The Texas Legislature Makes Huge Strides in Improving Mental Health Care
Charting the Texas Legislature: Mental Health — August 2017
Tex Med. 2017;113(7):31–33.
By Sean Price
Most public health measures languished in the 85th Texas Legislature, but those for mental health care stood out as a giant exception. Lawmakers passed more than a dozen bills aimed at improving mental health care. And at a time when most state budgets were slashed, funding for mental health care rose ― by a lot.
And at a time when most state budgets were slashed, funding for mental health care rose by $400 million or more, according to estimates.
"In some ways, it's unprecedented," said Andy Keller, PhD, who is president and chief executive officer of the Dallas-based Meadows Mental Health Policy Institute, a nonprofit, nonpartisan research group. "Just think about what happened to everybody else. Child welfare and mental health were really the only things that [the legislature] increased spending on."
Why did that happen? The effort really got started in 2015 when House Speaker Joe Straus (R-San Antonio) created the House Select Committee on Mental Health. The 13-member bipartisan committee chaired by Rep. Four Price (R-Amarillo) spent nearly a year conducting hearings and interviewing physicians and other stakeholders before the 85th session started in January.
"We realized quickly that it didn't really matter what area of the state you were from or what area you lived in or what party you belonged to, [mental health reform] was pretty commonly understood to be a need," Representative Price told Texas Medicine after the session closed in May. "So we addressed it from a very pragmatic position, and I think that's why it did receive a lot of attention and raised awareness of this issue. Folks just started talking about it long before the session ever started."
One of the biggest achievements of the session was the passage of House Bill 10, authored by Representative Price and supported by the Texas Medical Association. It expanded the Texas Department of Insurance's power to enforce how health insurance plans offer mental health and substance abuse benefits. Current state and federal laws are supposed to put mental health benefits at parity with other health care benefits, but the laws often don't go far enough, Representative Price says.
"In the past where you had some mental health parity for some conditions offered and covered under some plans, this broadened the scope [to include more health plans], which will really help more people," he said. "It also created an ombudsman. Instead of having a problem with mental health parity and contacting the federal government or trying to get some help or assistance, now you'll have somewhere in the state."
Thomas Kim, MD, an Austin internist and psychiatrist and a member of TMA's Council on Legislation, testified in favor of HB 10 for TMA. He said the bill is designed to stop insurance practices that effectively limit the number of times mental health patients can see their physicians.
"Just as we would never limit the number of encounters for a diabetic or a patient with hypertension, we should not do this for mental health," Dr. Kim said in an interview with Texas Medicine. "HB 10 helps to reinforce the notion that mental health is primary care."
Austin psychiatrist James Halgrimson, DO, says bills like HB 10 are important in part because they help provide appropriate payment for psychiatrists — one of the lowest-paid specialties. Dr. Halgrimson, who also is on the TMA Council on Legislation, said higher compensation is vital. Both Texas and the United States face a shortage of psychiatrists at a time when demand is rising due to factors like increasing opioid abuse.
According to a 2015 white paper by the Dallas staffing firm Merritt Hawkins, Texas has only 5.7 psychiatrists per 100,000 people. That puts Texas at 49th out of the 50 states, ahead of only Iowa. Meanwhile, the same white paper said that 59 percent of psychiatrists nationwide are 55 years of age or older. Given current trends in medical schools, it's possible more people will soon be leaving psychiatry than entering it.
"You can build all the buildings you want," Dr. Halgrimson said. "But if there aren't knowledgeable people to staff them, you aren't going to get anywhere."
Dr. Kim says that this year's passage of Senate Bill 1107, which updates the regulatory framework for telemedicine, is also likely to have a big impact on the behavioral health workforce. He says the bill, authored by Charles Schwertner, MD (R-Georgetown), gives mental health institutions increased leverage to change how they use their resources.
"Provider utilization is one of the key areas where telehealth shows so much promise," Dr. Kim said. "Technology creates numerous opportunities for providers to engage more patients in more places in more ways. … Doing more with less, or said another way, optimizing provider time so that we get the most value from this precious resource, has to be the first step." (See "Clearer and Simpler.").
Pressure for Reform
Several factors drove this year's legislative focus on mental health, Dr. Keller says, including one that occurred far away from Texas. The 2012 mass shooting at Sandy Hook Elementary School in Connecticut generated a renewed nationwide interest in improving behavioral health care. A Yale University study found that the shooter's untreated mental illness helped cause the tragedy, which left 20 schoolchildren and six staff members dead.
Dr. Keller says a lawsuit by Disability Rights Texas also put pressure on the legislature. The advocacy agency for Texans with disabilities sued the state over the number of people with mental illnesses waiting in county jails for a psychiatric bed. In effect, he says, county jails have become front-line mental health institutions.
"There will always be people in jail with mental health needs just as there are people in jail with cancer," Dr. Keller said. "People commit crimes, and they have mental health needs. But our estimates are that half of the people with mental illness in jail are there simply because they have a mental illness."
Representative Price said that Senate Bill 1326 improves how people with mental illness are processed in the criminal justice system. Its goal is to divert people with mental illness out of jails and into appropriate treatment. Likewise, Senate Bill 1849, also known as the Sandra Bland Act (named after a woman who died in custody), establishes better mental health screening and promotes diversion from jail into treatment.
"I think that's big because we're going to try to eliminate as many folks going into the criminal justice system on the front end so that our county jails see less congestion and our county hospitals get utilized more appropriately," Representative Price said.
The Texas Legislature passed several other measures designed to improve mental health care, including:
- Senate Bill 674, which will help bolster the physician workforce by fast-tracking licensing for psychiatrists.
- Senate Bill 292, which creates a $37.5 million grant program designed to reduce arrest, incarceration, and recidivism among people with mental illness.
- Senate Bill 1326, which includes recommendations on the criminal and judicial processes for mentally ill people charged with crimes.
- House Bill 13, which creates about $30 million worth of community collaborative grants. The grants can be used by a single county or region to address local mental health needs.
- House Bill 1486, which establishes training and certification requirements for peer specialists and authorizes Medicaid reimbursement for their services.
- House Bill 1600, which provides payment for adolescent mental health screenings at Medicaid's Texas Health Steps annual medical exams. The state budget also includes a $2 million grant program to increase access to high-quality treatment for children in the child welfare system.
- House Bill 2466, which provides payment for postpartum depression screenings.
- Senate Bill 344, which enables paramedics to provide transport to mental health facilities in cases approved by law enforcement.
- House Bill 14, which allows the state to ban firearms at Texas' 10 mental health hospitals.
Meanwhile, the 2018–19 state budget includes important upgrades for the state's mental health infrastructure. It provides about $160 million for repairs and deferred maintenance at existing state hospitals and state-supported living centers, and $300 million for new state hospital construction projects.
Representative Price says all these changes in mental health are welcome, but follow-up legislation surely will be needed.
"We'll monitor and measure how these are being implemented," he said. "If we need to make adjustments next session, then certainly we'll have the data to analyze it and see what we can do. I think we're laying a very solid foundation with these bills."
Sean Price can be reached him by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
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