Texas has lagged far behind virtually every other state when it comes to investment in mental health care. But after lawmakers allocated record levels of funding to mental health services during the 2013 legislative session, and with the beginning of expanded mental health care coverage under the Affordable Care Act, advocates say they see new cause for optimism — and still more room for improvement.
After a spate of mass shootings in 2012 sparked heated national debate about gun control and mental health — but little action from federal lawmakers — the Texas Legislature made mental health care a priority. State lawmakers approved some of the largest budget increases for mental health services in the nation, allocating roughly $300 million more than in the previous session. The 2014-15 Department of State Health Services budget contains $2.6 billion for the public mental health system, an amount that Katharine Ligon, a mental health policy analyst for the Center for Public Policy Priorities, called “unprecedented.”
In 2010, Texas ranked 49th in the nation in per capita expenditures for mental health services, spending less than one dollar for every three spent per patient in other states. Advocates say the recent allocations will put Texas closer to the median in 2014.
“We’re so far from the middle, this investment really moves us in the right direction,” Ligon said.
A significant spending effort will be eliminating waitlists at community mental health centers, said Greg Hansch, policy coordinator for the National Alliance on Mental Illness Texas chapter. In July 2013, there were more than 5,200 adults and 190 children on waiting lists to receive care at community health centers. The Legislature dedicated roughly $48 million to local mental health authorities to eliminate those waitlists — by hiring more psychiatrists or by other means at their discretion — “so that people who are in dire need of services are getting them,” Hansch said.
Lee Johnson, deputy director of the Texas Council of Community Centers, said that the 39 community mental health centers in Texas had taken different approaches to reducing waitlists since the start of the fiscal year on Sept. 1, but that "the bottom line is that this is working." He cited DSHS data indicating that waitlists had already been reduced 42 percent this fiscal year.
"The Legislature is making up for lost time," he said.
Hansch agreed that the Texas funding situation had improved, but he said work remains. He called for legislation that would promote family involvement in a patient’s mental health services, because the state's current health and safety code is more restrictive than the national law.
Other initiatives funded by state lawmakers include a program to train teachers to identify and assist students who show signs of mental distress, and a statewide expansion of the Youth Empowerment Services waiver, which funds community-based support for children with serious emotional disturbances. Josette Saxton, a mental health policy associate at Texans Care for Children, called the 2013 legislative session a "big win" for adolescent mental health care.
"There were great first steps in shifting the focus to what can we do around prevention and early intervention in childhood," she said.
Ligon said she hoped for continued state investment in future legislative sessions. She said many of the allocations made in 2013 were "seed money" for new initiatives, which will immediately generate "some improvements to individual access to care, but we won’t see the clinical outcomes until a couple of years from now.”
On the national level, mental health advocates have praised the Obama administration's federal health care reform for prioritizing of mental health care. Under the Affordable Care Act, treatment for mental health and substance abuse is mandatory for insurance plans offered in the federal marketplace starting this year. Additionally, a new parity rule issued by Health and Human Services Secretary Kathleen Sebelius in November will require that insurance plans not restrict mental health benefits more than coverage of physical illnesses, beginning in July 2014.
“What we’re hoping to see is over time the disparity diminish to zero,” said Stacy Wilson, associate general counsel for the Texas Hospital Association.
But those living below the poverty line in Texas will largely miss out on the expanded coverage. A disproportionate number of people suffering from mental illness and substance abuse disorders live in poverty, which means they are ineligible for tax subsidies to reduce the cost of insurance coverage under the Affordable Care Act. And because of Texas’ decision not to expand Medicaid to cover poor adults, many will not qualify for that federal program either.
Texas’ Medicaid eligibility requirements are among the country’s strictest, with an income requirement of less than $5,000 per year for adults in a family of four. Hansch estimated that about 250,000 Texans with mental illness would be without health insurance after coverage under the Affordable Care Act’s federal exchange began Wednesday.
Those with low incomes and histories of homelessness or incarceration are especially worrisome for mental health advocates, Wilson said, because those populations typically have the greatest demand for services but the least access to them.
“We’re interested in this because there is a lack of mental health coverage for some of the folks that we see most frequently with mental health issues,” she said.