them from falling in the first place.

“You can give people a bed. You can give them food. You can give them housing, but if we don’t give them the foundation of a strong mental health capacity, a lot of times, they don’t know what to do with what you’ve given them,” said Culver. “We’re back at square one in a couple months because we didn’t provide what they really really needed.”