GAINESVILLE, Ga. — In early December, Donald Brown stood nervously in the Hall County Courthouse, concerned he’d be sent back to jail.

The 55-year-old struggles with depression, addiction, and suicidal thoughts. He worried a judge would terminate him from a special diversion program meant to keep people with mental illness from being incarcerated. He was failing to keep up with the program’s onerous work and community service requirements.

“I’m kind of scared. I feel kind of defeated,” Brown said.

Last year, Brown threatened to take his life with a gun and his family called 911 seeking help, he said. The police arrived, and Brown was arrested and charged with a felony of firearm possession.

After months in jail, Brown was offered access to the Health Empowerment Linkage and Possibilities, or HELP, Court. If he pleaded guilty, he’d be connected to services and avoid prison time. But if he didn’t complete the program, he’d possibly face incarceration.

“It’s almost like coercion,” Brown said. “‘Here, sign these papers and get out of jail.’ I feel like I could have been dealt with a lot better.”

Advocates, attorneys, clinicians, and researchers said courts such as the one Brown is navigating can struggle to live up to their promise. The diversion programs, they said, are often expensive and resource-intensive, and serve fewer than 1% of the more than 2 million people who have a serious mental illness and are booked into U.S. jails each year.

People can feel pressured to take plea deals and enter the courts, seeing the programs as the only route to get care or avoid prison time. The courts are selective, due in part to political pressures on elected judges and prosecutors. Participants must often meet strict requirements that critics say aren’t treatment-focused, such as regular hearings and drug screenings.

And there is a lack of conclusive evidence on whether the courts help participants long-term. Some legal experts, like Lea Johnston, a professor of law at the University of Florida, worry the programs distract from more meaningful investments in mental health resources.

Jails and prisons are not the place for individuals with mental disorders, she said. “But I’m also not sure that mental health court is the solution.”

The country’s first mental health court was established in Broward County, Florida, in 1997, “as a way to promote recovery and mental health wellness and avoid criminalizing mental health problems.” The model was replicated with millions in funding from such federal agencies as the Substance Abuse and Mental Health Services Administration and the Department of Justice.

More than 650 adult and juvenile mental health courts were operational as of 2022, according to the National Treatment Court Resource Center. There’s no set way to run them. Generally, participants receive treatment plans and get linked to services. Judges and mental health clinicians oversee their progress.

Researchers from the center found little evidence that the courts improve participants’ mental health or keep them out of the criminal justice system. “Few studies … assess longer-term impacts” of the programs “beyond one year after program exit,” said a 2022 policy brief on mental health courts.

The courts work best when paired with investments in services such as clinical treatment, recovery programs, and housing and employment opportunities, said Kristen DeVall, the center’s co-director.

“If all of these other supports aren’t invested in, then it’s kind of a wash,” she said.

The courts should be seen as “one intervention in that larger system,” DeVall said, not “the only resource to serve folks with mental health needs” who get caught up in the criminal justice system.

Resource limitations can also increase the pressures to apply for mental health court programs, said Lisa M. Wayne, executive director of the National Association of Criminal Defense Lawyers. People seeking help might not feel they have alternatives.

“It’s not going to be people who can afford mental health intervention. It’s poor people, marginalized folks,” she said.

Other court skeptics wonder about the larger costs of the programs.

In a study of a mental health court in Pennsylvania, Johnston and a University of Florida colleague found participants were sentenced to longer time under government supervision than if they’d gone through the regular criminal justice system.

“The bigger problem is they’re taking attention away from more important solutions that we should be investing in, like community mental health care,” Johnston said.

When Melissa Vergara’s oldest son, Mychael Difrancisco, was arrested on felony gun charges in Queens in May 2021, she thought he would be an ideal candidate for the New York City borough’s mental health court because of his diagnosis of autism spectrum disorder and other behavioral health conditions.

She estimated she spent tens of thousands of dollars to prepare Difrancisco’s case for consideration. Meanwhile, her son sat in jail on Rikers Island, where she said he was assaulted multiple times and had to get half a finger amputated after it was caught in a cell door.

In the end, his case was denied diversion into mental health court. Difrancisco, 22, is serving a prison sentence that could be as long as four years and six months.

“There’s no real urgency to help people with mental health struggles,” Vergara said.

Critics worry such high bars to entry can lead the programs to exclude people who could benefit the most. Some courts don’t allow those accused of violent or sexual crimes to participate. Prosecutors and judges can face pressure from constituents that may lead them to block individuals accused of high-profile offenses.

And judges often aren’t trained to make decisions about participants’ care, said Raji Edayathumangalam, senior policy social worker with New York County Defender Services.

“It’s inappropriate,” she said. “We’re all licensed to practice in our different professions for a reason. I can’t show up to do a hernia operation just because I read about it or sat next to a hernia surgeon.”

Mental health courts can be overly focused on requirements such as drug testing, medication compliance, and completing workbook assignments, rather than progress toward recovery and clinical improvement, Edayathumangalam said.

Completing the programs can leave some participants with clean criminal records. But failing to meet a program’s requirements can trigger penalties — including incarceration.

During a recent hearing in the Clayton County Behavioral Health Accountability Court in suburban Atlanta, one woman left the courtroom in tears when Judge Shana Rooks Malone ordered her to report to jail for a seven-day stay for “being dishonest” about whether she was taking court-required medication.

It was her sixth infraction in the program — previous consequences included written assignments and “bench duty,” in which participants must sit and think about their participation in the program.

“I don’t like to incarcerate,” Malone said. “That particular participant has had some challenges. I’m rooting for her. But all the smaller penalties haven’t worked.”

Still, other participants praised Malone and her program. And, in general, some say such diversion programs provide a much-needed lifeline.

Michael Hobby, 32, of Gainesville was addicted to heroin and fentanyl when he was arrested for drug possession in August 2021. After entry into the HELP Court program, he got sober, started taking medication for anxiety and depression, and built a stable life.

“I didn’t know where to reach out for help,” he said. “I got put in handcuffs, and it saved my life.”

Even as Donald Brown awaited his fate, he said he had started taking medication to manage his depression and has stayed sober because of HELP Court.

“I’ve learned a new way of life. Instead of getting high, I’m learning to feel things now,” he said.

Brown avoided jail that early December day. A hearing to decide his fate could happen in the next few weeks. But even if he’s allowed to remain in the program, Brown said, he’s worried it’s only a matter of time before he falls out of compliance.

“To try to improve myself and get locked up for it is just a kick in the gut,” he said. “I tried really hard.”

KFF Health News senior correspondent Fred Clasen-Kelly contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Jamie Holmes says a surgery center tried to make her pay for two operations after she underwent only one. She refused to buckle, even after a collection agency sued her last winter.

Holmes, who lives in northwestern Washington state, had surgery in 2019 to have her fallopian tubes tied, a permanent birth-control procedure that her insurance company agreed ahead of time to cover.

During the operation, while Holmes was under anesthesia, the surgeon noticed early signs of endometriosis, a common condition in which fibrous scar tissue grows around the uterus, Holmes said. She said the surgeon later told her he spent about 15 minutes cauterizing the troublesome tissue as a precaution. She recalls him saying he finished the whole operation within the 60 minutes that had been allotted for the tubal ligation procedure alone.

She said the doctor assured her the extra treatment for endometriosis would cost her little, if anything.

Then the bill came.

The Patient: Jamie Holmes, 38, of Lynden, Washington, who was insured by Premera Blue Cross at the time.

Medical Services: A tubal ligation operation, plus treatment of endometriosis found during the surgery.

Service Provider: Pacific Rim Outpatient Surgery Center of Bellingham, Washington, which has since been purchased, closed, and reopened under a new name.

Total Bill: $9,620. Insurance paid $1,262 to the in-network center. After adjusting for prices allowed under the insurer’s contract, the center billed Holmes $2,605. A collection agency later acquired the debt and sued her for $3,792.19, including interest and fees.

What Gives: The surgery center, which provided the facility and support staff for her operation, sent a bill suggesting that Holmes underwent two separate operations, one to have her tubes tied and one to treat endometriosis. It charged $4,810 for each.

Holmes said there were no such problems with the separate bills from the surgeon and anesthesiologist, which the insurer paid.

Holmes figured someone in the center’s billing department mistakenly thought she’d been on the operating table twice. She said she tried to explain it to the staff, to no avail.

She said it was as if she ordered a meal at a fast-food restaurant, was given extra fries, and then was charged for two whole meals. “I didn’t get the extra burger and drink and a toy,” she joked.

Her insurer, Premera Blue Cross, declined to pay for two operations, she said. The surgery center billed Holmes for much of the difference. She refused to pay.

Holmes said she understands the surgery center could have incurred additional costs for the approximately 15 minutes the surgeon spent cauterizing the spots of endometriosis. About $500 would have seemed like a fair charge to her. “I’m not opposed to paying for that,” she said. “I am opposed to paying for a whole bunch of things I didn’t receive.”

The physician-owned surgery center was later purchased and closed by PeaceHealth, a regional health system. But the debt was turned over to a collection agency, SB&C, which filed suit against Holmes in December 2023, seeking $3,792.19, including interest and fees.

The collection agency asked a judge to grant summary judgment, which could have allowed the company to garnish wages from Holmes’ job as a graphic artist and marketing specialist for real estate agents.

Holmes said she filed a written response, then showed up on Zoom and at the courthouse for two hearings, during which she explained her side, without bringing a lawyer. The judge ruled in February that the collection agency was not entitled to summary judgment, because the facts of the case were in dispute.

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Representatives of the collection agency and the defunct surgery center declined to comment for this article.

Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms, said it was absurd for the surgery center to bill for two operations and then refuse to back down when the situation was explained. “It’s like a Kafka novel,” she said.

Corlette said surgery center staffers should be accustomed to such scenarios. “It is quite common, I would think, for a surgeon to look inside somebody and say, ‘Oh, there’s this other thing going on. I’m going to deal with it while I’ve got the patient on the operating table.’”

It wouldn’t have made medical or financial sense for the surgeon to make Holmes undergo a separate operation for the secondary issue, she said.

Corlette said that if the surgery center was still in business, she would advise the patient to file a complaint with state regulators.

The Resolution: So far, the collection agency has not pressed ahead with its lawsuit by seeking a trial after the judge’s ruling. Holmes said that if the agency continues to sue her over the debt, she might hire a lawyer and sue them back, seeking damages and attorney fees.

She could have arranged to pay off the amount in installments. But she’s standing on principle, she said.

“I just got stonewalled so badly. They treated me like an idiot,” she said. “If they’re going to be petty to me, I’m willing to be petty right back.”

The Takeaway: Don’t be afraid to fight a bogus medical bill, even if the dispute goes to court.

Debt collectors often seek summary judgment, which allows them to garnish wages or take other measures to seize money without going to the trouble of proving in a trial that they are entitled to payments. If the consumers being sued don’t show up to tell their side in court hearings, judges often grant summary judgment to the debt collectors.

However, if the facts of a case are in dispute — for example, because the defendant shows up and argues she owes for just one surgery, not two — the judge may deny summary judgment and send the case to trial. That forces the debt collector to choose: spend more time and money pursuing the debt or drop it.

“You know what? It pays to be stubborn in situations like this,” said Berneta Haynes, a senior attorney for the National Consumer Law Center who reviewed Holmes’ bill for KFF Health News.

Many people don’t go to such hearings, sometimes because they didn’t get enough notice, don’t read English, or don’t have time, she said.

“I think a lot of folks just cave” after they’re sued, Haynes said.

Emily Siner reported the audio story.

After six years, we’ll have a final installment with NPR of our Bill of the Month project in the fall. But Bill of the Month will continue at KFF Health News and elsewhere. We still want to hear about your confusing or outrageous medical bills. Visit Bill of the Month to share your story.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.