Minding Houston Episode VI: The Appropriate Appropriators

Last week we talked about the consequences about not investing in mental health. It makes sense to ask: So who are the investors? Or more accurately, who is making the decisions about how and how much our state spends on mental health care? It turns out, for those of us in Greater Houston, we have Legislators in positions of leadership in the Texas House and Senate. In this episode, we look at the Legislators in position to make the financial decisions we will be watching in 2015.

This is Minding Houston, I’m Bill Kelly.

There is always a lot of focus on the “Big 3” of Texas Government. The Governor, the Lt. Governor, and the Speaker of the House get most of the press when it comes to big legislative initiatives. However it is the individual legislators who make up the committees who play a very large role in determining which areas of the budget are funded and which policy are passed.

Greater Houston is very fortunate to have a number of our elected officials in well placed position to affect what the Legislature does for mental health. To start off, newly appointed House Appropriations Chair John Otto now holds one of the most powerful positions in the entire Legislature. Elected to Represent Dayton, Texas in House District 18, the heart of his district is only 35 miles from downtown Houston. Rep. Otto is the first CPA to ever head the budget writing committee and clearly wants to let the numbers do the talking. When laying out the budget to the new members of the Appropriations Committee, Chairman Otto had the Legislative Budget Board feature mental health funding during the Overview on House Bill 1.

otto

“… moving on to page nine on mental health funding. House Bill One as introduced includes $2.6 billion in general revenue and $3.4 billion in all funds for behavioral health and substance abuse services. That goes to 17 agencies across five articles …”

Below, you can see the slides lawmakers were looking at detailing where House Bill 1, first one showing how mental health services are funded across 17 state agencies. The next slide deals specifically deals with the mental health and substance abuse funding in the Department of State Health Services.

Chairman Otto can choose whatever portion of the budget he would like to present when it comes to these overview hearings. The fact he included mental health funding shows his own focus on the issues and will hopefully resonate with members of his committee.

Sitting beside Chairman Otto is the Vice Chair of the Appropriations Committee Sylvester Turner. Rep. Turner is a 25 year house veteran and is regarded as one of the most knowledgeable members of the Legislature when it comes to the Appropriations Process.

During the testimony from staff with the Legislative Budget Board, Rep. Turner noticed that the base funding in House Bill 1 is predicted to generate a waiting list of over 900 adults statewide for mental health services.

speakerTurnerRep. Turner:  “So in comparison to what we did in the last biennium to this biennium what is the increase or decrease or are the things the same?”

“Across all of the agencies, again on slide 10, you can see is a $200,000 dollar general revenue increase so approximately the same as 1415 and then the $61 million dollar decline in all funds.”

Rep. Turner: “And then there is a waiting? Because last time we eliminated the waiting list for juveniles and adults, did we not?”

“Yes sir, I believe the waiting list for adults and children were funded last time.”

Rep. Turner: “Okay and with regards to where we are today the waiting list is returning?”

“Yes sir.”

Rep. Turner: “And the necessary cost to eliminate the waiting list there would be what?”

Shannon Sabine: “The estimated amount to fund the adult waiting list would at the moment would be about $13 million.”

Remember from our previous blog entries how Harris County is very much affected when the state is unable to serve those on the waiting list, having almost 30% of the wait list before services were funded in the last session.

Turner has filed House Bill 1393 that helps counties like Harris in funding Home and Community Based Services that provide medical assistance to persons with severe and persistent mental illness who are at the greatest risk of institutionalization. I spoke with Rep. Turner about this in Austin:

Bill Kelly: “I just caught Representative Sylvester Turner, Vice Chair of the Appropriations Committee walking off the house floor. Representative Turner, thank you for talking with us. You filed a legislation that is going to help Harris County really target the number of individuals who are at the risk of institutionalization by providing more medical assistance for health services. Could you talk a little bit about that bill?”

Rep. Turner: “Yes, there is such as tremendous need. People want to stay at home. They want that independence, that independent living and it enhances their own quality of life. So what is intended by the bill is to provide the necessary resources to keep them at home, to provide them with that support that’s needed to keep them at home, so we don’t have to put them in an institutionalized setting. That really cuts against their own quality of life and also not even beneficial or advantageous for the family members as well. And what I have found in my own personal experiences is that if you can keep people at their homes, in their communities, within that environment it’s just better for everyone around, for them as well as their family members and friends. “

Last week, subcommittees were named so that the 27 member House Appropriations Committee could focus closely on specific topic areas, often called Articles, in the budget. The Subcommittee for Health and Human Services that makes up Article II of the budget contains some very familiar faces for Harris County.

davisRep. Sarah Davis returns to this committee for her second straight session. Last session, she oversaw the Department of State Health Services budget that increased funding for behavioral health services by over $300 million. Rep. Davis represents the Texas Medical Center and has many constituents that work in health related fields. I spoke with her in Austin at a Subcommittee meeting on Wednesday.

Joining her is Rep. Armando Walle who will be serving on the Appropriations Committee for the 1st time since being elected in 2008. Rep. Walle meet with MHA in our offices during the interim to discuss state mental health policy and understands the needs of his district in getting access to services.

walle

Kelly: “I’m here with Representative Armando Walle before the sub-appropriations committee meeting for Article II. Representative Walle, you visited with us this summer and talked about your concern with your constituents about access to services, not only for the people of your district but particularly with Veterans and your personal experiences that you have. Now that you are on the committee do you look forward to being able to address a number of those issues?”

Rep. Walle: “That is correct. Being on the committee, reviewing all the budget, PowerPoints, looking at where the money is going, item by item. Mental health is a huge issue, particularly for access in my district. Obviously, we’ve done better recently, but I think we can do a lot more to help folks access mental health because sometimes it is a taboo in a lot of our communities where they don’t want to seek out help. And we need to inform our folks, particularly low income communities, that it is okay to seek help. One example is the military, matters where military personnel come from combat, suffering from PTSD and they might not know it. Dear friends who have suffered from it, family members who come back from war and need mental health services; that is a huge issue for my district, particularly young kids that have disciplinary issues or be overrepresented in the juvenile justice system. So it runs a gambit, but we do need more access to effective treatment, diagnosis for our young kids.”

Over on the Senate side of the building, we have a number of Legislators from Harris County looking to use their experience to help shape policy as members of the Senate Finance Committee.

First, we previously mentioned Senator John Whitmire’s service as Chair of the Criminal Justice Committee. Known as “The Dean” as the longest serving State Senator, Whitmire has represented Harris County in the Senate since 1982. His experience huffmanwill be key in securing the needed funding for community based programs.

Senator Joan Huffman has a background as a prosecutor and as Vice Chair of the Criminal Justice Committee and as Chair of the Senate State Affairs Committee. Last session, she authored SB 1185 with Senator Whitmire to create the Harris County Mental Health Jail Diversion Program.

During the October 2014 Texas Tribune Tribfest panel entitled “What’s Next for Mental Health?”, Senator Huffman talked about how she was able to work with her colleagues, including Finance Chair Jane Nelson, about providing more resources for mental health.

Texas Tribune Pic

Senator Huffman: “I think it really got us thinking, what can we do in Texas to address these issues? Clearly we’ve fallen behind in treating those who are mentally ill and providing services that they desperately need. And I just think sometimes it’s an issue that everyone can understand. People want to be more informed about the issue and we had really good leadership. I served with Senator Nelson, who was the Chair of Health and Human Services. She made it a top priority and many of us followed her and made it our priority and resulted in good things happening in Texas.”

Senator Larry Taylor serves not only on the Senate Finance Committee but chairs the Senate Public Education Committee. Senator Taylor will be a key player in seeing mental health funding, such as Mental Health First Aide, is distributed to educators across the state. Last session, $5 million was allocated to train educators in Mental Health First Aide, and 8 hour program that teaches how to help people developing a mental illness or in crisis. In Harris County alone, that means 400 teachers trained in Mental Health First Aide.

Freshman Senator Paul Bettencourt is serving his first term in the Texas Senate, taking over the seat previously held by Lt. Governor Dan Patrick. Senator Bettencourt has meet with our office and from his seats on the Senate Public Education and Higher Education Committees has a very unique position to help with mental health initiatives, especially the mental health loan assistant repayment program in SB 239.

This impressive lineup has a difficult task in front of it in securing the needed resources for mental health. They will need to hear from people across Texas to make sure that mental health isn’t ignored or pushed to the side. So when and how are people reaching out to thank, educate, and persuade legislators? More on that, next time.

This is Minding Houston. I’m Bill Kelly.


Music from this episode: “Badass” and Funky Suspense” by Bensound, “Motown ton” by Ton, “Einsame Verfolger” by Melophon and Premium Music

Thank you to the Texas Tribune. To listen to the complete “What’s Next for Mental Health?” panel, visit their Soundcloud.

Minding Houston Episode V – Criminal Justice & Mental Health: Connected Because of Failure

We’ve talked about funding and workforce needs for mental health services. So why is it so important that Texas lawmakers prioritize mental health services in view of all the other needs in the state? Well, my argument would be we are already paying for these mental health services, in a much more costly and difficult way: the criminal justice system.

This is Minding Houston, I’m Bill Kelly.

Before we start this, I have a caveat I’d like to place on the connection between mental health and criminal justice. Way too often, we closely associate the two and it sometimes seems that having a mental health condition makes you a criminal or a risk to society.

Hogg Foundation for Mental Health

The Hogg Foundation for Mental Health recently hosted a forum about violence prevention and mental health at the State Capitol. Some interesting stats that Dr. Joel Dvoskin the University of Arizona brought up included:

  • People suffering from a Severe and Persistent Mental Illness are 11 to 12 times more likely to be victims of a violent crime
  • If all violence related to mental illness were to go away, the overall reduction in violent crime would be only 4%
  • The odds of someone with schizophrenia killing someone is approximately 1 in 140,000

Let me be very clear: the only thing criminal about mental illness is the way we have failed to invest in access for treatment.

With that, let’s get back to how mental health and criminal justice are connected. Far too often, this failure to invest in access has lead to individuals entering the criminal justice system, instead of the public health programs. This leaves jails and prisons becoming the safety net for Texans suffering from a mental illness. The statistics clearly bear this out.

The Meadows Mental Health Public Policy Institute list “Smart Justice” as a priority for their work. The statistics they offer show exactly why:

  • Individuals with untreated mental health and substance use disorders at 8 times more likely to be incarcerated, often due to the lack of access to appropriate crisis services and ongoing care.
  • 34% of Texas inmates have a mental health need and most have substance use disorders
  • 17% of adults entering jails and state prisons have a serious mental health illness (SMHI)

Hogg Institute - Smart Justice

What does that mean for us here in Greater Houston? Well, just listen to Sheriff Garcia talk about how much of his work is consumed caring for inmates who are mentally ill:

Adrian-Garcia2

Houston Matters – June 9, 2014

Sheriff: I completely agree and look, I take pride in a lot of things being Sheriff of Harris County, but the one I don’t take pride in is the fact that the Harris County jail system is often referred to as the largest psychiatric facility in the state of Texas. And look, we don’t want people in the county jail for being sick. We want them there for having committed some terrible crime, but we don’t want them there because they are sick and that it is there illness that principally drives them to come to the attention of local law enforcement. And so we need the state to be responsible about this issue, responsible about the care that these individuals need and provide the citizens of Texas a better way to respond to those challenges that some families inadvertently are confronting.

Craig Cohen: Roughly speaking, what percentage of the jail population falls under the category of ‘these are people who are mentally ill and need in patient care and by default you have to provide it?’

Sheriff: Approximately 30%. I mean, just as Bill mentioned that number is very accurate. It’s about 30% of my population at any given time and you have to recognize the significance of the fact that it’s been 30% regardless of when I was overcrowded and at 12,000 – nearly 12,000 capacity or right now when I’m not overcrowded it’s still 30%. And again, they’re there principally because they are sick, not because they are bad people.

Now, Sheriff Garcia sees the consequences of a lack of access. Another elected leader who has dealt with the state’s criminal justice system is long time Texas Senate Criminal Justice Chair Senator John Whitmire. He clearly draws the line between the lack of access for the population to mental health care and prison.

ABORTION_LEGE_61_TR

Houston Public Media – Pilot Jail Diversion Program For Mentally Ill – August 21, 2014

According to the Department of Criminal Justice, roughly one third of the people in the Texas prison system have some form of mental illness.

Houston state Sen. John Whitmire chairs the Senate Criminal Justice Committee. He says those inmates end up in jail because they fell through the cracks and were not being treated for their illness.

Harris County Crisis intervention Response Team

“Thirty-two-thousand have been identified, that were in a mental health program before they ever committed a crime. But because of the lack of community mental health services in this state, because of budget cuts at 2003, they do not get assistance when they’re having an episode or crying out for help,” said Whitmire.

The re-entry program for these people doesn’t exist anywhere in the state, and Whitmire says that probably means a return to prison.

“They don’t get their counseling. They don’t get their medication. They’re bipolar; they’re schizophrenic. They have an altercation with their family or a neighbor. Law enforcement is called, then they have an altercation with law enforcement. Welcome to the criminal justice system,” said Whitmire.

With these statistics and testimonials, I think we can all agree about the problem facing those with mental illness and the unfortunate burden on the criminal justice system in providing care.

So how do we make treatment more available and accessible so jails aren’t the largest providers of mental health services?

Harris County has an idea: let’s keep patients out of jail.

Last Session, Senate Bill 1185 created the Harris County Mental Health Jail Diversion program. With bipartisan support from Senators John Whitmire and Joan Huffman, County Judge Ed Emmett pushed the Legislature to match Harris County’s investment to establish a system to address individuals suffering from a mental illness that cycled in and out of the Harris County Jail. SB 1185 looks to concentrate resources and coordinate social services so that patients get the care they need outside of jail cell.

StateofCounty

Houston Public Media – Pilot Jail Diversion Program For Mentally Ill – August 21, 2014

The Harris County Mental Health Jail Diversion program is the product of legislation passed by Texas lawmakers last year, that provided $5-million dollars for the launch.

Director Reginia Hicks says some goals of the program include the reduction of the frequency of arrests, incarcerations and the number of days spent in jail, to increase access to housing, health and social services, and to improve the quality of life.

“We have a special mental health program within our jails. We have specialty courts with judges that are focusing on behavioral health issues,” said Hicks. “We have providers with many years of experience.

We have the opportunity of making some earlier interventions.”

After the official launch, Harris County Judge Ed Emmett said he felt confident the Mental Health Jail Diversion program will serve as the model for other cities to emulate.

“The Legislature wants us to do it for four years, and then we will present to the Legislature what works,” said Emmett. “Because if it applies in Harris County, it clearly applies in the rest of the state, and then perhaps even the nation. So, I hope that what we develop here is the model program for the whole nation.”

Emmett and other officials often describe the county lockup as the “largest mental health facility in the state of Texas.”

It seems an obvious notion that people suffering from mental illness would be better served in clinical, rather than criminal settings. It is also much less expensive to provide acute inpatient or outpatient mental health care than the constant cycling of through county jails, prisons, and courts. The Houston Chronicle lauds the local programs that try and address this problem with this from their Editorial Board:

MASTHEAD-Houston-Chronicle

Harris County has adopted some strong programs. Teams of police officers and mental health professionals partner on targeted calls to help ensure that people with mental illness are not arrested unnecessarily. Through its pilot jail-diversion program, judges work with these professionals to keep those with mental illness from cycling through the criminal justice system.

However when Texas fails to invest in the needed clinical capacity for providing mental healthcare, we pay for it in terms of tax dollars and suffering. In a separate Editorial focusing on this need, the Chronicle states, “Our current system is pennywise and pound foolish,” and concludes with the following:

Harris County is the most populous region in the state. One in 5 people, or 350,000 adults residing in Harris County, will suffer from mental illness during their lifetime, according to Harris County Psychiatric Center. The Legislature should act next session to expand the capacity of the mental health system and give us more beds for patients in Harris County, preferably in a modern facility closer to home.

Given the strong support from our local elected leaders about the need for resources to expand capacity, who are our state leaders making these decisions? As of last week, both the Texas House and Senate have named committee chairs. What do those positions mean for mental health policy in Texas? More on that, next time.

This is Minding Houston, a presentation of Mental Health America of Greater Houston. I’m Bill Kelly.


Music from this episode: “Please Listen Carefully” by Jahzzar, “The War of the Sun Fist” by Gasc@t, “Impact Prelude” by Kevin MacLeod, “Manhattan Skyline” by DeeTunez , and “I’m Fine, Dear” by Dexter Britain. To listen to the full interviews and news sampled in this program visit Houston Matters, Houston Public Media and the Houston Chronicle. And a very special thank you to Cody McGaughey for lending your voice to this episode. 

Minding Houston Episode IV: The Mental Health Workforce

With the 1115 Waiver making investments in behavioral health services throughout the state, and especially here in Greater Houston, it’s natural to ask the question about the professionals needed to staff these new programs. And we don’t just mean psychiatrists, but the full spectrum of mental healthcare positions, just like those masters degree clinicians from MHMRA riding along with police officers for our CIRT units. In this episode, we’ll look at the best data to describe the mental health workforce shortage that should catch everyone’s attention, especially our lawmakers.

This is Minding Houston, I’m Bill Kelly.

Before jumping into legislative solutions about how to attract more mental health professionals, it makes sense to ask the question, “do we really need them?” Or, to say it another way, what are the consequences of not having an adequate mental health workforce? A 2011 report by the Hogg Foundation for Mental Health entitled “Crisis Point: Mental Health Workforce Shortages in Texas” gives a clear answer on what we face:

The cost of mental illness does not simply disappear when service providers are not available. Instead, these costs transfer to other less effective, more expensive and unprepared environments, such as prisons and hospitals. Research and experience clearly show that the lack of sufficient mental health services often results in hospitalization, incarceration or homelessness, creating far greater economic and human costs.

Supporting a strong system of mental health services isn’t just for the benefit of people with mental illness. Mental health and wellness are important to all Texans. Without a strong mental health system, communities suffer through lost productivity, unemployment, job absenteeism, increased involvement with law enforcement, and increased local hospital costs.

Now, for anyone who cares about the bottom line in budgets, the quality of life for patients, and need for a healthy Texas, these consequences are simply unacceptable. Alright, so we know there is a problem, but how bad is it?

Hogg 11

The report sites the following:

  • Compared to California, New York, Illinois and Florida – the other four most populous states – Texas has the most severe short¬age of psychiatrists, social workers and psychologists
  • The pool of mental health professionals is aging. In the coming decade, many psychiatrists, social workers and other providers will leave the workforce for retirement.
  • These shortages are felt most acutely in rural and under served areas of Texas, such as the border region.

Code Red LogoUnfortunately, things haven’t improved since this report was released in 2011. One of the most respected health care groups in Texas just released a report this January that echoes many of the same concerns. In an interview with Houston Public Media, Code Red’s task force chair and former state demographer Steve Murdock discusses the situation with behavioral health:

Maggie Martin: Medicaid wasn’t the only issue or concern that was raised in this report and something maybe especially raised for Houston, being the home of the Texas Medical Center. What are some of the issues and concerns the task force found within the health care profession itself?

Steve Murdoc: Well, I think that’s one of the things that we found is of course In areas, particularly in behavioral health, we are very short in terms of personnel. We have a wonderful medical center and it does lots of things very well but when it comes to behavioral health we lag behind many other states. I gave you the earlier example of 49th in terms of psychiatry in the country and so certainly we have areas in our health care system where we need to provide more physicians. We have for years, for example, lacked enough residencies. Now the reason that is so important is that one of the best predictors of where a physician will end up practicing is where he or she does their residency and we actually export people to residencies in other states which means that they are likely or less likely to come back and practice in Texas. So a number of things about our program are such that indicate we can also do a better job of ensuring we can get as many of those excellent students that we produce from our medical schools to stay and practice in Texas …

The good news is the Legislature is paying attention. In fact, during the last legislative session in 2013, Republican Representative Cindy Burkett from North Texas, and Democratic Representative Carol Alvarado from Houston co-authored a bill calling for a study of the Texas Mental Health Workforce Shortage and possible solutions.

The final report was issued in the September of 2014, and as you would expect, it confirmed the very serious problems Texas will face without immediate investment. Out of the five themes discussed in the report, the first recommendation is the most important in addressing this problem. Quoting from the report:

At its core, the mental health workforce shortage is driven by factors that affect recruitment and retention of individual practioners. Chief among these factors, as studies and stakeholders suggest, is that the current payment system fails to provide adequate reimbursements for providers, especially in light of the extensive training necessary for practice.

Furthermore, more students may be attracted to the mental health professions by strengthening graduate medical education and by exposing them to opportunities in the mental health field earlier in their education.

Like a lot of public policy, it boils down to money. Our state has failed to invest in this area, and unless we start making a down payment for our mental health workforce, we will undoubtedly suffer the consequence that a lack of access brings.

That’s where Sen. Charles Shwertner comes in. The new Texas Senate Chair of Health and Human Services is tackling the issue of mental health workforce for the full spectrum of providers. The Texas Tribune’s Alana Rocha reports:

Bluebonnet officials say that a bill by health and human services committee chairman Charles Schwertner could elevate the prestige of the profession and help workers balance their desire to serve the mentally ill, make ends meet, and pay off their loans. Schwertner filed a bill Monday to create a grant program to repay loans for licensed professionals, social workers, psychiatrists and psychologists.

“Money spent on mental health is money that is effectively spent. It keeps people out of the emergency room, it keeps people out of the jails and also the school resources that are spent on individuals that need help. If you can catch someone early, get them the right treatment in the right setting that’s the way to handle mental health. It’s cost effective.”

“There’s a huge return on investment for this.”

Andrea Richardson knows first-hand as the executive director of Bluebonnet she worked with Senator Schwertner, himself a practicing physician on developing the bill that creates a commitment from professionals seeking loan reimbursement. The percentage of the loan repayment grows with each year they work in the field.

“It recognizes the value of mental health. It allows for mental health to become a part of the health care system. You know so often we disconnect the mind from the body when in reality it’s the mind and the body working together that keeps us healthy.”

An integrated approach to addressing a growing need.

So, how did this trained orthopedic surgeon suddenly becomes one of the leading advocates for mental health in the entire Texas Legislature? Well, as the Houston Chronicle Editorial Board writes in support of his bill, he might have just been listening to mother:

MASTHEAD-Houston-Chronicle

Each of our incoming legislators will bring varied life experiences to the next session and its upcoming debates over spending and priorities. That’s certainly true of state Sen. Charles Schwertner, R-Georgetown. Schwertner, one of the few doctors in the Legislature, is not only an experienced orthopedic surgeon but also has some familiarity with mental health care. Schwertner’s mother spent over 25 years as a nurse in Texas’ mental health system. The state senator has a habit of saying that he knows firsthand what impact a dedicated mental health professional can have on the life of someone suffering from mental illness.

After reviewing many of the same statistics cited in the previous studies, the Chronicle concludes:

The Legislature should make Schwertner’s mother proud and act to pass his bill, a good first step in heading off this growing crisis.

So we’ve heard from the Hogg Foundation for Mental Health, the medical experts at Code Red, a workforce shortage study of House Bill 1023, and the newly filed mental health loan repayment bills and we hope our Legislators listen to Senator Schwertner’s mom.

But what happens when we don’t listen? In this case, what happens when we fail to provide access for mental health services? Quite simply, we face the same health challenges but we face them in a criminal justice setting. More on that next time.

From Minding Houston, I’m Bill Kelly.


This weeks episode includes “Dirty Night,” “Settling In,” and “Slow Motion Strut” by composer Dexter Britain and “Ego Grinding” by Megatroid. Hear more of Dexter Britain’s music at DexterBritain.co.uk and Soundcloud and listen to “Ego Grinding” at FreeMusicArchive.com

View the 2011 Hogg Report here and read Code Red: The Critical Condition of Health in Texas for detailed information about the Texas mental health workforce shortage. Listen to the full Houston Matters interview with Code Red’s task force chair and former state demographer Steve Murdock and hear more about Charles Schwertner’s loan reimbursement bid at the Texas Tribune website.