One Month In: A Look at the 85th Legislature

On Tuesday, January 10, the 85th Texas Legislature was officially gaveled into session. As we mark the close of the first month of this biennial 140-day period, our team at Mental Health America of Greater Houston took a quick look back at what has happened thus far inside Austin’s Pink Dome.

Biennial Revenue Estimate
Comptroller Glenn Hegar released the 2018-2019 Biennial Revenue Estimate (BRE) on Monday, January 9, kicking off the 85th Legislative Session with a bleak fiscal report that left lawmakers with roughly $104.9 billion in general revenue funding for the state’s two-year budget. The 2018-2019 BRE is approximately $7 billion less than the 2015 allocation, largely because of low oil prices coupled with the required reallocation of billions of tax revenue dedicated to the State Highway Fund following the passage of Proposition 7* in 2015.

Estimates suggest that it would require $109 billion in general revenue monies to fund state programs at currently established levels. In July, anticipating the budget shortfall to come, Governor Greg Abbott, Lt. Governor Dan Patrick and House Speaker Joe Straus requested all state agencies to scale back their budget requests by 4 percent in an effort to curb government spending. Mental and behavioral health services were deemed priority funding areas, along with funds for public schools, border security, and Child Protective Services, and were excluded from the required 4 percent scale back scenarios. However, the 2.7 percent decrease in overall funding for state provided services established by the Comptroller’s BRE in January leaves less money available for schools, child welfare, and health care, among many others, than originally expected – leading some advocates to call for legislators to dip into the Economic Stabilization Fund, commonly known as the “Rainy Day Fund,” which is currently valued at nearly $12 billion. Legislators have been reticent to draw funds from this emergency fund in the past, which points to difficult – and contentious – decisions to come.

*Proposition 7, passed by taxpayers in November 2015, requires the state to dedicate up to $5 billion in sales tax revenue to the State Highway Fund.

Base Budget Breakdown: SB 1/HB 1
On Tuesday, January 17, State Senator Jane Nelson, Finance Chairman, filed SB 1 – the  Texas General Appropriations Act, which serves as the Senate’s base budget and establishes state funding priorities for the next two years. SB 1 includes $103.6 billion of general state funding with overall spending — including federal and other funds — of $213.4 billion.

Like many of her colleagues, Senator Nelson shared concerns regarding “difficult decisions to make this session,” which makes the inclusion of key funding items for mental and behavioral health significant as they signal the Senate’s commitment to prioritizing these issues this session. Included in the budget is funding for workforce development, with an additional $44.1 million for Graduate Medical Education to ensure residency slots are available for Texas medical school graduates; and $260 million for Child Protective Services. To address current needs, SB 1 committed $1 billion for the state hospital system and facilities and $63 million for community mental health services to eliminate waitlists. Women’s health and veterans’ services programs maintained existing funding levels, including funding for Texas Veterans + Family Alliance, a $20 million grant program to assist veterans with post-traumatic stress and other mental health issues.

Shortly after SB 1 was filed, Texas House Speaker Joe Straus filed HB 1, the House’s initial 2018-2019 budget. HB 1 includes $108.9 billion in general fund allocations, approximately $4 billion more than the Comptroller’s estimated available revenue, and a total budget of $221.3 billion.

The House’s base budget touts a significant investment in public education, child protection, and mental health services, while only increasing the state budget by less than one percent. “We keep overall spending low while making investments in children and our future … This is the first step toward producing a balanced budget that reflects the priorities of the Texas House and does not raise taxes,” said Speaker Joe Straus.

Under the House budget, mental and behavioral health services receive $162 million of additional funding. These funds would eliminate wait lists for mental health services and allow for the implementation of many of the House Select Committee on Mental Health’s recommendations, including efforts to increase the implementation of early identification and jail diversion programs across the state. As in SB 1, HB 1 also earmarks monies for the treatment of post-traumatic stress disorder among veterans.

Nearly $8 billion separates the Senate and House base budgets [difference between the Senate and House base budgets ] and we have until May 29th to see how negotiations between the two chambers unfold.

House Select Committee on Mental Health – Interim Report to the 85th Texas Legislature
In early January, the House released an interim report from the Select Committee on Mental Health. Speaker Joe Straus formed the Select Committee in November 2015 to better understand the existing behavioral health system for adults and children in Texas. Chaired by Representative Four Price, the Select Committee on Mental Health held eight hearings throughout 2015-2016. Representatives Garnet Coleman, Sarah Davis, and Senfronia Thompson served as Houston’s representatives on the committee.

When he announced the formation of the committee, Speaker Straus identified the need for “[a] smarter approach to mental health” and expressed his hope that this approach would result in “improve[d] treatment and care while saving taxpayers money.” The interim report is intended to “give the House valuable guidance,” on how to make positive advancements in behavioral health during this legislative session.

The interim report highlights opportunities to solve existing service gaps and key takeaways include:

  • Prioritizing early intervention and prevention measures – especially among school age children;
  • Expanding innovative public school-based programs;
  • Sustainability of the 1115 Transformation Waiver / DSRIP funded programs;
  • Expanding bed capacity by expanding step-down beds to provide a continuum of care, including expanding jail diversion programs for nonviolent offenders;
  • Continuing to address mental health workforce shortages through educational incentives and by expanding the availability and utilization of technology, such as telemedicine;
  • Integrating healthcare to treat the whole person, physically and mentally, although questions remain among the committee surrounding the implementation.

Committee Assignments: Senate and House Committees Announced
On January 18, Lt. Governor Dan Patrick announced Senate committee assignments for the 85th Legislative Session. The Houston delegation includes Chair and Vice Chair assignments to the Criminal Justice, Education, and State Affairs, Intergovernmental Relations, and Business & Commerce Committees, and is represented on committees relevant to behavioral health work.

houston-senate-delegation

Traditionally, behavioral health bills pass through the Senate Health and Human Services Committee, but to monitor the Center for School Behavioral Health’s bills and issues relevant to Veterans Behavioral Health Initiative, MHA of Greater Houston will also watch the Senate Education Committee and Senate Veteran Affairs & Border Security. Houston Senator Borris Miles is a member of the Health and Human Services Committee. The Education Committee had two members of the Greater Houston delegation: Senator Larry Taylor, Chair, and Senator Paul Bettencourt.

Health and Human Services Committee

Role Senator City
Chair Charles Schwertner Georgetown
Vice Chair Carlos Uresti San Antonio
Member Dawn Buckingham Lakeway
Member Konni Burton Colleyville
Member Lois W. Kolkhorst Brenham
Member Borris L. Miles Houston
Member Charles Perry Lubbock
Member Van Taylor Plano
Member Kirk Watson Austin

Education Committee

Role Senator City
Chair Larry Taylor Friendswood
Vice Chair Eddie Lucio, Jr. Brownsville
Member Paul Bettencourt Houston
Member Donna Campbell New Braunfels
Member Bob Hall Edgewood
Member Don Huffines Dallas
Member Bryan Hughes Mineola
Member Kel Seliger Amarillo
Member Van Taylor Plano
Member Carlos Uresti San Antonio
Member Royce West Dallas

Senate Veteran Affairs & Border Security

Role Senator City
Chair Donna Campbell New Braunfels
Vice Chair Don Huffines Dallas
Member Dawn Buckingham Lakeway
Member Bob Hall Edgewood
Member Eddie Lucio, Jr. Brownsville
Member José Rodríguez El Paso
Member Carlos Uresti San Antonio

On February 9, Speaker Straus shared House assignments to the 38 standing committees, as well as the creation of two new select committees: the Select Committee on State and Federal Power and Responsibility and the Select Committee on Texas Ports, Innovation & Infrastructure.

houston-house-delegation

The Houston delegation includes Chair assignments to Appropriations, County Affairs, General Investigating & Ethics, Government Transparency & Operation Juvenile Justice & Family Issues Local Consent & Calendars, Public Education, Special Purpose Districts, and Urban Affairs. Vice Chairs committee assignments from the Greater Houston area include Corrections, Environmental Regulations, Economic & Small Business Development, International Trade & Intergovernmental Affairs, Judiciary & Civil Jurisprudence, Special Purpose Districts, and Texas Port, Innovation, & Infrastructure.

House Committees of particular interest to MHA of Greater Houston are Public Education, Human Services, Public Health, and Defense & Veterans’ Affairs. Representative Dan Huberty chairs Public Education and members include Representative Alma Allen, Harold Dutton, Jr. and Dwayne Bohac. Public Health membership includes Representatives Garnet Coleman and Tom Oliverson. Houston-area legislators make up half of the membership of the Human Services Committee with Representatives Mark Keough, Rick Miller, Valoree Swanson, and Gene Wu.

Public Education

Role Representative City
Chair Dan Huberty Houston
Vice Chair Diego Bernal San Antonio
Member Alma Allen Houston
Member Joe Deshotel Beaumont
Member Harold Dutton, Jr. Houston
Member Lance Gooden Terrell
Member Dwayne Bohac Houston
Member Ken King Canadian
Member Linda Koop Dallas
Member Morgan Meyer Dallas
Member Gary VanDeaver New Boston

Human Services

Role Representative City
Chair Richard Peña Raymond Laredo
Vice Chair James Frank Wichita Fall
Member Mark Keough The Woodlands
Member Stephanie Klick   Fort Worth
Member  Toni Rose  Dallas
Member Rick Miller Sugar Land
Member Ina Minjarez San Antonio
Member Valoree Swanson Houston
Member Gene Wu Houston


Public Health

Role Representative City
Chair Four Price Amarillo
Vice Chair J.D. Sheffield Gatesville
Member Garnet Coleman Houston
Member R.D. “Bobby” Guerra Mission
Member William “Bill” Zedler Arlington
Member Diana Arévalo San Antonio
Member Nicole Collier Fort Worth
Member Phillip Cortez San Antonio
Member Stephanie Klick Fort Worth
Member Tom Oliverson Cypress

Defense & Veterans’ Affairs

Role Representative City
Chair Roland Gutierrez San An
Vice Chair César José Blanco El Paso
Member Diana Arévalo San Antonio
Member Stan Lambert Abilene
Member Briscoe Cain Deer Park
Member Dan Flynn Canton
Member Terry Wilson Marble Falls

Stay Engaged: Know Your Reps, Advocacy Taskforce, and Social Media 

The procedural nature of the Texas Legislature requires a somewhat paradoxical mix of steadied patience and swift action. In this space, we’ll discuss effective advocacy strategies in the weeks ahead. One simple step to begin to make your voice heard in Austin is to become familiar with the offices of your State Senator and State Representative. Find their district and capitol offices, save their phone numbers, and research the issues they care about the most.

Here within Mental Health America of Greater Houston, the Center for School Behavioral Health and the Women’s Mental Health Initiative joined forces and launched an Advocacy Task Force for the 85th Texas Legislature. The Task Force will be instrumental in advancing legislation around children and women’s mental health in the coming months. We welcome anyone interested in helping our cause to join the Task Force and our Rapid Response Team. For more information, visit our Advocacy Task Force page or email Lauren at lpursley@mhahouston.org.

To keep up with our advocacy work, check back in with Minding Houston every other Thursday starting February 23, like us on Facebook and follow us on Twitter.

Minding Houston XVI: Capacity Questions Answered

 

Whenever the topic of mental health is discussed, one of the most repeated solutions is to increase capacity, usually in the common phrase, “we need more beds.” But do people really have the facts on what the bed capacity issues are for Harris County, and how does that play into what bed capacity issues face the state? Today, we talk to a leader for Harris County’s inpatient mental health hospital to get very specific on capacity issues.

This is Minding Houston, I’m Bill Kelly

Sgt. Joe Friday should have taught public policy. His “just the facts” line is one of my favorites and carries the objective tone of trying to boil down a problem to its core. So it is in that Dragnet spirit that I hope you don’t mind if we focus on a few graphs and numbers to get the story on capacity for state psychiatric beds.

DSHS Graph - Bed Capacity

The Texas Department of State Health Services has often presented the above slide in talking about the number of publicly funded beds available in the Texas State Hospital system. The graph shows two sets of numbers: first, the state hospital psychiatric beds represented with the light blue line, and secondly state funded (or private) psych beds represented by a red line. The black line at the top shows the sum of these two numbers and the overall trend in patient capacity for the state.

What’s apparent from this graph are two things which are important to note when looking at future trends regarding capacity options:

First, the number of state-owned beds has largely flat-lined since 2006, which shows that despite recent investments at the state level, Texas has not increased inpatient capacity for state-owned beds.

Secondly, the number of state-funded, private beds has more than doubled during that same time period, moving close to 20% of the state bed capacity total.

Clearly, the preferred option to increasing state bed capacity has been to buy, rather than build.

However, one number is not included in this data set that is the most important in answering what the real situation is with regards to the capacity of inpatient beds in Texas, and that’s population. Anyone who is living in Texas knows the explosive population growth seen in the past two decades, and in order to get the whole picture, the number of Texans needs to be accounted for in this data.

In a presentation to the Senate Finance Committee on January 15th, Assistant Commissioner Lauren Lacefield Lewis presented the following slide that tracks the total number of state beds to state population, and the numbers are not encouraging:

DSHS - Capacity Rate

From the graph, you can see that Texas is currently at the lowest ratio of beds to population since 1994. So in talking about what the psychiatric bed capacity for Texas is, we are starting from the lowest point based on population.

But aside from just the overall population, there’s another factor putting added pressure on the number of psych beds available for Texans: the criminal justice system. In the same presentation to Senate Finance, Mrs. Lewis showed the following slide that confirms a trend that first reached a tipping point in 2014. That trend is that more people are admitted to the Texas State Hospital system through forensic commitments than civil.

DSHS - Commitments

2014 marked the first year that more people entered the state hospital through the criminal justice system (a forensic commitment) than were voluntarily committed (civil commitment). And the trend has continued in 2015 and 2016.

This is a dangerous situation, as the public safety of Texans is now using up resources designed to make sure Texans have access to mental health beds. And the consequences are already showing up in real world situations right here in Harris County.

Chronicle

According to a March 4th Edition of the Houston Chronicle, the number of beds for forensic commitments were supposed to take up a third of the Texas State Hospital system but have instead become a majority.

The case of Shannon Miles, who stands accused of the murder of Harris County Sheriff’s Deputy Darren Goforth last August, has had more than its share of strange twists and turns. The case also has highlighted yet another problem with how the state deals with the mentally ill among us.

To review, Goforth was shot 15 times as he walked to his patrol car at a gas station. Sheriff’s deputies within a day arrested Miles, who has a history of mental illness. On Feb. 9, he was found mentally incompetent to stand trial after experts agreed he suffers from schizophrenia, and he was ordered to Vernon State Mental Hospital in North Texas. There he would receive a 120-day mental evaluation to determine whether so-called competency restoration is possible. As of this writing, he’s still in the Harris County Jail – the state’s largest de facto mental health facility, by the way – because some 60 other Harris County inmates are in line to go to Vernon ahead of him.

In 2012, a Travis County judge ruled that defendants requiring a forensic bed at a state mental hospital couldn’t be made to wait in jail for more than three weeks. Forensic beds are the spaces set aside for defendants, like Miles, who need psychiatric treatment to get well enough to stand trial. As Emily DePrang reported in the Texas Observer in 2014, they’ve had to wait in recent years for an average of six months.

Long waits are still the rule, despite the judge’s ruling, because Texas has less than 2,500 beds at its 10 state mental hospitals; less than a third of those are designated for forensic commitments. The cruel irony is that every bed used by someone from a jail is one less bed available for people who have committed no crime.

The wait list for the state hospital is another example of the lack of access for mental health owing to a capacity for treatment. The bottleneck for violent offenders at the Vernon State Hospital is just one example.

Houston Matters

Another example is the overall number of people who are dependent on the public mental health system. Recently, our favorite radio program Houston Matters had me on to talk about the need for crisis clinics while highlighting a new walk-in clinic opened in Meyerland by Memorial Hermann. Houston Public Media has done an extraordinary job when it comes to highlighting mental health, which I think is evident from the questions asked by Houston Public Media’s Craig Cohen. Here’s the part of our interview focusing on the need for services:

Craig Cohen: Bill Kelly, we do tend to think of the need for 24/7 physical health emergency care. Is it something that we tend to forget or not take seriously that there is a need for 24/7 – particularly in the overnight hours – emergency mental health care?

Bill Kelly: Well, I would just point to the overall numbers and then when you look at the gap in coverage and access it really emphasizes the need to invest in them. And according to our State Health and Human Services Commission, we have about half a million Texas adults that suffer from a severe and persistent mental illness. Now severe mental illness results in a serious functional impairment which substantially interferes or limits one or more major life activities. When you add the “persistent” that means that those symptoms have lasted over a year. So if you have half a million adults that breaks down in Harris County to right at 150,000 adults. Now, we know from our Mental Health Needs Council assessment that about 90,000 of that 150,000 have no access to public or private insurance. So the very systems that Memorial Hermann and other partners with the 1115 waiver are trying to build out are badly needed for this group. Like Theresa said, if people do not get the medical services that they need and the mental health care that they need, their safety net all too often is emergency rooms that are already crowded and a system that has a coverage gap or, unfortunately, our criminal justice system.

The capacity question here in Harris County is one that should draw attention. Having such a scarcity of access will place an inordinate demand on existing resources. The relief provided by the expanded footprint of behavioral health from the 1115 Waiver’s DSRIP projects, such as this crisis clinic, should be viewed as vital. We cannot afford to lose these new programs when the waiver expires later in 2016.

Fortunately, we have a resource locally that helps with the inpatient capacity that makes Harris County the envy of other places in Texas. I sat down with Stephen Glazier, Chief Operating Officer of the Harris County Psychiatric Center, or HCPC, to talk about the role his facility plays in helping provide capacity right here in Harris County:

GlazierBill Kelly: I’m here at the Harris County Psychiatric Center (HCPC) with Steve Glazier. Thank you so much for taking the time to meet with us today. I wanted to first go through and describe the mission and capacity here at HCPC and how it really fits into the behavioral health network of providers here in Houston.

Steve Glazier: So HCPC is primarily a short-term acute care psychiatric hospital. We do have a few units that are designed for patients that stay a little bit longer, three or four or five weeks, but the majority of beds are short term acute care which means the patients stay roughly seven to eight days. We are a 276 bed hospital. Currently, we are renovating units; we are going to have our 30th birthday in the fall and 30 years of 8,000 admissions a year. It’s time to do some renovations. So not only are we making the units nicer, we’ve been able to redesign them in a way that also makes them safer, it makes them more therapeutic. So we are keeping one unit closed, we will renovate it and move units in and then we go to renovate the next one so we are operating 250 beds right now. We are the second largest academic psychiatric hospital in the country and we stay functionally full all the time. What I mean by functionally full is if we have an empty bed, it only means that the patient that has been assigned to that bed hasn’t arrived here yet. Every morning we start the day with a list of anywhere from 30 to 45 patients waiting to come in. Most days we are able to find everyone a bed the same day. We get the same number of discharges in a day, but we stay very busy and functionally full all the time. Houston-Harris County has very, very few civil commitments to the state hospitals anymore, so HCPC essentially fills that role for this area as well.HCPCUT

Kelly: And you mentioned being one of the second largest in the nation with regards to academics so to be clear, who funds HCPC?

Glazier: The majority of the beds and the patient days are funded by the state, out of state general revenue. A smaller portion is funded by the county and then also a small portion are funded – we have a few beds that are available for patients with third-party funding, so another small portion is third-party funding. Most of our funding comes from the Harris Center, through our contract with the Harris Center. We do have one contract that is direct with the county with the juvenile probation department so we have one unit that is set aside specifically for adolescents from the juvenile detention center, but the majority of our funding comes from state general revenue.

Kelly: And with that, what’s probably the biggest challenge that you face here at HCPC in order to really carry out your mission?

Glazier: One of the biggest challenges is trying to do our very best with the beds we have to accommodate all the demand for admissions that we have. We take very seriously our role to try to make sure that patients that are in emergency rooms and in hospitals around the medical center, patients that have been court ordered into treatment, patients that are coming in from the neuropsychiatric center that the Harris Center runs, that when we get requests that we are able to get those patients transported here and admitted as quickly as possible. But trying to balance that with trying to manage the patients and treat the patients that are here as thoroughly as possible is a real challenge; it’s a balancing act. We don’t want to push patients out early just to make a bed for someone else who is waiting. On the same token, I don’t want patients to be waiting inordinately long times in an emergency room or a psychiatric center. So trying to manage that queue, that waiting list, can be a real challenge.

Kelly: And on that exact challenge, taking it to the state-wide level, you’re in a position to be able to look at the way the state of Texas delivers a lot of that care. Do you want to talk a little bit about that position, some of the thoughts you bring with your experience at HCPC to that council?

Glazier: One of the difficulties that we have right now, and it’s worse in certain parts of the state, is there are some patients that need longer term care than just short-term acute care, than just a week. And it’s very difficult sometimes to get a civil commitment to a state hospital where a patient can stay longer and get the treatment they need. That is something that we have to figure out because the lack of those types of beds, not only those but also the lack of residential treatment beds for adults which is another low level of care, the lack of supportive housing beds, the lack of a continuum of beds from longer term acute care to shorter-term acute care to residential to supportive housing is what is causing this constant recidivism of some of our patients and is also part of what is causing this huge number of psychiatric patients who are in the Harris County jail. The Harris County jail is commonly said to be the largest psychiatric institute in the state. In fact, the Harris County jail on any given day has more psychiatric patients that it is housing than in all of the state hospitals combined in the state of Texas. Part of the reason for that is that there are some gaps in our treatment system that if we could fill those, if we had better places that had some treatment of care to discharge someone from HCPC into, and also had sufficient case management services to surround them with, we could eliminate a lot of those recidivists and a lot of those patients who end up in jail.

Kelly: Well, thank you for your time. I know all of you are busy doing so many things so thank you so much for taking some time to be with us.

HCPC

The Harris County Psychiatric Center has helped thousands of Harris County residents, and yet we know thousands more needs services. Capacity, especially for inpatient mental health services, is a challenge for all of Texans.

There are many issues to be brought up during the interim, and we look forward to hearing more from Chairman Four Price’s Select Committee on Mental Health. We hope this look at capacity has shown how statewide policy must address the ability for those seeking inpatient care to find it, and the consequences of a lack of investment in access.

This is Minding Houston, I’m Bill Kelly.


 

Music: “Clear Your Head” by Cory Gray and back beats by Frank Nora

Minding Houston XV: Workforce Shortage? We have an app for that!

Welcome to the first Episode of Minding Houston for 2016. While it has been a while since we last spoke, we’ve been holding off as this episode isn’t just about policy discussions, it’s about results. And we need your help to get the word out about a program critical to the future workforce of Texas.

This is Minding Houston, I’m Bill Kelly

Astute listeners to this blog know that we have talked a lot about the mental health workforce being a big obstacle to access. In fact, we devoted a whole episode to it last February (See: Minding Houston IV), and almost a year to the day later, we are happy to announce the state of Texas is taking applications.

Senate Bill 239 by Senator Charles Schwertner creates the Mental Health Loan Repayment Assistance Program and is funded with almost $3 million. Details of the plan are shared below. The most encouraging aspect of the legislation (now law) is the recognition that it isn’t not just a lack of medical physicians, but the full spectrum of mental health providers are sorely needed to treat Texans.

LR slide
While in Austin talking about the lead up to the February 8th application launch, I was able to sit down with one of the leading voices for health care in Texas, Stacy Wilson of the Texas Hospital Association, to talk about the importance of this program:

 

StacyWilson and THA

Bill Kelly: Here with Stacy Wilson of the Texas Hospital Association. Thank you so much for joining me today.
Stacy Wilson: It’s a pleasure.
Kelly: We are talking about SB 239 and the specific loan repayment mental health professions bill. Who should really be looking at taking advantage of these monies.

Wilson: There are five groups of mental health professionals that are targeted under the bill: psychiatrists, psychologists, APRNs who have specialized training in mental health, licensed professional counselors, licensed clinical social workers.

Kelly: And I know we are big fans of the inclusion of social workers, especially in Houston, on it. When we talk about the monies that are available – and I know there is some restriction on exactly how many of each group can be included on that – what do people need to watch out for if they are interested in pursuing a degree in one of these fields?

Wilson: Well the great thing is that now we have included this beyond just physicians as you mentioned, but there are requirements around serving the CHIP and/or Medicaid populations and/or working in a state prison. So there are some certification requirements that you have to do, there is an application you have to fill out and at the end of each year in order to be eligible, you have to certify that you actually served that population and that you’ve met the other requirements.

Kelly: And we are going to be posting a link to information from the college coordinating board on our website, but what are some of the deadlines for people who would be applying for this for some of their graduate education?

Wilson: So what we’ve heard from the higher education coordinating board is that the applications will be available around February [8] and that they will probably be due around April 30. So there is a specific website that links to this as you have mentioned and those dates are a little flexible but obviously beginning February [8] you should start looking for them.

Kelly: And as we talk to different advocacy groups around our area, how important is this to get the message out about our workforce for behavioral health?

Wilson: It’s imperative. We can ask for all the services we want to ask and more impatient beds and outpatient services but unless you have that dedicated workforce, it doesn’t mean anything. So it is the backbone of everything else that we do

Kelly: Staci, thank you so much for joining us.

Wilson: Thank you so much

So, now here’s our deliverable. You will find a link to the Texas Higher Education Coordinating Board’s application for this program here. Now, we need you, the loyal listeners and mental health care advocates, to help get the message out by forwarding this information on to a number of audiences that need to hear it.

People we are targeting including undergraduate students looking to pursue a degree in one of the above-mentioned fields, current students already pursuing a graduate degree, college faculty or administrators, or anyone else who cares about access to mental health services.

Forward this message or cut and paste the URL for this blog to help us share this information. Our goal is to have as many people as possible help us spread the word about this new program. Texas deserves a workforce to help treat people suffering from a mental illness, and by getting the word out, you are doing your part to help make that happen.

Just as one of the newest mental health programs is rolling out, the Legislative focus is starting to heat up. On January 26th, the Senate Finance Committee, the budget crafting body for the upper chamber in the Texas Legislature, met to discuss two primary budget issues.

First, and what took up all of the media attention, was “Discussion on the Impact of Oil Prices and Production on State Revenue and the Budget” with Texas Comptroller Glenn Hegar testifying. Clearly, this was an important conversation to have, but for this session, it really boiled down to two numbers:

From the Texas Tribune:

Texas-Tribune

Texas Comptroller Glenn Hegar on Tuesday faced some skepticism as he sought to soothe lawmakers’ fears about what plummeting oil prices mean for the state’s bottom line.
“Is the sky falling?” asked Sen. Royce West, D-Dallas, at a hearing of the Senate Committee on Finance, which helps write the state budget.

“No, sir,” Hegar replied, adding that while there are “clouds on the horizon,” he’d rather be in Texas than in any other state.

“I just don’t want to live in a state of denial,” West responded.

{…}

Though Hegar has noted that oil’s plunge means Texas will send hundreds of millions fewer dollars toward road construction and maintenance than originally expected, the drilling slowdown should not leave lawmakers with a revenue shortfall, he said.

In fact, much of the certified revenue estimate Hegar released in October has stayed accurate — even though it was based on significantly higher oil prices — because producers are pumping more oil than anyone expected, Hegar said.

“The budget you passed – it works, and it will continue to work,” Hegar said, noting that lawmakers also left a significant cushion of unallocated funds.

That wiggle room totals about $4 billion, said Ursula Parks, director of the Legislative Budget Board.

There’s the number: a current $4 billion surplus of unspent funds available for the 2016-2017 session. Hegar’s assessment that despite the fall in oil prices that “the sky is not falling” is a very insightful remark. Especially in view of the second number.
According to testimony given by Comptroller Hegar on January 26th, the state has $9.6 billion in the Economic Stabilization Fund, commonly referred to as the state’s “Rainy Day Fund.” Given that the two-year total, or biennium budget, for the state was set at $209.4 billion, having almost $10 billion in the bank is a good position to be in, but should Texas not be spending some of that on needed programs?
The Pew Charitable Trusts released a report on January 19th describing how state’s save money in rainy day accounts and takes a special notice of Texas. Here’s what Pew writes about how Texas has decided to move on this issue:
Pew Trust log

Given the state’s other pressing budgetary priorities— particularly the need for improved water and transportation infrastructure and a desire to reduce the state’s total amount of outstanding debt—Texas lawmakers have been divided over whether the current level of reserves is sufficient or excessive.
At the heart of this debate lies a basic disagreement over the intended purpose of the Economic Stabilization Fund. “It’s become a surprisingly emotional issue in the political debate,” said Dale Craymer, president of the nonprofit Texas Taxpayers and Research Association and a former legislative aide who helped House leaders draft the 1987 constitutional amendment that created the fund. “The last two sessions, the rainy day fund has taken on this sacred nature that was never really intended. It was intended as a management tool.”
As revenue and spending pressures shift along with the booms and busts of the economy, states stand to benefit from the additional flexibility provided by robust rainy day funds to smooth over unexpected bumps in the road. Despite having billions of dollars in its rainy day fund, Texas struggles to answer the question of how much is enough because the state lacks a clear consensus on why the fund exists in the first place. Absent a clear purpose for saving, other states also find it extremely difficult to set a meaningful savings target, which can confound their efforts to manage the budgetary ups and downs of economic activity.

View Report: Pew Charitable Trusts – Why States Save

 

jane nelson

Senator Jane Nelson

While the Legislature deals with those numbers, one thing is clear: there is no need to cut services, especially for newly expanded behavioral health access. The Comptroller was clear in his assessment, and we hope lawmakers continue their investments in better access and quality of services, no matter what the cost of a barrel of oil.

The second part of the meeting, after all the media attention on oil prices left, was on behavioral health funding. Chair Jane Nelson was distressed about inaccurate news reports about how much Texas was spending on behavioral health.
As followers of Minding Houston, you should know all of our numbers come from the Legislative Budget Board, the same body that testified before Senate Finance. A link to their presentation is below, and as someone who has worked for a member of the House Appropriations Committee, these are the numbers I use when looking at state expenditures.

To give a recap of the presentation, the most informative slide is pictured below in what was the main point of the budget conversation: Texas spends about $3.6 billion in a biennium on behavioral health services across 18 agencies in 5 separate articles of the state budget. And as Chair Nelson repeatedly (and very rightly) points out, that total does not include Medicaid expenditures. See the slide below for a good breakdown:

BH Slide

With everyone on the same page with regards to the numbers (again, minus Medicaid), the Finance Committee expressed concern regarding the ability to coordinate spending and break down silos among various state agencies.
This is where Sonja Gaines steps in. As the Associate Commissioner for the Office of Mental Health Coordination for the Health & Human Services Commission, not only does she have a long job title, but a long list of programs to oversee and make work together.

SonjaGaines
A good example of how programs are being integrated came from Sean Hanna, Director of the Military Veteran Peer Network. He testified that after meeting with Gaines, this agency had begun to better coordinate with existing state resources of the Texas State Guard. This has greatly expanded the network of mental health peers working with our state’s armed services by maximizing existing resources.

The presentation notes that the statewide coordinating council should be developing a coordinated expenditure proposal for fiscal year 2017, and that as state budget writers, Chair Nelson will make sure any exceptional items match up within those plans.
The Health and Human Services Commission will submit that proposal to the Legislative Budget Board on June 1st of 2016.

Lastly, I wanted to mention that the new House Select Committee on Mental Health will be holding their first hearing on February 18th. We are looking forward to seeing what direction Chairman Four Price of Amarillo takes in the initial hearing.

 

photo series

Chairman Price, Rep. Thompson, Rep. Davis, Rep. Coleman

As a quick reminder, our Harris County members on this committee include Representatives Senfronia Thompson, Garnet Coleman, and Sarah Davis.

As the Legislature starts to dig into policy and resources, be sure to stay tuned to Minding Houston for the latest information on how mental health policy discussions translate to better access and services in Houston.

This has been Minding Houston, I’m Bill Kelly.

 


 

Music in this episode: “Viper” by Ray Rude, “True Hearts” by Nick Jaina, and “Fly Drexler” by Lazlo Supreme

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.

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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 III: The 1115 Medicaid Waiver in Houston

What if I told you the State of Texas and the federal government are working together, on an $11.4 billion partnership to help increase access to care for Texans? There are no lawsuits, political posturing, or name calling. The program is praised by Republicans, Democrats, and every healthcare organization across the state. Sound impossible? Well, let me tell you: it’s all true. And when it comes to increasing behavioral health services, it’s even better.

This is Minding Houston, I’m Bill Kelly. 

Today, we wanted to talk about the biggest expansion of behavioral health services in Texas. Ever heard of the 1115 Waiver? Well, if not, maybe it’s because it hasn’t generated the, let’s call it the “heat” that other federal initiatives have here in Texas.

So first things first, what is the 1115 Waiver? Simply put, it is a 5 year agreement between the federal Center for Medicare & Medicaid Services, or CMS, and the Texas Health and Human Services Commission, or HHSC. Together, CMS and HHSC have negotiated a plan to combine state dollars spent on healthcare to draw down matching federal funds all in an effort to expand the footprint of healthcare services in Texas.

1115 Medicaid Waiver made easy

       1115 Medicaid Waiver made easy

So what does this really mean for us in Greater Houston? As it turns out, quite a lot. Over our nine county Regional Health Partnership (one of 20 organized throughout the state), we stand to gain over $2.3 billion dollars in expanded healthcare services.

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So, what do these programs look like? Well, let me introduce you to two programs funded
by the 1115 Waiver. First, in a report by Houston Public Media’s Carrie Feibel, is a look at Mental Health Crisis Clinics set up by Memorial Hermann.

Now, as we’ve noted before, the lack of access to mental healthcare leaves an increasing number of cases to be handled by law enforcement. That’s where our second example, the Crisis Intervention Response Team comes in. In this story by KHOU reporter Jeff McShan, you can see first hand the difference having both a mental health professional and law enforcement training has in dealing with a mental health crisis.

Both the Memorial Hermann mental health crisis clinics and three CIRT details are funded by the 1115 Waiver using Delivery System Reform Incentive Payments, or DSRIP funds. In our area, there are 55 projects specifically for Behavioral Health totaling $457 million dollars. Now, remember from last week, our state spends just over 1 billion a year in mental health services through DSHS for the entire state, and DSIRP dollars put almost half a billion right here in our own backyard.

This badly needed expansion of access for mental healthcare represents a huge step forward for the State of Texas. But it also brings a number of challenges. Like, do we have enough of a workforce to staff this expansion? What is the mental health workforce shortage and what we can do about it? More on that, next time.

This is Bill Kelly for Minding Houston, a presentation of Mental Health America of Greater Houston.


Music from this episode: “Rollin at 5 – 210” by Kevin MacLeod and “Sand Castle” by Pitx.

To hear Carrie Fiebel’s full report about the Humble Crisis Center, listen here at Houston Public MediaTo hear more about the HPD Crisis Intervention & Response Team (CIRT), watch here at KHOU.com.