The Deadly Cost of Ignoring Clinical Need

Iryna Zarutska immigrated to North Carolina in August 2022, fleeing war-torn Ukraine. Exactly three years later, she was taking the subway home from a shift at a local Charlotte pizzeria when, abruptly, Decarlos Brown fatally stabbed her. As I will explain in this blog post, her murder is a stark reminder of the contributing role serious mental illness (SMI) plays in the criminal legal system’s revolving door.

Decarlos Brown had cycled in and out of the criminal legal system for over a decade, probably struggling with schizophrenia all the while. After release from a five-year prison stint in 2020, Brown’s demeanor had noticeably changed. His mother said he began violently slamming doors, hearing things, muttering to himself, pacing around her house, and punching walls. But she wasn’t sure what was causing it, and officials declined to say whether Brown had been diagnosed with or treated for schizophrenia while in prison. Regardless, the situation quickly became too much for his mother to handle, and she and her husband attempted to have Brown admitted to a psychiatric facility.

This first attempt failed. According to his mother, the facility, owned by Atrium Health, said they could not take him involuntarily unless he threatened to kill himself or someone else. Indeed, state law considered Brown not dangerous enough to be treated against his will. After Brown’s condition worsened and his physical violence against his sister, mother, and her husband increased, Brown’s mother tried again in 2023 — this time with a court order from a magistrate judge. Atrium Health accepted Brown, officially diagnosing him with schizophrenia and prescribing him medication. However, he was released after 14 days, despite objections from his mother. The facility apparently said it was not possible to house him any longer. Thereafter, while living with his mother and her husband, he started refusing to take his medication and became increasingly violent, leading his mother to kick him out in 2024. 

Why was it not possible for Atrium Health to house him until he was stabilized? I think it was, at the very least, legally possible; the facility just would have had to (literally) pay the price. Two possibilities existed for Brown’s release: the district court judge ordered his release, or the facility itself deemed Brown ready for release. In my view the latter was more likely true. Let’s look at the options:

• Possibility #1: Legal Mandate for Release?

Is it probable that a district court judge ordered his release? No, though it certainly is possible. Brown’s mother filed a layperson civil commitment petition, and the magistrate judge approved it — to grant law enforcement (which comes with its own host of issues) custody to transfer him to evaluation. Then, within 10 days, a district court would have had to issue an order for release, for outpatient commitment, or for inpatient commitment. Given the fact that Brown was committed for more than 10 days, an order was probably granted for inpatient commitment. 

• Possibility #2: Influence of the IMD Exclusion?

Is it probable that the facility’s decision to release him after 14 days was driven by fiscal reasons? Although I can’t prove it definitively, I believe this is what occurred here.

From the time that Medicaid was enacted in 1965, federal Medicaid dollars have been prohibited from being used to pay for mental health and substance use disorder treatment in “Institutions for Mental Diseases” (IMDs). IMDs are facilities with more than 16 beds in which more than half of the patients are receiving behavioral health care. However, states may apply for waivers. North Carolina, the state in which Iryna’s murder and Brown’s commitment occurred, has successfully waived application of this exclusion for the first 14 days of an individual’s inpatient psychiatric stay. Perhaps unsurprisingly, the facility Brown was committed to had more than 16 beds, and Brown was a patient for exactly 14 days. In other words, the facility likely released Brown after 14 days because that is when Medicaid reimbursement ends in the state. 

Potential Changes to the IMD Exclusion

The IMD exclusion has drawn congressional attention this session as the public has begun to recognize that the exclusion’s intent to incentivize deinstitutionalization from psychiatric facilities has only resulted in the carceral institutionalization of people with SMI. H.R. 4022 proposes its repeal, and H.R. 5462 its reform. While a full-blown repeal might be too cost-prohibitive, the suggested reform might not effectively mitigate the lack of funding for psychiatric services. 

As mentioned earlier, federal Medicaid funds may only go to facilities with fewer than 16 beds, yet research suggests that such facilities constitute less than 8 percent of existing psychiatric facilities. What this means in practice is that Medicaid beneficiaries cannot access 92 percent of existing facilities. While the reform proposed in H.R. 5462 increases this limit to 36 beds, this would result in only 68 additional facilities and 1,750 additional beds. Given the fact that most psychiatric facilities currently have approximately 100 beds, experts have suggested increasing the limit to 108 beds, which would increase available facilities by 322 and beds by 20,591.

A Shared Responsibility of Federal and State Governments

Civil commitment rates are rising as states, encouraged by the federal government, expand both the criteria and application of commitment. For instance, North Carolina itself mandated that more people who are arrested be considered for civil commitment in a recent law passed in response to Iryna’s murder. 

The federal and state governments therefore undertake a shared responsibility to ensure that there is funding to sustain these mandates, or individuals will begin languishing in detention facilities awaiting treatment but never receiving it — just as those awaiting competency restoration treatment prior to trial already do. If we don’t, we risk seeing the same human rights violations that occurred prior to the deinstitutionalization movement in the “insane asylums” of the 1960s. 

Conclusion

It was perhaps important to expand civil commitment criteria in North Carolina. After all, Brown was deemed not dangerous enough to be committed or treated against his will, even as his mother — who tried her best to care for him — found him too dangerous to keep at home. 

Yet, when the facility finally did admit Brown, the system failed again at the exit. He should have been released only when stable enough to stay with his family, but was instead discharged over his mother’s objections — a decision I argued was likely driven by financial incentives rather than medical judgment. Had funding followed clinical need instead of counting calendar days, Brown likely would have received the care that could prevent his mind’s deadly decline, and Iryna Zarutska might still be alive.