Minding Houston XVII: Parity Disparity

With all the issues surrounding mental health, perhaps none has a bigger impact than parity. But parity also happens to be one of the hardest to understand and hardest to implement. In this episode, we will look at the legislative history of parity, current problems with enforcement, and a new ruling that impacts parity across the country. Insurance parity for behavioral health coverage makes providing behavioral health services possible and it is impossible to improve access without it.

This is Minding Houston, I’m Bill Kelly.

When we talk about parity, we need to talk a little political history. The Houston Chronicle’s Jenny Deam wrote about the situation regarding parity and its roots in federal legislation, and she sums it up nicely:

Chronicle

“President George W. Bush signed a law requiring any insurance policy that included mental health treatment to be equal in coverage to medical treatment, in an effort to stop the long-standing practice of charging higher co-pays for mental health care, limiting treatment or denying it outright. It was cheered as a triumph for the nation’s millions with mental illness.

The measure was further strengthened in 2010 with the passage of the Affordable Care Act, which extended federal parity requirements to individual and small-group plans and mandated mental health and substance abuse be covered in any plan sold on the federal marketplace or state exchanges.

But the lofty goal of equality has fallen far short of its promise, providers, patients and policy experts say.”

So with federal legislation passed, what’s the problem? Parity is the law of the land, why isn’t it the standard practice of providers? Well, as Ben Franklin once said, “”Justice will not be served until those who are unaffected are as outraged as those who are,” which I think was his way of stirring up those of us who care about behavioral health coverage. Deam’s article continues:

“In fact, certain managed care groups are well known within the Houston behavioral care community of having a “predictably higher rate of denials” and a “higher hassle factor,” says Dr. George Santos, chief medical officer and executive medical director at Houston Behavioral Hospital. “They hide behind statements like, ‘We are not telling you what to do.’ But I have had many instances where these physicians will make specific treatment recommendations regarding medications and doses. They will certainly say a patient no longer needs inpatient care and will deny approval.”

Take Dr. Richard Noel, medical director at IntraCare North, a Houston psychiatric facility. He spends hours each week on the phone arguing with doctors paid by insurance companies who have never seen his patients. He says he now has to prove that medications for inpatient children and teens are being adjusted every few days – often before the drugs have had a chance to work – or insurers will no longer cover a hospital stay. He says he has had issues with nearly all of the major insurance companies.”

What are the consequences when parity for behavioral health isn’t enforced with providers? Well, I would refer to statements made by Dr. William Streusand, an adolescent child psychiatrist at the Texas A&M Health Science center. He testified in front of the House Select Committee on Mental Health on March 22nd and answered the following question from Rep. Greg Bonnen, also a physician:

Bonnen: “You don’t take private insurance in your practice, why is that?”

Streusand: “I don’t have to.”

Bonnen: “Well, okay, could you elaborate on why you wouldn’t have to?”

Streusand: “Yeah, like I said it is a seller’s market.”

While that is true, what else is true, as followers of Minding Houston well know, is Texas has a scarcity of providers. How bad is the situation and how does it affect parity? From the Chronicle article:

“Texas ranks 47th out of 50 states and the District of Columbia in access to mental health care, and 50th in the number of mental health providers with only one for every 1,757 in the state, according to a study by Mental Health America. By contrast, Massachusetts, which ranks first, has one provider for every 248 people.

“They flat out tell me, ‘We don’t take insurance anymore because we have too much trouble getting paid,’ ” says Carrie Stowell, a single mother whose 16-year-old daughter has been diagnosed with bipolar disorder, attention deficit hyperactivity disorder and anxiety. She lives in Conroe and found 10 doctors in a 40-mile radius who treat adolescents, but only one is taking new patients or is in her plan. The wait for an appointment is six months.

Santos also feels the shortage. “It is extremely difficult to recruit a physician willing to work at an inpatient setting because of insurance,” he says.”

Because of poor parity enforcement, Texas finds itself in a situation where access to care is being limited not only to the number of providers but the number of providers that take insurance. Having a “cash only” payment model for behavioral health is a dangerous trend for Texas and can be one of the most limiting factors in the provision of care. Texas has too many people needing services to be a “seller’s market.” It is time to make some changes.

So how can this parity enforcement problem be addressed? Based on his experience as a prosecutor and his observations of the mental health needs of so many in the criminal justice system, Congressman Joe Kennedy III has a plan that he believes can help enforce the parity laws on the books. We talked with the Congressman about his Behavioral Health Coverage & Treatment Act last week:

BK & Kennedy

Bill Kelly and Congressman Joe Kennedy III

Kelly: I’m here today with Congressman Kennedy. Congressman, thank you so much for joining us. In December you filed your Behavioral Health Coverage and Transparency Act and, unlike in Texas where we face large problems due to our large uninsured population, this act primarily goes after folks with insurance looking to access services. What particular aspect really raised this on your radar screen?

Kennedy: So, I’ve been diving into issues around mental health now for a while, since I came into office and, actually, really beforehand. Before I ended up running for office, my first campaign, I was a prosecutor. I cannot tell you how many cases came across my desk from the district courts, lower courts, criminal courts in Massachusetts for folks struggling with either mental illness, substance abuse, drug abuse, or alcoholism and my boss at that point, a Republican DA,  said, “Your job is to make sure that person never commits another crime.”

And some folks are bad people and you lock them up for a long time. For others suffering from mental illness or substance abuse, the way you can do that is to treat the underlying condition. It doesn’t matter if you lock them up for three months if they are not able to get treatment for their mental illness or get clean off of a heroin addiction.

So use the tools that you have in your tool kit to help address the underlying concern. As a prosecutor, there are some tools we got; there’s a lot that we don’t and from my perspective trying a bunch of drug cases and working with a lot of drug cases, I became convinced that the way to ensure that those files that were people’s lives on my desk, the way to actually address them much further upstream is to focus on prevention and treatment rather than on prosecution.

The question then becomes how do we make sure there is access to mental health care throughout our society? And as we start peeling back the layers on this, from my perspective on it, there are two main segments. There is the public side of things where folks get their healthcare from the federal government, Medicaid primarily. Medicaid is, of course, the largest payer of mental health care services in the country. Then there is, of course, the private side doing private insurance. We’ve started by looking at the private side marketplace.

What this bill’s focus is to say, look, the combination of mental health parity, which is a simple law that has helped expand coverage, but it’s the combination of mental health parity and the Affordable Care Act that actually said as an essential health benefit in order to participate in these exchanges, you have to actually cover mental health care. So we have the combination of the Mental Health Parity Act, which says we have to treat mental health care like we do physical health care, and then the Affordable Care Act, which says you have to now cover mental health care. That leads to a huge expansion in coverage for states, particularly those who took the Medicaid expansion, which not all states did.

The challenge though is that the marketplaces still are not functioning so we still hear cases all over the country that say “I don’t need to take insurance,” because there are so many people that are in need of care and so few doctors that the doctors are essentially empowered to say “I can cherry pick my clients, I can make sure to get rates that are higher that other insurance companies will reimburse me for and I’ll just be an all-cash doctor.”

The problem with this is that you can’t just create more doctors overnight. So there are systemic issues that are affecting our ability in this country to have patients that are suffering from mental illness to actually access mental health they need. One other step for you: according to one study I saw recently 55% of the counties across our country do not have a single practicing psychiatrist, psychologist or social worker, 55% of the counties across our country!

So when we start talking about trying to get access to care, insurance is an important part to this, but we have to make sure you can actually get a doctor and stay treated. So the bill that we filed is a first step in trying to basically force insurance companies to divulge information around how they are actually covering mental health care. As you know, there are many people that are suffering from mental illness who get their insurance claims denied at a much higher rate than those suffering from typical, physical maladies such as a broken leg or a broken arm. So this bill will hopefully shine a light on some of those practices and force insurance companies to actually make this transition to focus on prevention and treatment, rather than triage at the back end of mental health.

Kelly: And you mention that this bill, it doesn’t put forth any new regulations as much as it focuses on transparency the for given laws that you mentioned with parity and the ACA.

Kennedy: Absolutely. Part of the way we crafted this is to say, look we are not trying to add any additional burden to these insurance companies, but disclose the methodology at which you end up making your decisions and make sure that information is available and digestible to regulators so we can actually start to shine a light on this and ask are things actually going as they should – which case there might be something else that needs to be done – or are they not?

And the idea behind this bill is that if insurance companies can essentially get away with not covering people at the back end when they are in need of mental health care, then there is essentially no reason for them to make the investment they need to actually force the focus of treatment to move up that scale to prevention and treatment rather than just focusing on the back end for folks that end up in a crisis point.

So what we want to do is try to take a step back and say how are we going to address access to mental health care in the system? It needs a full-on continuum of care adjustment. We need the private sector to play a role in that and I think a critical piece to it is by getting insurance companies to not just focus on the back end, the really expensive cases of triage after you’re becoming the victim of mental illness, but to focus on treatment and prevention on the front end. How do we flesh that out? We make sure that you are actually abiding by the terms of the regulation that are already in place.

Kelly: When you talk about the regulations that are already in place, one of the things that make mental health and behavioral health a very bipartisan issue is that people in a very partisan health care landscape, have been really willing to come together. You’ve seen bills move both in the House and the Senate. Do you see your bill possibly being able to hitch onto one of these bills that seem to be making some headway down the track?

Kennedy: Absolutely hope so. This is something that I think Democrats and Republicans agree on, that our mental health system is in crisis. Whether it was folks in Congress that have had similar experiences to me as prosecutors saying this is a real problem, whether you see it in emergency rooms because you have some doctors in Congress, or you are a member in Congress involved in trying to help our access to health care period.

And if you go around even hospitals in Massachusetts it’s one of the things you will hear about in emergency departments is there are a lot of people in their EDs suffering from mental illness. So we hear about this all the time; the question is how do we go about addressing it, again in that full-on continuum of care model? I hope that this legislation will address this, either as a standalone or perhaps as an amendment to one of those other pieces of legislation that we have been working hard on. We have been working with some of our colleagues on it and they have been doing a really good job. There is also a really tricky issue on how to make these reforms across the entire system and some of my colleagues and I are trying to dive into this so hopefully we will get there.

Kelly: Well, thank you, Congressman so much for your time today and for your work on this really important issue that I hope gets the traction that it needs. Like you said, this is a critical first step to ensuring that those with private coverage get the help that they need.

Kennedy. Thank you for your time too, Bill.

As the Congressman mentioned, the largest payer of behavioral health services in the country is Medicaid. And a recent announcement by the Department of Health and Human Services is good news for increasing access.

On March 29th, the Center for Medicare & Medicaid Services (often referred to as CMS) announced the new rule in coordination with President Obama’s visit to the National Rx Drug Abuse and Heroin Summit. From the press release:

CMS

” . . . the Centers for Medicare & Medicaid Services (CMS) today finalized a rule to strengthen access to mental health and substance use services for people with Medicaid or Children’s Health Insurance Program (CHIP) coverage, aligning with protections already required of private health plans. The Mental Health Parity and Addiction Equity Act of 2008 generally requires that health insurance plans treat mental health and substance use disorder benefits on equal footing as medical and surgical benefits.

“The Affordable Care Act provided one of the largest expansions of mental health and substance use disorder coverage in a generation,” HHS Secretary Sylvia M. Burwell said. “Today’s rule eliminates a barrier to coverage for the millions of Americans who for too long faced a system that treated behavioral health as an unequal priority. It represents a critical step in our effort to ensure that everyone has access to the care they need.

“This rule will also increase access to evidence-based treatment to help more people get the help they need for their recovery and is critical in our comprehensive approach to addressing the serious opioid epidemic facing our nation.”

“The need to strengthen access to mental health and substance use disorder services is clear,” said Vikki Wachino, Deputy Administrator of CMS and Director of the Center for Medicaid and CHIP Services. “This final rule will help states strengthen care delivery and support low-income individuals in accessing the services and treatment they need to be healthy.”

The protections set forth in this final rule will benefit the over 23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP.

A link to the press release and the finalized rule can be found here

Overall, our goal at MHA of Greater Houston has been to make the provision of behavioral healthcare a successful business model. After all, if people want to access services, there needs to be providers available to treat them. Parity can help provide the basic regulatory functions under which providers can be paid in a timely manner for their services. And it is already the law . . .

Parity will continue to be a big issue at the state and national level. We look forward to continuing to work with our elected leaders in Austin and Washington to make sure parity coverage is enforced. Without this level playing field, progress in mental health care access continues to be an uphill battle.

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


 

Music for this Episode: “Hotel Rodeo”, “Quisling”, and Bricolage” by Anitek and “Vacate the Premises” by Deadly Combo

TGSO–Thank God Session’s Over–Post

Monday, May 27th, marked the 140th and final day of the 83rd Regular Session of the Texas Legislature–Hallelujah! Though the Governor immediately called a special session to deal with redistricting, I think I can say that we’ve seen all we’re going to see regarding behavioral health. Lots of bills have passed, lots of bills have died, and lots of money has been appropriated to improve the statewide mental health and substance abuse service system. Read on for more…

Budget Wrap-Up

The conference committee report for SB 1 passed both the House and Senate over the weekend and will soon be on its way to the Governor. In the end, the Legislature appropriated an additional $312.5 million over and above the base budget to mental health and substance abuse services. Key (though not all) initiatives that were funded include:

Mental Health

Children and Adult Mental Health Waiting List Elimination: $48.2 million
1915i Home and Community Based Services and Rental Assistance: $24.8 million
YES Waiver: $58.6 million
Crisis Services: $25 million
Haven for Hope-like Projects: $25 million
Underserved at LMHAs: $17 million
School-based Training on Prevention/Early Identification: $5 million
Public Awareness: $1.4 million
Harris County Diversion Program: $10 million
Harris County Psychiatric Center: $2.4 million
Veterans Mental Health Services: $4 million
NorthSTAR Increase: $6 million

Substance Abuse

Substance Abuse Capacity Expansion: $4.9 million
Substance Abuse Provider Rate Increase: $10.7 million
Oxford House Expansion: $1.1 million
Substance Abuse Slots for DFPS: $10.1 million

In addition, the Legislature designated $43 million to address the per capita inequities between Local Mental Health Authorities (LMHAs) across the state. This means that Harris County MHMRA will receive additional funding to bring it closer to the statewide per capita average.

Finally, I should mention that the Legislature restored about $3.9 billion in funding to public schools, though with inflation and enrollment growth, it still leaves schools far short of where they were before last session. This funding includes an increase of just over $11 million for Communities in Schools, which will allow the program to serve approximately 30,000 more students per year.

To look more closely at mental health and other items in the budget, check out LBB’s budget documents here.

Behavioral Health Legislation

There were many great pieces of behavioral health legislation that passed during the 83rd Legislature. A couple questionable ones passed as well, but the good far outweighed the bad. Instead of posting all of the legislation that passed, I’m going to refer you to our trusty bill chart here. Just about everything is updated, except for some of the summaries that don’t reflect amendments that were made to the bills after they were introduced. To read the text of the bill, simply click on the bill number. Bills that have a black box next to them died, with the exception of a few that were successfully amended onto other legislation. I will discuss some of those bills, and a few other key ones below.

The first bill I want to boast about is SB 460, which will require mental health trainings in educator preparation programs. The bill was successfully amended to include SB 1178/HB 3225, which will require mental health trainings for current teachers and administrators and SB 1352/HB2477, which will require local school health advisory committees to make recommendations on strategies to prevent mental health concerns among students. This bill, which originated from the Harris County School Behavioral Health Initiative, was one of MHA Houston’s top priorities for the session. Additional legislation that quite nicely dovetails with this bill is HB 3793. Included in HB 3793 is language from SB 955, which will set up a fund for LMHAs to train individuals to deliver Mental Health First Aid (MHFA). The fund will allow MHFA to be delivered to educators free of charge. With the passage of these important bills, expect a significant and positive shift in the way students with behavioral health issues are handled in our schools!

Another big win was passage of HB 3105. This bill puts Texas in line with national insurance law standards by striking the provision in current statute that allows an insurer to refuse a claim of loss or injury due to the insured being intoxicated or under the influence of controlled substances. This was a top priority for the Association of Substance Abuse Programs and the Texas Association of Addiction Professionals and represents a major step in removing the stigma associated with substance use disorders.

Some great legislation affecting children also passed. SB 44 will require the Department of Family and Protective Services to report the number of children whose parents relinquished custody of them to the state solely for the purpose of obtaining mental health services and to study and make recommendations to prevent this practice. SB 421 will convert the Texas Integrated Funding Initiative to the Texas System of Care consortium to oversee and implement strategies to expand a state system of care for minors receiving residential or inpatient mental health services, who are at risk of being placed in a more restrictive environment to receive mental health services, and other at-risk populations. Both of these bills should help provide additional supports to children with SED and their families.

With the passage of SB 7 and HB 3793, the so-called “big three” of schizophrenia, bipolar disorder and major depression will be no more…that is, as a required diagnosis for treatment through LMHAs. Both of these bills included language from HB 2625, which expanded the list of diagnoses to include post-traumatic stress disorder, obsessive compulsive disorder, anxiety disorder, eating disorders, and “any other diagnosed mental health disorder”. As a result, indigent individuals with these “other” diagnoses can receive needed ongoing treatment through LMHAs rather than being managed from crisis to crisis, which all too often is the case.

Lots of other great bills passed, so be sure to check MHA Houston’s bill tracker for more detailed information.

A Little on Medicaid Expansion

Of course, one of the biggest missed opportunities this session was making headway on the expansion of coverage for individuals up to 133% of the Federal Poverty Level as set forth by the ACA. The expansion rider that the Senate initially included in the budget ultimately was removed due to concerns that the House would kill the entire budget as a result. So where does this leave us? Some speculate that during the interim the Governor will allow HHSC Commissioner Kyle Janek to negotiate some type of “Texas solution” with CMS after all. This blogger, who’s been observing the Governor since 1999 when he was a younger and far more flexible Lt. Governor, is somewhat doubtful of that. But would Gov. Perry really allow Texas to leave billions of federal dollars on the table and leave hundreds of thousands of Texans uninsured? I think the answer lies in his plans for 2014 and 2016, which are still unknown.  I’m sure we’ll hear far more on this issue in the coming months.

Has This Blog Been Helpful?

Well, if you’ve read this far (or at least skipped to the bottom), I consider you a Texas Legislative Blog Stalwart! This will be my last post for a while as I work on session wrap-up and oh, all the other stuff I’m supposed to be doing in my job besides legislative stuff! But if this blog added a little knowledge, a little joy, a little humor, a little something, ANYTHING to your life, why not post a comment and let me know? Your feedback is much appreciated! 🙂

That’s all for…a long time. Stay tuned for MHA Houston’s biennial Legislative Wrap-up.  Otherwise, enjoy your interim!

State and Federal Updates

In this post, surprisingly NO budget updates, but a little on Medicaid and federal and state behavioral health legislation.

Medicaid Expansion Being Debated Today

This morning, the House Appropriations Subcommittee on Budget Transparency and Reform heard testimony on HB 3376 by Rep. Sylvester Turner, which would expand Medicaid to all individuals eligible under the ACA.  As previously mentioned, it is estimated that 90% of individuals currently receiving public mental health and substance abuse services would be eligible for Medicaid under such an expansion.

Dozens of advocates were out in full force to express their support for this important legislation.  NAMI Policy Director Greg Hansch and Hogg Foundation for Mental Health Fellow Peter McGraw gave testimony about the positive impact Medicaid expansion would have on people with mental illness.  The hearing recessed for House proceedings but will resume after the House adjourns for the day.

Other legislation the subcommittee will consider include HB 3791, Rep. Zerwas’ “Texas solution” Medicaid expansion bill, and HB 3339 by Rep. Martinez-Fisher, which would allow the use of Rainy Day Funds to restore the $5.4 billion cut from public schools last session.

Comprehensive Federal Behavioral Health Legislation Moving Forward

Last week I shared a little about S. 689, the Mental Health Awareness and Improvement Act, which is being sponsored by Health, Education, Labor and Pensions (HELP) Committee Chairman Tom Harkins. The bipartisan bill was introduced after the HELP Committee’s January hearing to assess the state of the country’s mental health system. The bill was voted unanimously out of the HELP Committee last Wednesday and is now awaiting action by the full Senate.

The bill takes a number of positive steps to promote prevention and early intervention and improve the delivery of mental health and substance abuse services. From the Section-by-Section analysis (with a few minor revisions), key provisions of the bill include:

• Encouraging the development of school-wide prevention programs, such as positive behavioral interventions and supports.

• Encouraging states to provide technical assistance to school districts and school personnel on the implementation of school-based mental health programs.

• Reauthorizing the Youth Suicide Early Intervention and Prevention Strategies grants to states and tribes.

• Reauthorizing the Mental Health and Substance Use Disorder Services on Campuses grant program and updates the use of funds to allow for the education of students, families, faculty, and staff to increase awareness and training to respond effectively to students with mental health and substance use disorders, to provide outreach to administer voluntary screenings and assessments to students, and to enhance networks with health care providers who treat mental health and substance use disorders. Incorporates consideration of the needs of veterans enrolled as students on campus.

• Reauthorizing grants to states, political subdivisions of states, Indian tribes, tribal organizations, and nonprofit private entities to train teachers, appropriate school personnel, emergency services personnel, and others, as appropriate, to recognize the signs and symptoms of mental illness, to become familiar with resources in the community for individuals with mental illnesses, and for the purpose of the safe de-escalation of crisis situations involving individuals with mental illness.

• Reauthorizing the National Child Traumatic Stress Initiative.

• Requiring a Government Accountability Office (GAO) report on the federal requirements affecting access to mental health and substance use disorder treatment related to integration with primary care, administrative and regulatory issues, quality measurement and accountability, and data sharing.

• Directing the Substance Abuse and Mental Health Services Administration to advance the education and awareness of providers, patients, and other stakeholders regarding FDA-approved products to treat opioid use disorders; calls for a report on such activities, including the role of adherence in the treatment of opioid use disorders, and recommendations on priorities and strategies to address co-occurring substance use disorders and mental illness.

• Requiring a GAO report on the utilization of mental health services for children, including information about how children access care and referrals; the tools and assessments available for children; and the usage of psychotropic medications.

• Encouraging the Secretary of HHS to disseminate information and provide technical assistance on evidence-based practices for mental health and substance use disorders in older adults.

• Requiring a GAO study on the status of implementation of recommendations developed after the Virginia Tech tragedy, as well as identification of any barriers to implementation and identification of additional actions the Federal government can take to support states and local communities to ensure the Federal government and laws are not obstacles at the community level.

We will continue to monitor and share updates on this bill as it makes its way through the legislative process.

Behavioral Health Legislation

Many pieces of legislation MHA is tracking continue to be on the move. In the last week, the following bills have passed out of committee or their respective chambers:

VOTED OUT OF COMMITTEE

HB 592
Relating to the definition of serious mental illness for purposes of certain group health benefit plans. 

HB 1947
Relating to the criteria for commitment of a person with mental illness.

HB 1952
Relating to professional development training for certain public school personnel regarding student disciplinary procedures.

HB 2392
Relating to the mental health program for veterans.

HB 2812
Relating to an annual report by the reentry and integration division and the parole division of the Texas Department of Criminal Justice.

SB 34
Relating to the administration of psychoactive medications to persons receiving services in certain facilities.

SB 861
Relating to requiring certain notices to be posted on the premises of certain alcoholic beverage retailers. 

SB 913
Relating to the reexamination of an applicant for a professional counselor license. 

SB 914
Relating to a behavior improvement plan adopted for certain students with an individualized education program.

SB 1356
Relating to requiring trauma-informed care training for certain staff of county and state juvenile facilities.

VOTED OUT OF CHAMBER

HB 232
Relating to allowing certain minors convicted of certain alcohol offenses to perform community service instead of attending an alcohol awareness program.

HB 807
Relating to the practice of psychology; authorizing a fee.

HB 1738
Relating to a standard form of notification for the detention of a person with mental illness.

SB 718
Relating to voluntary and involuntary mental health services.

SB 831
Relating to a list of mental health, substance abuse, and suicide prevention programs that may be selected for implementation by public schools.

SB 898
Relating to the mental health program for veterans.

SB 1057
Relating to information about private health care insurance coverage and the health insurance exchange for individuals applying for certain Department of State Health Services health or mental health benefits, services, and assistance.

SB 1114
Relating to the prosecution of certain misdemeanor offenses committed by children and to school district law enforcement.

SB 1178
Relating to training for public school educators in identifying mental health and suicide risks among students.

SB 1352
Relating to inclusion of mental health concerns in existing state and local coordinated school health efforts.

For a more in-depth view of behavioral health legislation and MHA’s position on these bills, check out our bill tracker here.

More next week!

The Budget, Parity and Bills

In this post, more about the budget, a little news on parity, and bill updates, including exciting news about school behavioral health legislation.

Budget Amendments

As I mentioned last week, the full House is scheduled to take up and consider CSSB 1, the budget bill, this Thursday. House members pre-filed a total of 267 budget amendments, which will make for a loooong day for members. Several behavioral-health related amendments have been pre-filed, including:

An amendment by Alonzo, which would require the collection of behavioral health outcomes data for indigent & Medicaid-eligible LGBT youth;

An amendment by Bohac, which would designate 5% of children’s mental health funding to mental health promotion, literacy and personal safety activities. This is a recommendation from the School Behavioral Health Initiative;

An amendment by Burnam to require expansion of Medicaid to all populations eligible under the Affordable Care Act;

An amendment by Sarah Davis to fund best practice-based school behavioral health programming; and

An amendment by Naishtat to fund an institution of higher education to provide technical assistance to communities across the state in implementing evidence-based and promising practices to serve children with Serious Emotional Disturbance.

All 267 amendments can be found here.

Getting Serious on Parity

As many of you know, the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act (MHPAEA) passed in 2008. However, to this date, the Obama Administration has not issued final rules for the law, which leaves in limbo some of the treatment and coverage requirements of the law. There has been speculation that some insurance companies have been skirting provisions of the law, and now, finally, the first class-action lawsuit citing MHPAEA violations has been filed. The lawsuit, which was filed in New York, accuses United-Health, UHC Insurance, United Healthcare of New York, and United Behavioral Health of violating the law by, among other things, limiting psychotherapy visits and denying long-term treatment. In the absence of final rules, there may be more lawsuits filed that seek to clarify these provisions.

If you are someone you know feels your insurance company is denying you needed mental health or substance abuse services in violation of MHPAE, please visit the national Mental Health America Parity Center to share your story. The Obama Administration needs to hurry up and issue those almost 5 year-late rules, or they may end up writing themselves through lawsuits!

Bill Updates

We’ve had some major movement on a number of mental health and substance abuse bills, but before I cover the full list, I want to hone in on specific school behavioral health legislation that passed Senate Education last week.

For those who recall, I mentioned in an earlier post that Sen. Dan Patrick, Chair of the Senate Education Committee, has previously expressed support for behavioral health initiatives and that I hoped we would see that reflected in the legislation that passes his committee. Well, last Thursday that hope came true!

The Senate Education Committee heard 3 pieces of school behavioral health legislation that MHA is supporting:

SB 831
Relating to a list of mental health, substance abuse, and suicide prevention programs that may be selected for implementation by public schools;

SB 1178
Relating to training for public school educators in identifying mental health and suicide risks among students; and

SB 1352
Relating to inclusion of mental health concerns in existing state and local coordinated school health efforts.

Particularly on SB 1178, the committee heard very moving testimony from a number of family members who have lost loved ones to suicide, including Linda de Sosa, a School Behavioral Health Initiative participant. After the testimony, two witnesses who initially were opposed to the bill withdrew their opposition.

All three bills sailed out of the committee unanimously, and the bills were referred to the Local and Uncontested Calendar. If they remain on that calendar, they will pass the Senate without debate.

Thanks to everyone who testified in favor of, or registered support for, these important bills.  We’ve got to start investing in prevention and early intervention if we are truly going to improve outcomes for children and adults down the line!

Other behavioral health legislation on the move include the following bills that have been voted out of committee:

HB 915
Relating to the administration and monitoring of certain medications provided to foster children.

HB 978
Relating to the transportation of certain patients to a mental health facility.

HB 1738
Relating to a standard form of notification for the detention of a person with mental illness.

SB 11
Relating to the administration and operation of the Temporary Assistance for Needy Families (TANF) program.

SB 1115
Relating to reporting, standards, and restrictions regarding public school disciplinary actions.

In addition, the following bills have been voted out of their respective chambers:

HB 144
Relating to a mental examination of a child subject to the juvenile justice system.

SB 36
Relating to the detention and transportation of a person with a mental illness.

SB 58
Relating to the integration of behavioral health and physical health services into the Medicaid managed care program.

SB 152
Relating to the protection and care of persons who are elderly or disabled or who are children.

SB 250
Relating to the requirements of using certain technology to conduct certain mental health hearings or proceedings.

SB 256
Relating to tracking career information for graduates of Texas medical schools and persons completing medical residency programs in Texas.

SB 401
Relating to a notification requirement if a school counselor is not assigned to a public school campus.

SB 462
Relating to specialty court programs in this state.

SB 715
Relating to use of consistent terminology to refer to school counselors in the Education Code.

SB 944
Relating to criminal history record checks for certain employees of facilities licensed by the Department of State Health Services.

SB 1185
Relating to the creation of a mental health jail diversion pilot program.

To see MHA’s full bill tracker for summaries and positions, click here.

That’s all I’ve got for now!  Toodles!

A Little News Here and There

In this post, an update on the budget, a look at how Harris County squares up health-wise, and the status of a few bills.

On the Budget

Last Wednesday, the Texas Senate passed CSSB 1, the budget bill, on a vote of 29-2. The only “no” votes were newly elected Senator Sylvia Garcia and Senator Wendy Davis, largely due to the fact that the Senate version restored only $1.4 billion of the $5.4 billion cut from public schools last session. On Thursday, the House Appropriations Committee substituted the bill with its own version and voted it out unanimously.

There are not significant funding differences for mental health and substance abuse services between the two bills, but one issue of note is that the House version added $2.5 billion for public education–over $1 billion more than did the Senate.

The full House is scheduled to take up CSSB 1 next Thursday, April 4th. A great thing about the House (at least to an advocate like me) is that all 150 members have an equal opportunity to put their imprint on the budget by offering amendments on the Floor. Expect anywhere from 200-300 amendments to be filed by this Thursday’s deadline, including a couple recommended by MHA. 🙂

State of Health in Harris County

In the recently released 2013 County Health Rankings and Road Map, a joint project of the Robert Woods Johnson Foundation and University of Wisconsin Population Health Institute, Harris County ranked 70th among 232 counties. This is down from a rank of 53 last year. Williamson County was ranked first, and Polk County was ranked last. The rankings take a variety of health factors into consideration, including poor health and mental health days, excessive drinking, physical activity, and the rate of uninsured. For a complete look at the rankings, click here.

Bills on the Move

Many pieces of legislation that MHA is tracking are on the move.  You can view an update on them all by checking MHA’s bill chart.  Bills that recently have been voted out of committee include:

HB 232
Relating to allowing certain minors convicted of certain alcohol offenses to perform community service instead of attending an alcohol awareness program.

HB 591
Relating to the health professions resource center.

HB 1872
Relating to federal firearm reporting for a person who voluntarily identifies as a person with mental illness.

SB 1185
Relating to the creation of a mental health jail diversion pilot program.

In particular, I want to call attention to HB 1872, which would require the Department of Public Safety (DPS) to include in the information it reports to the Federal Background Check System a person who voluntarily identifies himself or herself to DPS or local law enforcement as a person with mental illness who should be precluded from purchasing a gun.

MHA and several other advocacy organizations oppose this legislation because it unfairly and discriminatorily singles out people with mental illness.  While there may indeed be people with mental illness who would voluntarily place themselves on this list, there are likely just as many people without mental illness who would do the same.  In my view, this legislation unnecessarily stigmatizes an entire group of people. Thankfully, the good folks at MHA Texas are working on a floor amendment that would strike the reference to mental illness in the bill.  If it comes up for a vote on the Floor, look for an advocacy alert on that amendment, and please be sure to contact your representative and show them your support!

“A pen rather than a lance has been my weapon of offence and defence; with its point I should prick the civic conscience and bring into a neglected field men and women who should act as champions for those afflicted thousands least able to fight for themselves.”

–Clifford Beers: mental health consumer,Yale graduate, and founder of the National Committee for Mental Hygiene, predecessor of Mental Health America

Write ya next week!

All About the Budget…and a Little More

In this issue, get more detailed information on the mental health and substance abuse services funded by the House and Senate budget bills, information on how sequestration will affect behavioral health, and as always, a bill update.

Senate Budget On Its Way to the Floor

Last Wednesday, the Senate Finance Committee voted out its budget bill, CSSB 1, which includes over $200 million more for behavioral health services.  Since I’ve previously outlined the approved Senate mental health and substance abuse initiatives, I won’t repeat all of that information. However, there are a few budget riders–“footnotes” that designate funding for certain purposes–worth mentioning:

  • Requirement that DSHS withhold 10% of appropriated funds to each Local Mental Health Authority (LMHA) for ongoing community and crisis mental health services and distribute the funds based upon a performance-based incentive plan
  • Requirement that DSHS develop a 10-year plan for the provision of psychiatric services at state hospitals (with the inclusion of public input)
  • Designation of children’s mental health prevention and early intervention funds for  evidence-based curricula that train school personnel and community members about the signs and risks of mental health issues
  • $8 million of appropriated funds designated for the veterans mental health program
  • $8 million of appropriated crisis funds designated for outpatient competency restoration programs

House Makes Amends

As I mentioned in my last post, also on Wednesday, the House Appropriations Committee approved over $200 million more for mental health and substance abuse services as well. This was a reversal from earlier Article II Subcommittee decisions that amounted to just $33 million more for behavioral health. The House budget bill, which will be substituted in place of the Senate bill when it makes its way over to the House, funds the following services:

Mental Health

  • $54.2 million to eliminate the ~6,500 person waiting list for mental health services
  • $24.8 million to expand housing support options for people with mental illness
  • $32.5 million to expand the YES waiver
  • $25 million for Haven for Hope-like community parterships
  • $25 million to expand crisis services
  • $20 million to expand community mental health services for children and adults
  • $17 million to increase service package offerings for underserved children and adults
  • $6 million to expand NorthSTAR services
  • $4 million for veterans mental health
  • $2.4 million for 6 long-term treatment beds (up to 90 days) at the Harris County Psychiatric Center

Substance Abuse

  • $6 million to increase substance abuse provider rates by 3.9%
  • $5 million for substance abuse services for individuals referred by DFPS
  • $4.9 million to eliminate the 946-person substance abuse service waiting list
  • $1.1 million to expand the Oxford House model across Texas

Additionally, Representatives Sylvester Turner and Ruth Jones McClendon submitted a rider to the budget that would ensure that increased mental health funding would address inequities among LMHAs. If maintained in the final version of the bill, this would mean that Harris County MHMRA, which has one of the lowest per capita funding rates among the LMHAs, would receive a disproportionate amount of the additional monies. The House Appropriations Committee also adopted the performance-based incentive plan rider adopted by Senate Finance.

Regarding funding for behavioral health services, so far, so good! If you didn’t get a chance to respond to the MHA alert sent out yesterday, how about take a moment to call your favorite members of House Appropriations and Senate Finance to thank them for their good work?

Federal Behavioral Health Funding Cut

While the budget is looking good at the state level, things are shaky at the federal level. As a result of sequestration–the automatic federal budget cuts that are kicking in due to lack of Congressional action on deficit reduction–the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) is set to lose $168 million, or about 5%, of its total funding by September 30th of this year. This will include across-the-board cuts to all programs, including the mental health block grant (funded at a level of $460 million) and the substance abuse block grant (funded at a level of $1.8 billion). As a result, funding will be reduced accordingly at the state level.

According to DSHS, funding for substance abuse services will need to be reduced by $6.7 million and funding for mental health services by $1.7 million. DSHS has asked stakeholders to complete a survey to give input on how DSHS should implement these cuts.

Obviously, substance abuse programs will take a bigger hit, so it’s important to try and minimize the impact to the most important programs. For whatever my 2 cents is worth, I probably would recommend that funding for children’s substance abuse prevention, intervention and treatment services remain unharmed. If the adults take cuts, it may be better to target those to prevention and intervention, rather than treatment, since we still have a substance abuse treatment waiting list (at least in the current fiscal year). Again, that’s just what I think.  If the substance abuse community has any thoughts, please share!

That being said, please take a moment to complete this survey. It is due this Friday, March 22nd.

Behavioral Health Legislation

As you know, MHA is tracking over 200 mental health- and substance abuse-related bills. You can view them all here. Many of the bills have been progressing quickly through the process.The following legislation has been voted out of committee:

HB 908
Relating to the assessment of an elderly or disabled person’s psychological status for purposes of an emergency order authorizing protective services.

SB 36
Relating to the detention and transportation of a person with a mental illness.

SB 58
Relating to integrating behavioral health and physical health services provided under the Medicaid program using managed care organizations.

SB 152
Relating to the protection and care of persons who are elderly or disabled or who are children.

SB 256
Relating to tracking career information for graduates of Texas medical schools.

SB 401
Relating to a notification requirement if a school counselor is not assigned to a public school campus.

SB 462
Relating to specialty court programs in this state.

SB 944
Relating to criminal history record checks for certain employees of facilities licensed by the Department of State Health Services.

In addition, the Senate already has voted a few bills out of its chamber, which are now awaiting action in the House. These include:

SB 50
Relating to the Children’s Policy Council, including the composition of the council.

SB 109
Relating to a housing plan developed and certain housing information collected and reported by the Texas Department of Housing and Community Affairs.

SB 126
Relating to the creation of a mental health and substance abuse public reporting system.

SB 426
Relating to a home visiting program for at-risk families.

Again, check out summaries of these bills, MHA’s positions, and more by viewing our bill tracker.

Catcha next week!

State and Local Updates: Part 2

Well, I don’t have any more local updates (at least that I can share…yet!), but I’ve got some more budget news and the much-awaited bill tracker!

Behavioral Health and the Budget

I’ve already laid out the Senate mental health and substance abuse budget recommendations for the Department of State Health Services (DSHS), but below you can find out about the House recommendations, as well as a few other behavioral health-related budget items of interest. These include:

House Appropriations Committee Mental Health Recommendations (DSHS)

  • $20 million to reduce (not eliminate) the statewide waiting list for adult mental health services
  • $2 million for beds to prevent the relinquishment of parental custody to DFPS

House Appropriations Committee Substance Abuse Recommendations (DSHS)

  • $4.9 million to eliminate the 948-person statewide waiting list for substance abuse services
  • $5 million for substance abuse services for individuals referred by DFPS
  • $1.1 million for expansion of the Oxford House model across Texas

Other House Appropriations Committee Behavioral Health-Related Recommendations

  • $39 million for restoration of most of the funding cuts to the Prevention and Early Intervention Service programs (Services to At-Risk Youth, Community Youth Development, Texas families, and other prevention programs)
  • $545,761 to restore funding for the statewide coordination of the Community Resource Coordinating Groups and a statewide data reporting tool
  • $6 million to expand the Texas Corrctional Office on Offenders with Medical and Mental Impairments (TCOOMMI) caseload of adults with serious mental illness
  • $15.2 million for the hiring of mental health professionals in each juvenile probation facility

Other Senate Finance Committee Behavioral Health-Related Recommendations

  • $10.4 million to partially restore funding cuts to Communities in Schools
  • $850,000 for behavioral health personnel to assist soldiers and airmen through the Family Support Services Group (Adjutant General’s Department)
  • $6 million to expand the TCOOMMI caseload of adults with serious mental illness
  • $15.2 million for the hiring of mental health professionals in each juvenile probation facility

While the House still needs to come a long way in increasing funding for mental health and substance abuse community services, it is good to know that these issues are still being addressed in other areas of the budget!

Bills, Bills Coming Out of My Ears!

Well, a few folks have been asking for the updated bill chart, and you can find it here in all of its glory! March 8th was the bill filing deadline, and almost 2,600 bills–or about 44% of total bills–were filed last week! That made for a long weekend and is at least partially responsible for the delay in getting this out for public consumption. But, I’m sure you’ll all forgive me!

MHA is now tracking over 200 bills and will update them weekly. Please note that we will only be tracking the major actions of bills, e.g. when they are voted out of committee and voted out of a chamber. We will not include when a bill is set for hearing or when it’s set to be heard on the floor.  However, on some legislation MHA is supporting, you will see Action Alerts when a bill is set for Floor debate. All of that being said, let’s check out some of the major mental health and substance abuse bills filed last week:

HB 2625 by Coleman, which expands the Priority Population served by LMHAs to include single episode or recurrent major depression, post-traumatic stress disorder, paranoid disorder, pervasive developmental disorder, obsessive compulsive disorder, panic disorder, dysthymia, attention deficit disorder, or tic disorder/tourette’s syndrome;

HB 2881 by Toth, which creates the Task Force to Reduce the Habitual Incidents of Driving While Intoxicated to study and make recommendations regarding best practices to reduce habitual incidents of driving while intoxicated, as well as fatalities related to driving while intoxicated;

HB 2887 by Davis, which requires DSHS to make Haven for Hope-like grants to local entities to coordinate services for homeless individuals, people with mental illness, and people with substance use disorders.

HB 3003 by Allen, which requires school districts to establish a program to help students transition back into school after being placed in a DAEP, JAEP, TJJD or juvenile probation facility, residential treatment center or public or private placement for 30 or more instructional days;

HB 3326 by Coleman, which requires a private group health plan, including those for small employers, to provide health insurance coverage for the diagnosis and treatment of mental disorders as defined by the DSM;

HB 3632 by Canales, which requires certain minors convicted of alcohol- or drug-related offenses to take an alcohol awareness program or a drug, alcohol, and substance abuse education program as a condition of community supervision;

HB 3635 by McClendon, which requires school districts to employ a licensed psychologist or licensed professional counselor on each campus in the school district and allows school districts to receive state aid in an amount necessary to carry out these requirements;

HB 3684 by Naishtat, which updates the current Texas Integrated Funding Initiative Consortium statute by giving the consortium responsibility to oversee a state system of care for minors receiving inpatient mental health services, or who are at risk of being placed in a more restrictive environment to receive mental health services;

HB 3692 by Branch, which changes the Primary Care Residency Program to the Graduate Medical Education Program and expands it to include psychiatry and surgery

SB 1114 by Whitmire, which allows a county, municipality or justice or municipal court to employ case managers to provide intervention services to youths at-risk of juvenile justice involvement; prohibits peace officers from issuing citations to students who commit offenses; establishes progressive sanctions for a student before a school district may file a complaint against the student in criminal court;

SB 1178 by Deuell, which requires that school districts train teachers, principals, counselors and all other appropriate school district personnel in how to recognize and appropriately respond to students exhibiting signs of mental illness or of being at risk of suicide

SB 1185 by Huffman, which Requires DSHS to establish and operate a mental health jail diversion pilot program in Harris County for between 500 and 600 individuals using the Critical Time Intervention model;

SB 1291 by Ellis, which makes the possession of a trace amount of a controlled substance a Class C Misdemeanor;

SB 1356 by Van de Putte, which requires juvenile probation officers, detention officers, and court-supervised community-based program staff to receive training in trauma-informed care; and

SB 1477 by Deuell, which requires HHSC to negotiate with the United States Secretary of Health and Human Services for flexibility in the Texas Medicaid program and in obtaining a block grant to cover the Medicaid expansion population under the ACA through premium assistance for the purchase of private health insurance coverage.

In addition, the following bills have been voted out of committee:

HB 144
HB 243
HB 424
HB 473
HB 617
HB 807
HB 808
HB 838
HB 908
SB 715

Remember, you can track all these bills, read their text and find out MHA’s position on them by using our trusty bill chart!

Until I post again…