Grading the States 2006
The Nation's Voice on Mental Illness
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Grading the States 2006: Texas - Narrative

In January 2006, the University of Texas Longhorns won the national championship for college football. The likelihood of the Texas mental health system achieving a similar result is remote, but a chance of success makes rooting for the underdog worthwhile.

The stakes also are higher when human lives are involved.

Texas has an immense, difficult service environment. Its geography includes sprawling urban areas, small towns, rural expanses, and sparse frontier areas. Population is growing steadily. Approximately 35 percent are Latinos, and the state is expected to become a minority-majority state in the not-so-distant future.

Unfortunately, the mental healthcare system has been chronically underfunded. State-directed mental health spending per capita has ranked only 46th nationally. Adjusted for inflation, state appropriations for mental health have declined by 6 percent since 1981. For a state that has one of the largest uninsured populations in the country and a large number of immigrants without access to healthcare, Texas hasn't invested enough in the system to meet minimum levels of need.

But it's not because the state doesn't have the capacity to do so. It is a wealthy state, with significant oil, agriculture, and tourism revenues. The primary reason that the state lags behind is because its policymakers simply do not make caring for society's most vulnerable populations a priority.

In 2003, the state enacted legislation to bring about a fundamental shift in mental healthcare. State resources are now prioritized primarily to treat people with the most serious mental illnesses. Adults living with schizophrenia, bipolar disorder, or major depression receive services under a disease management approach - based on the premise that mental illness is best managed through extensive interventions, monitoring, andholistic strategies.

But extensive problems exist:

  • Because of the priority given to people with serious mental illnesses, other consumers are required to seek services through a fragmented, non-profit social services network.
  • Prior to 2002, Texas was nationally known for open access to medications and a disease management model, known as the Texas Medication Algorithm Project, (TMAP), which outlines levels of care. However, implementation in its current form has resulted in restrictions on some medications. A recent recommendation by the state's pharmacy and therapeutics committee might reverse this barrier to services.
  • There is not enough capacity. Approximately 2,300 state hospital beds currently serve a population base of 22 million. Consumers are cycled in and out without regard to the length of stay actually needed for recovery goals. The forensic population - for whom hospitalization is required - has grown from 20 percent to 30 percent, which further restricts access.

Overall, capacity hinges on community services. Every mental health system requires carefully balanced levels of care. That includes state hospitals, but also crisis centers and short-term acute inpatient and intermediate care facilities in communities, as well as outpatient services like Assertive Community Treatment (ACT), supported housing, and independent living options. When community services are not available, the entire system backs up. Long waiting lists result. Overcrowding and shortages become commonplace.

Lack of capacity merely shifts costs. Emergency room visits and hospitalizations increase. Greater burdens fall on police, who are often the first responders duringpsychiatric crises, and on the criminal justice system.

Not surprisingly, the 2002 legislation mandated jail diversion programs for each of the state's 254 counties. They were desperately needed. In 2002, approximately 150,000 persons with serious mental illness received services from the state. Sadly, an equal number who once received such care had moved on to jails and prisons. Such programs are most successful, however, when effective community services are readily available.

Texas also has received national attention for Northstar, a collaborative behavioral health model that draws on several funding streams - including Medicaid and state appropriations - and contracts with providers through managed care behavioral health organizations. Established in the Dallas-Fort Worth area, the program incorporates data-driven decision making and healthcare management. Although plagued initially by lack of competition among providers and overutilization of hospital beds, Northstar has endured and inspired innovations elsewhere, such as New Mexico's Behavioral Health Purchasing Collaborative. Challenges still remain, however, such as waiting lists and difficulties in getting newer-generation psychiatric medications. Providers in certain parts of the state are opposed to its expansion.

Texas deserves special commendation in one area: The state is providing national leadership in seeking to eliminate the use of restraints and seclusion—through internal agency mandates and a statewide review that includes all agencies within the Texas Department of Health and Human Services (DHHS).

Texas may be an underdog, but this state bears watching.

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