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Mental Health and Mental Retardation Authority of Harris County

Council approves hoarding ordinance

I think they’re on the right track.

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The Houston City Council unanimously approved an anti-hoarding ordinance Wednesday without a clear idea of how it will be enforced.

The ordinance, which does not apply to single-family homes, clarifies when police can seek a warrant to enter a home and prioritizes mental health treatment before turning to daily fines of up to $500.

The ordinance does not specify how deep piles of apparent junk must be, nor how long neighbors can be expected to battle insect or rodent infestations while city officials seek treatment of a suspected hoarder and a clean-up of the property.

To a large extent, Mayor Annise Parker said, enforcement will be at the discretion of responding police officers.

Internal policies outlining possible hoarding thresholds, how agencies will coordinate a response and who will have a final say in the decision still must be written.

[…]

Council members said they expect the ordinance to reinforce the existing relationship between HPD and the Mental Health and Mental Retardation Authority of Harris County, who often perform joint welfare checks.

MHMRA Executive Director Stephen Schnee said the agency would complete assessments and recommend treatment, but not be involved in enforcement decisions.

[…]

Despite the ordinance, Parker said enforcement by authorities is not her preferred first choice for dealing with hoarders.

“Having the ability to say to a family member, ‘This is against the law. If you don’t do this, if you don’t work on this issue, if you don’t seek the help you need, there will be a police intervention,’ is one more tool that can help resolve the issue,” she said. “The goal is never to write a citation for something like this because we understand it’s a mental health issue, but this gets us in the door.”

See here for the background. For what it’s worth, as someone who was a fan of Hoarders on A&E, in nearly every episode the hoarder in question had to be backed into a corner before agreeing to get help and do some cleanup. Often, this included some kind of threat from local authorities to impose fines or even condemn the property. One gets the impression that this kind of leverage can be very useful to help persuade someone who doesn’t believe he has a problem to do something about the situation at hand. As the story notes, in the past the only legal leverage the city had was if there was a credible complaint about animal abuse. This gives them another way to open the door and assess the condition of the residence, and hopefully connect the person inside with the resources they will need to help them address the problem. I’d like to see the city revisit this in a year or so, and if it’s getting results to see about extending the ordinance to include standalone houses. I think they are pointing in the right direction, and I hope this works. Texpatriate has more.

Council considers hoarding ordinance

I hadn’t realized Houston didn’t already have an ordinance to deal with hoarding. Apparently, we are not at all unique in this regard.

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A proposed ordinance would begin to expand the city’s options for resolving hoarding situations even when the hoarder owns the property. The measure, which would not apply to single-family homes, would create fines, clarify when police could enter a property with a warrant and refer violators to social services.

If City Council approves the proposal next week, Houston could be the first city in Texas to create a specific ordinance to address hoarding, said Bennett Sandlin, executive director of the Texas Municipal League. Other cities have discussed the hoarding issue when adopting building and fire codes, he said.

“In society it’s becoming more noticeable, probably because of the notoriety from TV shows,” Sandlin said.

The Greater Houston Chapter of the Community Associations Institute, a group for local homeowner associations, supports the proposed ordinance as a starting point, but called for the inclusion of single-family homes. The group also would like to see a mechanism to assist with cleanup since the bill often falls to neighbors, President-Elect Sipra Boyd said.

Sherri Carey, a board member of the group and a property manager who has dealt with three hoarding cases in the last two years, said she wants the ordinance to mandate mental health treatment or follow-up visits to ensure the problems do not resume.

“Just like parole,” she said. “Someone to make sure they’re not breaking the law still.”

[…]

The Mental Health and Mental Retardation Authority of Harris County consulted with the city on the development of the ordinance and its executive director, Stephen Schnee, submitted a letter of support to council.

I would support including single-family homes in this ordinance. Hoarding is both a mental health problem and a public health problem. The goal of this should be to better identify people who need help, to connect them with services that can help them, and to get their property cleaned up. That’s a win all around. Fines should be used as leverage rather than as actual punishment if possible. I look forward to the discussion on this. Texpatriate has more.

If you want to be treated for mental illness, go to jail

You’ve heard it said that the Harris County Jail is the largest mental health facility in Texas. Here’s a great story in the Observer by Emily DePrang that illustrates what that really means.

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Of the 9,000 or so inmates here, more than a quarter take medication for mental illness, meaning that many days, this jail treats more psychiatric patients than all 10 of Texas’ state-run public mental hospitals combined.

Most of those patients live in the general population and get their psychotropic drugs alongside inmates taking blood thinners or insulin. But some stay here on the second floor, in the Mental Health Unit, an award-winning program that functions as a full psychiatric hospital within the jail. The unit can treat almost 250 inmates at a time for serious mental illnesses. All receive medication; some also attend therapy and visit with caseworkers who help them plan for life after release. Many leave the jail more stable and connected to social services than when they came in.

Outside the jail, Houstonians with mental illness often can’t find those kinds of services. Harris County has one of the most underfunded public mental health systems in a state that consistently ranks last, or almost last, in per capita mental health spending. The Mental Health Needs Council, a policy advisory group made up of mental health practitioners, estimates that in 2012, almost 70,000 adults and more than 14,000 children in Houston with severe mental illness needed help from the public system but couldn’t get any. Hundreds of people are currently on a waiting list for basic mental health services—and that’s progress, down from 1,600 during the summer.

This isn’t because of some inefficiency in the public system versus the jail, but because of who pays for each. Community-based mental health care is funded mostly by state government, and for years, the Texas Legislature starved its public system. Like all public services, community-based mental health care was never flush, but in 2003 lawmakers slashed funding and limited treatment to just three diagnoses. Thousands of people who relied on the system were suddenly ineligible. Many went into crisis and were picked up by police or wound up in emergency rooms, where they stayed briefly, stabilized, and were released, still unable to get treatment in the community.

A crisis-driven system evolved, one that was inefficient, ineffective and unkind. It was also expensive. While the state initially saved money in 2003 and with subsequent cuts, it passed the cost on to counties, which had to deal with the real consequences of untreated mental illness. In Harris County, the number of law enforcement calls about people in psychiatric crisis jumped from fewer than 11,000 in 2003 to more than 27,000 in 2012.

As people with mental illness filled the jails, counties like Harris were forced to act. They added mental health programs to their law enforcement agencies and jails, a humane move, but one that shifts costs from the state to local taxpayers and blurs the lines between institutions designed to punish and those meant to treat. That’s how Texas’ largest jail became its largest mental hospital. And that’s why many Texans can get better mental health treatment inside the jail than out of it.

Again, when I say that Rick Perry and his cronies don’t want people to get health care, I’m talking about more than just the refusal to expand Medicaid. But the refusal to expand Medicaid is still a big part of the problem.

White men, age 22 to 55, who are medically indigent—meaning they don’t have insurance and aren’t eligible for Medicaid—are the group most likely to end up both needing the public mental health system and, at some point, going to jail. Preston Murski is all these things. He’s a Houston native, 22, blond and chatty, and he slips easily into a grin. But he faces an uncertain future. When we meet in the Harris County Jail’s chaplaincy room—just a concrete floor, plastic chairs, a dry-erase board and a battered wooden podium—he flickers between bravado and worry. Like all the inmates, he wears baggy orange clothes, but a purple hospital wristband signifies that he’s in the Mental Health Unit.

“I started coming to jail when I was 14,” Murski says. “It’s been in and out, doing six months in, a month out, a year in. I’ve been with MHMRA since I was 14.” MHMRA is the Mental Health and Mental Retardation Authority of Harris County, the primary provider of public mental health services for medically indigent Houstonians like Murski.

“When I was in juvenile [detention], they give you one or two free refills of your medication. My medication costs like $800 because I take a lot of Seroquel, and I take a lot of Adderall. So [after] I get that free refill, my dad’s like, ‘I’m not paying this money. I ain’t got the cash.’ And I’m not on insurance, nothing. I’m just walking around. So meds run out. I go to jail. It’s always been the story of my life. If my meds run out, I go to jail.”

Access to services for juveniles is a major challenge in Houston. The Mental Health Needs Council found that in 2012, about 19,300 children and adolescents in Harris County suffered serious emotional disturbance and needed help from the public system. Most had already developed substance abuse problems and 40 percent had been exposed to trauma. But 74 percent of those 19,300 kids received no mental health treatment at all.

Many ended up in trouble with the law. Almost 69 percent of the children referred to the Harris County Juvenile Probation Department in 2012 had a diagnosable mental illness.

[…]

But once in the jail, help is available. Dr. Scott Hickey, director of outcomes management for the county mental health authority, says that’s both good and a symptom of the public system’s problems. “There are any number of individuals who have dropped out of the treatment system who reconnect through our jail mental health services,” Hickey wrote in an email. “In addition, there are many who received care only through the jail [T]he root cause of many system problems, including this one, is our inadequate outpatient service capacity.”

The mental health authority estimates it would need a fourfold budget increase to satisfy the current demand in Harris County. But there is a way lawmakers could decrease demand: expanding Medicaid. Andrea Usanga, policy director for Mental Health America of Harris County, an advocacy group, says that had Texas chosen to expand Medicaid under the Affordable Care Act (aka Obamacare), it would have made an enormous difference. “Close to 90 percent of the individuals who are currently served in the public mental health and substance abuse system would be eligible for Medicaid if it were expanded,” she says. Gov. Rick Perry’s choice not to expand it, she says, was “all political. It’s really sad. Ideology hurts everyday people all the time. Everyday people are suffering.”

Harris County’s public mental health authority not only lacks the funds to meet the demand in the community but also can’t offer whole areas of needed services, Usanga says. When I tell her about Murski’s alcohol problem, she nods. “I’m not surprised.” She says that one of the major barriers to effective mental health care is that the public system still treats mental illness and substance abuse separately. “If you have a substance abuse issue, there’s a very, very high likelihood that you’re having some type of mental health issue, too,” she says. “MHMRA will treat the mental health issue, but you can’t go to MHMRA to learn how to safely withdraw from substances. Our system is not set up to do this. So it’s a very ineffective way to be dealing with folks with co-occurring issues.”

We’ve discussed this before. Expanding Medicaid wouldn’t solve all problems, but it would be a huge step forward and would be a big help for an awful lot of people. Really, we’d all benefit from it. We’d benefit by not having to pay for costlier and less effective care for fewer people. We’d benefit by the increased economic potential of thousands of people who could be productive citizens if only they could get the help they desperately need. We’d benefit by having a lower crime rate and by being able to direct police resources to more productive pursuits. And we’d benefit directly because whether we realize it or not, we all almost certainly know someone who needs this help but is unable to get it. We are perfectly capable of making this situation better. We just have to choose to do it. That’s not going to happen with the current state leadership. There’s really not much more to it than that.

County jail diversion program moving forward

News like this is always welcome.

Harris County is moving forward with a much-anticipated jail diversion program aimed at reducing the soaring number – and the associated cost – of mentally ill residents who repeatedly cycle through the county lockup.

Harris County Judge Ed Emmett this week announced his pick to head the four-year pilot program, authorized by the Legislature this year. Regenia Hicks, former director of children’s mental health services at Mental Health & Mental Retardation Authority of Harris County, started as program director last week.

The Minneapolis native, 61, is “somebody that’s got a lot of background, experience and training in this,” Emmett said. “She’s familiar with the community here, so I was glad she was available.”

Hicks is tasked with creating a diversion model that state and local officials hope eventually will serve as a template for a statewide program aimed at reducing the jail recidivism rate among mentally ill populations.

[…]

“Our hope is that we’re going to be able to help pull together the existing services that we right now have here in Harris County, layer over some additional services and support that will really be able to stop that kind of revolving door,” said Hicks, who has lived in Houston for 19 years and previously worked as a research scientist for the American Institutes for Research, a Washington, D.C.-based nonprofit behavioral and social science research organization.

Harris County has done a commendable job on expanding mental health services and diverting folks who need treatment to the proper services and away from the jails. Commissioners Court, Judge Emmett, Sheriff Garcia, and a whole mess of non-elected people deserve kudos for it. Imagine how much more they could get done if Texas expanded Medicaid and took advantage of all the mental health and other services that come with it. Harris County would certainly benefit, but that’s out of their hands. We need new leadership at the top for that. Be that as it may, the county is doing what it can with what it’s got, and good on them for it.

The next step to closing the city jail

The sobering center was Step 1. Step 2 is a joint processing center with the county, and that is now closer to happening.

With backing from the city of Houston, Harris County is reviving a long-discussed plan to build a facility to process inmates into the county jail, and to offer the mental health services that many of them need after they are released.

Commissioners Court on Tuesday authorized searching for an architect to draw up plans for the so-called joint processing center. The City Council is expected to follow suit by agreeing to pay half of the $250,000 needed for those plans in the coming weeks.

“The mayor’s office is ready to participate with us in the study and the evaluation, but the first assignment is to pick somebody to do it, and we’re taking the lead on that,” Art Storey, director of the county’s public infrastructure department, told commissioners on Tuesday.

The goal is to complete the proposal and cost estimate by June so that the facility could be financed through a bond referendum as early as this November. Other financing options also are being explored, said Bill Jackson, the county’s chief budget officer.

The county has been discussing the need for a new booking or processing center for years as its current one has been operating over capacity even as the jail population has fallen. The city is partnering in the effort as it hopes an expanded intake facility would allow it realize its longstanding goal of shuttering its two aging jails.

You may be thinking “Wasn’t there a bond referendum for this back in 2007, and didn’t we vote it down?” The answer is Yes on both counts. What’s different about it this time is that the county jail is no longer overcrowded, inmates are no longer being outsourced, and most importantly there’s a recognition that keeping the inmate population down is a good thing. The concern in 2007 was that we were simply being asked to build more jail space so we could hold more inmates. Whether that really was the plan or not back then, there’s no question that this is not the purpose of the joint processing center now. We’ve got our priorities in order now.

Commissioner Steve Radack said the center “needs to go a long way in keeping the mentally ill out of jail.”

“The last time this was really looked at, there wasn’t probably as much thought in it as there is today in reference to the mentally ill,” he said. “Today begins the new process.”

A recent county analysis showed 920 inmates cycled through the county jail more than five times in the past two years, 60 percent of whom were mentally ill and 63 percent of whom were homeless.

“A joint processing center, I think, will provide an opportunity for us to do a much improved job for potentially diverting certain low-level offenders who are not a threat to society with mental illness from incarceration,” said Steve Schnee, executive director of Mental Health and Mental Retardation Authority of Harris County.

That would be a huge step forward. There are still a lot of details to be worked out here, but all the indicators, from our attitude about how to deal with mentally ill offenders to city-county relations, are pointing in the right direction.

Spending a little to save a lot

Remember HPD’s Chronic Consumer Stabilization Program, in which the police department attempted to deal with some of the people who interact with them the most often in a better, more humane, and more cost-effective way? Well, it’s been working.

Since the program began, run-ins between police and the top 30 chronic consumers have declined by 53 percent, as have the number of trips to the county psychiatric hospital, HPD officials said.

Based on that, City Council on Wednesday voted to double the program, expanding it to four case managers to keep tabs on 60 people.

The initiative was born of the 2007 fatal shootings of two people with mental illness by police in a three-month span. In one case, a woman entered the downtown police headquarters and lunged at an officer with a knife. In the second, a man wielding a pipe charged an officer on a street in southeast Houston. Police shot both people after Tasers failed to subdue them. Two years later, the police ran the numbers and MHMRA dispatched the case managers.

Wednesday’s unanimous vote to increase spending on the program to $256,000 this fiscal year was a formality after Councilman Ed Gonzalez, a former police officer, attached an amendment to this year’s budget to double the size of CCSI.

Gonzalez said the program protects people with mental illness, the officers dispatched for crisis encounters and the taxpayers’ wallets. He looked at the numbers police reported to Council and said, “There’s a lot of savings in those percentages” in avoided arrests, ambulance rides and psychiatric center commitments.

“That’s a much more effective and humane way of dealing with the problem,” Gonzalez said.

The International Association of Chiefs of Police recognized the program with its community policing award in 2010.

See this Grits post for further background, and this Malcolm Gladwell essay for more context. Projected savings in police, emergency room, and other resources was projected to be $500,000 for the first year of the pilot program, which has now been doubled in scope. It just makes sense to try to deal with the root cause of the problems rather than treat the symptoms over and over again. And it’s a beautiful thing to see it work and get expanded.

A better way for law enforcement to deal with the mentally ill

Good.

Three Harris County Sheriff’s deputies will have new partners riding shotgun soon, if county officials approve a pilot program pairing them with mental health workers to deal with mentally disturbed suspects.

Sheriff Adrian Garcia said he wants to treat the mentally ill, not jail them.

“This will help keep those in crisis from becoming a greater danger to themselves or another, and if they get the right treatment and services, they will be less likely to behave in a way that attracts the attention of the police again,” Garcia said recently.

[…]

On Tuesday, the court will consider allowing the sheriff to hire three deputies for the pilot program. The deputies would respond to calls in the unincorporated parts of Harris County, accompanied by a clinician from the Mental Health and Mental Retardation Authority.

The three Crisis Intervention Response Team units would add to the round-the-clock coverage provided by 10 such units now operated by the Houston Police Department. Those units have responded to crisis calls outside city limits, said HPD Lt. Mike Lee, but only rarely.

When the mentally ill interact with the criminal justice system, everyone loses, Garcia said.

“When these calls involve nonviolent minor crimes or disturbances, it is better for the suspect, better for the police, better for the public, and better for the criminal justice system to arrange medical treatment for the suspect rather than charge them with a crime and then take them to jail,” Garcia said.

County Judge Ed Emmett noted the staggering cost of incarceration, adding, “It’s such a desperately needed program.”

Diverting folks who need mental health treatment away from the jail and into treatment where appropriate is far more humane and a lot cheaper than what we’re doing now. I hope this pilot is a big success and quickly gets ramped up to meet the full need. Kudos to all involved.

The mental health catastrophe is coming

Here’s yet another story about the forthcoming disaster in mental health care that is about to be perpetuated by the Legislature. It starts with one of the best analogies I’ve seen:

Dr. Steven B. Schnee, executive director of the Mental Health Mental Retardation Authority of Harris County, offered up an extended metaphor one day recently to illustrate the consequences of what he considers catastrophic cuts in state funding for mental health services. Schnee is a licensed psychologist whose agency assists more than 45,000 county residents annually through a variety of community-based programs.

“It’s like saying, we’re short money — and we are short money – so we’re not going to put oil in our car. Or we’re just going to put a little bit of oil in the car,” he said, sitting in his fifth-floor office on the Southwest Freeway. “But when the engine blows up and we’re spending thousands of dollars on the engine – because now the car doesn’t work – we go ‘Oh, my goodness! What happened here?’ ”

The way I’ve been thinking about the approach being taken is to go back to the cliche of your household budget and note that there are some parts of it you just don’t cut in hard times unless there truly are no alternatives. For example, you don’t skip eating two days a week, and you don’t turn off your electricity every day at 5 PM, even though doing so would undoubtedly save you a few bucks. Dr. Schnee’s example works brilliantly as well.

If you’ve been paying any attention to this, you’re familiar with the story and the effects of the budget cuts that the Lege is about to visit on us. This particular anecdote was new to me, but it encapsulates the overall problem as well as anything I’ve seen:

Texas, which ranks 49th in per capita funding for mental health, has chosen not to fund community care and other measures that could help prevent men and women afflicted with an illness of the brain from ending up behind bars.

They are people like Tony Daugerty, 62, who was diagnosed 30 years ago with manic-depression and who has been in and out of jail at least 15 times in five years. For Daugerty and others, it’s easier to get arrested than it is to get treatment. Jail also is a more reliable provider of the treatment he needs.

Wearing a standard-issue orange jumpsuit, the balding, bespectacled man sat at a metal table in the jail’s mental health area recently and spoke about his decades-long battle with his illness. During his manic phases he stays up all night, night after night. “I design the solutions to all the world’s problems,” he said.

Daugerty was on probation last year when he boarded a Metro bus carrying a black canvas bag. When he told the driver, “Keep driving or I’m going to blow up the bus,” the driver called the police.

Daugerty is scheduled to be released next month, although the sheriff and members of his mental health unit, not to mention Daugerty himself, know they are likely to see him again.

“We do incredible work at stabilizing these folks,” [Sheriff Adrian] Garcia said, “but it’s a shame that we do the work that we do, at the price that we do it, just to have them go back out into the community and have them deteriorate again. They’ll be back in our facility. It’s a horrible revolving door when there’s a lack of capacity out in the community.”

We reap what we sow. And we’re about to sow a whole lot more.

Is it finally time to do something with the Dome?

A few days ago, a woman named Cynthia Neely took to CultureMap to demand that we Do Something about the Astrodome.

Regardless of whether you love or hate the Astrodome, the building is owned by the county and in effect belongs to all of us taxpayers. And you are paying for it.

Consider these options:

  • It would cost about $128 million to tear it down — that’s $128 million of public funding (which includes the existing $40 million bond debt that has to be satisfied no matter what is done).
  • To repair the Dome just enough to become habitable (and able to produce at least some revenue), the Sports and Convention Corp says it would cost $30 million (though some reports say less).

Hmmm …$128 million to end up with nothing versus $30 million to stop the bleeding and still have an historic building with both revenue and jobs potential.

The Commissioners have allowed it to deteriorate, not protecting our investment — even though it is likely the county’s biggest asset; the Astrodome’s doors were slammed shut in July 2008 due to fire code and building inspection violations.

Had somebody been on the ball, these problems would not have come as a surprise. Modifications could have been made all along to maintain its certificate of occupancy and thereby its ability to create revenue. It could have been self-supporting, or on its way towards being self-supporting, and not have wasted at least $3 million in taxes every year to do nothing.

Instead, since the Astrodome has been permanently closed in 2008, taxpayers have forked over a minimum of $9 million for it to collect dust. If the Commissioners had begun correcting those violations three years ago, some of that money could have gone into repairs, not down the toilet.

Most property owners and landlords who have the means fix their leaky roofs, have their furnaces checked before turning on each winter, repair a broken window to keep the rain out, and that kind of thing. It’s called upkeep. It is the responsibility of the County Commissioners to do the same, particularly since we are entrusting them with our money. It is their fiduciary responsibility.

Neely, in case you’re wondering, had previously been with the company that had proposed turning the Dome into a movie studio. I don’t know if she had a wire on this or what, but it appears that someone was listening.

Harris County should move this year to renovate the Reliant Astrodome into a special events arena, County Judge Ed Emmett told a Greater Houston Partnership luncheon audience Friday.

Emmett said he favors a “minimalist” approach that would see the Dome’s roof replaced, its seats removed, its shell intact, and grass laid down. He did not have a cost estimate for the idea.

“Anything we do to or with the Dome is going to be expensive, but it really is time to move forward,” he said during the annual State of the County speech to roughly 1,100 people at the Hilton Americas-Houston Hotel. “I think we owe it to future generations to preserve the Dome as a gathering place for special events.

“The taxpayers have to be engaged early in the process, for it is their Dome,” he continued, “but now’s the time to make a decision.”

Houston’s major festivals could be held at the Dome, he said, rather than in a less-than-ideal spot around downtown’s City Hall, where property is hard to secure at night.

“I think people would flock to it,” Emmett said. “Is that a revenue generator, enough to pay for the Dome? No. It would have to be a decision that the community said, ‘You know what? We want this to be part of our community.'”

Emmett said he hopes Commissioners Court will reach a decision “in a matter of months” to be presented to the voters of Harris County, perhaps a year from now, in a bond referendum.

The main thing I take away from this is that Judge Emmett, at least, no longer thinks getting a private investor to turn the Dome into a movie studio or convention center/hotel or whatever is viable. A corollary to that is that the fabled three options are no longer in play – the Emmett Option is far more minimalist than any of them. It’ll be interesting to see how the County Commissioners react to this – Steve Radack is quoted expressing skepticism about spending money on the Dome while the economy is still weak; none of the others were quoted having a reaction. Beyond that, I don’t have any strong feelings about this as yet. I don’t have the sentimental attachment to the Dome that many people have, Judge Emmett apparently included, but we have always needed to do something about this sooner or later. The only real complaint I have about this is that we’re still paying off bonds from the Dome’s 1987 facelift. It would be nice to be off the hook for this thing once and for all.

Anyway. The West U Examiner has some good coverage on this and the rest of Judge Emmett’s State of the County address, which you can read in full here. As I have called on Judge Emmett to push back against looming cuts in mental health services by the Legislature, I’m glad to see this from his speech:

Harris County is home to the world’s greatest medical center, a hospital district that is a model for the nation, and many neighborhood clinics and organizations supported by thousands of dedicated people. Yet we have far too many residents with no medical home, so they come to our emergency rooms. That is tragic and costly. Fortunately, the Greater Houston Partnership, working with the Houston Galveston Area Council, is working toward a regional concept to provide better care for more people at lower cost in the long run. Ultimately, the Legislature and, to a degree, the federal government must provide the framework to make a new system, but Harris County will be a driving force.

Now is not the time to cut funding for such efforts. Now is the time to move forward.

While on the subject of health care, mental health issues are a top priority to be addressed. Let me rephrase that. We have a lot of Harris County residents who suffer from mental health conditions, and we must do a better job of caring for them. Far too many of these people end up in our county jail – time after time. The cost of incarceration and treatment in a criminal justice setting is staggering compared to proper preventive care and treatment.  

Now is not the time to cut funding for mental health programs. Now is the time to move forward ‐ fully funding those programs so that the taxpayer reaps huge benefits in the long run and our residents receive better care.

From your lips to the Lege’s ears, Judge.

Finally, I note that while Judge Emmett spoke about the need to do something with the Dome a little more than a month ago, his press release in advance of the State of the County address gave no indication that it was going to be a topic for discussion. Way to keep us all on our toes, dude.

Harris County pleads its case to the state

Grits ran into some Harris County officials in Austin the other day and got some information from them about their lobbying efforts with the Lege. Not too surprisingly, it’s mostly focused on mental health services.

Harris Couty is primarily worried that cuts to community supervision, diversion programming and mental health services for adults and children go so deep that the state won’t even qualify to receive federal matching funds. A document from the Harris County Commissioners Court further suggests that, from a fiscal standpoint, state spending for mental health should prioritize funding for the “least expensive services” i.e., community based services, because they are eligible for federal matching funds through either Medicaid or Mental Health Block Grants, or even (in the case of Medicare), fully paid by the feds. Those types of services should be maintained or increased, they argue, while decreasing use of Crisis Services and state mental hospitals, which are not eligible for federal matching funds, through prevention, diversion, and community-based programming.

I’ve been aware for years that the state pays 100% out of general revenue for mental and acute health care for the incarcerated, while indigent people with serious health problems on the outside are typically served through programs either paid for or matched by the feds. That makes a big difference, in aggregate, regarding how much their health care costs in the state budget, especially for the seriously ill. But I hadn’t considered that the same distinction applies to Crisis Services and state mental hospitals. (Half of Texas’ state mental hospital beds are designated as “forensic beds” and there’s already a months-long waiting list to get treatment for defendants who’ve been declared incompetent by the courts to stand trial.)

As always, there’s plenty of detail, so click over and see what’s being said. One point to note, in that recent story about Harris County’s budget for the upcoming year, there was this tidbit:

Because three-quarters of the budget is spent on salaries, deep cuts are almost certain to result in layoffs. Constables, in particular, have warned of hundreds of possible layoffs. Precinct 4 Constable Ron Hickman, under the proposal, would see his budget slashed $3.1 million despite his warning that as many as 100 jobs could be at stake.

And in Grits’ post, we learn this:

Also from ’07-’10: Constables transported 32% more patients in psychiatric crisis from one facility to another,” and “The number of persons in psychiatric crisis that the Constables picked up pursuant to court order (Mental Health Warrant) increased by 55%.

Seems to me that could be a problem. Anyway, check it out.

Here comes Harris County’s budget

It’s as bad as you’d expect.

A budget on its way to Harris County Commissioners Court on Tuesday would cut $138 million from current spending on roads, inoculating against disease, promoting economic development, constables’ patrols and performing other services.

The county must bring its spending down to $1.2 billion for the year that begins March 1 because the biggest source of its income — property taxes – is expected to plummet in the wake of a recession that has eroded the taxable value of local homes and businesses.

The cuts make this year’s budget the starkest in decades.

[…]

County Judge Ed Emmett had spoken of the fiscal crisis throughout last fall as an opportunity to limit county government to necessities and to shed nonessential functions. He also called for zero-based budgeting, in which each department would start without money and justify each expense as it built a new spending plan.

None of that happened.

“It’s a delayed opportunity,” Emmett said of the proposed budget. “I do think we need to be looking at what county government should be doing instead of just saying, ‘Well, we’re going to do less of what we’ve always been doing.’ ”

[…]

Commissioners Court has not raised the overall property tax rate in 15 years and, in fact, lowered it in 2007. In September, Commissioners Court cut the county government tax rate, forgoing $19 million in the process, to offset an increase in the tax rate for the Port of Houston Authority, to expand the Bayport Container Terminal.

It seems to me that one could just as easily argue that the county has never done all of the things it should be doing. I’ve no doubt that Judge Emmett would agree that there is a great unmet need for mental health services in Harris County. That is sure to continue, even though providing MHMRA with sufficient funding would allow for greater savings elsewhere, specifically in the jails. And given our long-term aversion to any increases in the property tax rate, perhaps the problem isn’t just spending money on stuff we could do without, but not providing enough revenue to adequately spend on the stuff we can’t do without.

But let’s grant Judge Emmett’s wish and say we go with a budget that only provides for the absolute necessities. What then happens when property values recover and the county starts taking in more revenue? My fear is that we’ll just cut the tax rate again, thus ensuring we will be right back in this position again the next time there’s a downturn, having to define “necessity” down. That doesn’t sound like a sustainable path. What kind of long-term vision do we have, and how do we expect to pay for it?

Budget testimony from the Sheriff’s office

In addition to all of the education and HHSC-related testimony before the Senate Finance Committee this week, law enforcement agencies who will be affected by cuts to mental health services were also heard from. Here’s a press release sent out by Harris County Sheriff Adrian Garcia about what they had to say:

The Harris County Jail’s executive director for health services, Dr. Michael Seale, and its Detention Bureau commander, Major Mike Smith, say in written testimony to the Finance Committee of the Texas Senate that proposed severe reductions in state funding for community-based mental health care programs would hurt taxpayers while degrading the quality of life for thousands of ill individuals, their families and their communities.

Seale is also an appointee of Gov. Rick Perry to the Texas Commission on Jail Standards. Smith has served as a patrol deputy, narcotics officer, crime-fighting leader and administrator during his more than 30 years with the Harris County Sheriff’s Office. Their testimony reflects the views of Sheriff Adrian Garcia and the Sheriffs Association of Texas’ legislative committee, of which Garcia is vice chair.

“In these challenging times for the Texas economy, is there a way to reduce these costs for local and state taxpayers? The answer is yes — the state can make sure that it is adequately funding community-based mental health services. Not only do these programs help to prevent the type of psychotic episodes that require costly police intervention, jail bookings and jail care, they also save money,” Seale wrote. “According to information from the Department of State Health Services and the Legislative Budget Board, the average daily cost of mental health services per person is approximately $12 in a community-based setting and $137 in prison. Clearly, state and local taxpayers enjoy greater safety and greater savings when state-funded mental health programs succeed with proper resources.”

The Harris County Sheriff’s Office spends at least $27 million yearly in general funds from the county — whose main revenue source is property taxes – on direct mental health care for jail inmates in accordance with constitutional requirements.

“On any given day about 2,400 detainees in the jail are taking prescribed psychotropic medications — approximately one fourth of the total jail population. This makes the Harris County Jail – reluctantly — the largest mental health institution in the state of Texas,” Seale said.

Smith supervises the bureau that provides housing for the approximately 10,000 inmates in Sheriff Garcia’s custody.

“With less funding for community-based mental health care, more inmates will come to the Harris County Jail in crisis,” Smith said in prepared testimony. Among other things, “this leads to more danger and more challenges for my staff,” which is under a hiring freeze. “Further erosion of state mental health funding for programs in the county will lead to more strain on law enforcement and higher bills for taxpayers.”

The point, as we all know, is that cuts made by the state to mental health services will result in much larger expenses being borne by local governments and local taxpayers. It’s a false economy, and would be a repeat of what we did in 2003. Everyone should know this by now, it’s just a matter of whether or not the Republicans in the Legislature care about it, or if they prefer to balancing their own budget by shirking their responsibilities.

Harris County braces for state budget cuts

More joy to look forward to.

Proposed state budget cuts could cost Harris County government nearly $50 million a year, according to a legislative analyst’s rough estimates, rolling back or eliminating state allowances for dozens of programs that include mental health services, auto theft prevention, alternatives to jail and a school for juvenile offenders.

The starting-point House budget introduced in in Austin last week would possibly take a $13 million chunk out of money the Mental Health and Mental Retardation Authority of Harris County uses to treat adults and children.

[…]

If the state cuts come to pass, the sheriff’s unit dedicated to auto theft would be halved and a camp for youth offenders would have to turn away kids who need its intensive counseling to prevent them from becoming career criminals, county officials said.

In other cases, the state cuts would transfer the burden onto a county government already contemplating hundreds of layoffs.

For example, the state mandates that the county run a school for children expelled from their neighborhood schools for weapons and serious drug offenses. But the starting-point budget would take away $3 million of the $12 million the state sends to cover the cost of busing, educating and counseling kids from all over the county at a school near Reliant Park.

Tom Brooks, the county’s juvenile probation director, said the school would be “crippled” by the proposed cut and that he would ask the state to lift the mandate if the proposed spending plan is what emerges from Austin this year.

[…]

Sheriff Adrian Garcia, County Judge Ed Emmett and MHMRA executive director Stephen Schnee have been saying for months that such drastic state cuts will transfer the bill to county agencies as people who could have benefited from treatment in community centers end up in emergency rooms and jail cells.

“Harris County will pick up the tab for them to be staying in jail and the mental health care they receive in jail, which is much more expensive than in the free world,” sheriff’s spokesman Alan Bernstein said Wednesday.

The state budget in its current form would eliminate the entire $1 million in state money spent on auto theft prevention and detection in Harris County. The Houston area accounts for about 30 percent of the state’s stolen cars, according to the sheriff’s office. Sheriff’s spokespeople were particularly puzzled by the auto theft cut, since the money comes from a surcharge in motorists’ auto insurance premiums and not from taxes.

So expect there to be more firings and more crime, not to mention higher local taxes in many places as the state sloughs its responsibilities off on cities and counties. Oh, and quite possibly your insurance rates, too.

Budget drafts call for a 10 percent reduction in payments to Medicaid providers and deep cuts in health and human services spending, including mental-health programs.

[…]

Proponents of the reductions call them necessary to control spending on the state’s Medicaid program, which cost a total of $24.7 billion in fiscal 2011. The federal government picks up $16.6 billion of that.

More than $7 billion a year in Medicaid money is paid to the state’s 500 hospitals.

Texas hospitals have protested the reductions, saying they will further strain hospitals’ resources and lead more providers to drop Medicaid. The program now covers only about 60 percent of a provider’s cost for treating a patient. Less Medicaid coverage would lead more patients to seek help in emergency rooms, where care is far more expensive, hospitals say.

An effort to shift more Medicaid patients into managed-care programs could exacerbate the financial pain for providers, according to the Texas Hospital Association.

“Reductions of this magnitude will seriously jeopardize access to healthcare and shift more healthcare costs to local governments and insured Texans,” said Dan Stultz, association president, in a statement.

Funny thing, just because the state refuses to pay for a need doesn’t make that need go away. It just means some other entity winds up paying for it. In many cases, they wind up paying more than what the state would have paid. In the end, of course, it all comes out of our pockets. But hey, at least we balanced the state budget.

More on mental health

Stephen Schnee, the executive director of MHMRA of Harris County, and Octavio N. Martinez, Jr, the executive director of the Hogg Foundation for Mental Health and a clinical professor in the School of Social Work at The University of Texas at Austin, make the case again for not cutting mental health services in the state budget.

The Houston-based nonprofit organization Children At Risk found that in 2009, an estimated 229,055 kids in Harris County had a diagnosable mental illness. MHMRA of Harris County serves an average of 2,490 kids per month, just a small fraction of those who desperately need treatment. Houston’s mental health system is already stretched to its limits – it can take weeks for kids to receive noncrisis services, exacerbating their symptoms and creating a need for even more intense treatment and services. If devastating budget cuts come to fruition, this will further restrict access to care. See this KTRK story for more.

Texas ranks 49th in mental health expenditures per capita – how much worse can it get? We are already almost at rock bottom. If lawmakers cut funding for public mental health services, some children and families will have no place to go for care that shouldn’t be considered optional. Is this really the best we have to offer our kids? And if it is, what message are we sending to the future leaders of Texas?

That message would be “Dan Patrick’s property taxes are more important than you”. Any questions?

If we deny children appropriate mental health care now, we’ll just pay a higher cost in the future. Left untreated, kids with emotional disturbances are more likely to drop out of school – a 2008 national study found that in 2005-06, only 43 percent of kids with a mental illness graduated from high school. Children At Risk reports that high school dropouts cost Texans a huge amount in the long run – an estimated loss of up to $9.6 billion per cohort. Additionally, high school dropouts contribute to higher rates of crime, incarceration and use of welfare and social services. Given these statistics, it makes sound fiscal sense to provide adequate mental health care for youth at an early age, or else taxpayers will just pick up a much bigger tab in the future.

[…]

This is an issue where everyone can agree. Hospital districts, community leaders, advocates, sheriffs and police chiefs across Texas believe that any cutback in funding for mental health will likely result in increased traffic to hospital emergency rooms, juvenile justice facilities and jails, and that equals increased costs for government and taxpayers. Underfunding mental health services simply shifts the cost to other agencies and to local government authorities, whose budgets are already inadequate.

It’s estimated that 52 percent of youth in the Harris County juvenile justice system have at least one mental health condition. The Texas Public Policy Foundation found that youth who become career criminals cost taxpayers and victims an estimated $2 million during their lifetimes. Community-based services for youth with mental illness like those provided by MHMRA are far less expensive, and in most cases, far more effective.

Sure, this is an issue on which everyone should agree, but let’s be real. The same TPPF that recognizes the cost of skimping on early intervention is one of the leading voices right now arguing that we don’t have a budget shortfall, we just need to adjust the level of services we’re providing to the amount of revenue we have and ignore all that wailing and gnashing of teeth about the effect that would have. They don’t even agree with themselves. Good luck getting anyone in their thrall to agree with you.

Grits on the CCSI

Scott Henson got the same information I did about the HPD “Chronic Consumer Stabilization Initiative” pilot program, and as always his take is worth reading. In that post, he pointed to this Malcolm Gladwell article that puts this initiative into a larger context, and which is also well worth your time. Also, he got a response from Harris County Sheriff’s Office spokesman Alan Bernstein to her earlier post about his visit to the HCSO and the jails, which he added as an update at the bottom. Check ’em out.

The Chronic Consumer Stabilization Initiative

In the comments to my previous post about mental illness and the criminal justice system, reader Katherine reminded me of this Houston Press article from last December, about a pilot program between HPD and the Mental Health Mental Retardation Authority of Harris County. Called the Chronic Consumer Stabilization Initiative, it was designed to work closely with the people who interact the most often with the police so as to come up with a treatment regimen for them that would minimize their contact with the police. (The story’s headline, which used the word “crazy” to describe these “chronic consumers”, was harshly criticized in the comments for being derogatory.) By all accounts, the pilot was a success. Here’s the executive summary from the final report, given in February:

The Chronic Consumer Stabilization Initiative is a progressive strategy designed to engage individuals with serious mental illnesses who are in a perpetual state of crisis. These individuals utilize police services and other emergency services on a habitual basis resulting in excessive calls for service and needless law enforcement encounters. The main objective of this pilot program was to reduce and minimize overall police contacts through intensive case management. The long term benefits of this program for the police department would be redirected resources which can be more appropriately utilized by patrol officers. In terms that are meaningful to executive management, this translates to potential savings in operational costs associated with manpower, redirected patrol services to address other criminal activities or calls for service, and possibly reducing the probability of officers being involved in a situation where deadly force may be used.

To identify the variables of this program we researched six months of the top 30 most documented cases and totaled 553 reported events which were identified as calls for service, offense reports, and emergency detention orders (EDO) filed by Houston Police Officers. We then compared the end results of the case managers’ efforts after six months of intensive case management. After intervention there were a total of 169 events which included 65 offense reports, 39 EDOs, and 65 calls for service. Due to the complexity of most CIT calls, it is estimated that it takes an average of one hour for an officer to complete each event. Additionally, department policy requires that two officers respond to every CIT call. Assuming that department policies were followed, this would mean approximately 1106 (553 events doubled) man hours were spent on addressing the needs of these 30 individuals. After the CCSI intervention of the same 30 consumers, 338 manpower hours were spent (169 events doubled). As a result, man power hours were reduced because of intensive case management objectives.

With a proposed expansion of up to four case managers and a full time police officer handling 60 clients, the projected savings in reduced manpower hours would be approximately 3,072 hours during a 12 month period, and 15,360 hours over a five year period. Hence, these potential savings in man power hours would be better utilized within patrol operations.

Actual cost savings, projected to be over $500,000 in the course of a year, are given in this addendum. Defense attorney George Parnham, who was part of the original task force on mental health that was formed in 2008 and which led to this pilot, wrote an op-ed about it in March. This is exactly the sort of thing I had in mind when I wrote that earlier post, and I’m delighted to see that HPD is a national leader in this.

One more thing: The funding for the CCSI pilot came from the city of Houston. Normally, as the Press article noted, the state provides funding for mental health programs. There was a sort-of predecessor to the CCSI called the Assertive Community Treatment Team, which had nothing to do with the police department and was run by the Department of State Health Services. I note that as a way to introduce this:

More than 20,000 Texans who receive state-funded psychiatric care would lose or get fewer services under budget cuts proposed this week by the Department of State Health Services.

The state’s 39 publicly-funded community mental health centers, which provide low cost psychiatric care for poor or uninsured people, would lose $80 million. State hospitals, including Austin State Hospital, would lose $44 million. Psychiatric crisis services would lose $10 million.

[…]

The mental health budget reductions are among $245 million in proposed cuts put forward by the Department of State Health Services. Cuts to mental health services total $134 million of that.

Even though the earlier ACT incarnation of this program wasn’t nearly as successful, this is exactly the kind of short-sighted budget cut that will wind up costing a lot more than it saves. Of course, it’ll be city and county governments that pay the bulk of those costs. The good news is that as I understand it, funding for the CCSI is in the city’s budget for this fiscal year. So at least we’ll be doing something constructive about this problem.

Grits visits the Harris County jail

Here’s a thoughtful post by Scott Henson on his visit to the Harris County jail and the proposed booking center, which was touted as a gateway primarily for arrestees with mental health issues. While acknowledging the need for more resources there, Scott hits upon an issue that I don’t think has gotten adequate discussion.

Both in booking and the mental health ward, I was told by several folks that the jail sees the same “repeaters” or “frequent flyers” over and over. The problem isn’t necessarily that the number of people sent to jail is increasing, in other words, but the same people are going to jail more often, too often.

At root, failures in community supervision are driving Harris County Jail overcrowding. Frequent flyers are almost all subject to the jurisdiction of the probation department, but intensive supervision and services clearly aren’t being applied, or at least applied effectively, to the most high-risk folks. There are just a few thousand people cycling in and out of the jail – many of them mentally ill, homeless, addicted, or with other major barriers to successful rehabilitation – who are primarily responsible for the demand for increased capacity. These folks generate high per-person costs over time but as a matter of policy (a de facto if not an intentional one), Harris County is spending money on them at the jail instead of seeking community-based alternatives.

How much cheaper would it be to focus on reducing the number of visits and lengths of stay by frequent flyers than to simply build more capacity to accommodate a dysfunctional system? Quite a bit, I suspect. That’s why IMO Harris County can’t build it’s way out of this problem: The same number of people can soak up a seemingly infinite amount of resources unless officials find smarter, more cost-effective ways to supervise them. Many folks, I was told (I’ve asked for an exact number), are processed through booking three or more times per year, and for a few of them the number is much higher.

Basically, what this says to me is that the problem is that we’re asking the criminal justice system to solve a problem that it’s not best suited to solve. Actually, we’re not so much asking them to solve it as we are leaving it to them to solve it because there are no other alternatives. We could have, as we once did, more public mental health facilities that would deal with these problems. We could have all kinds of other programs and outreaches and oversight, to ensure people with mental health problems had places to stay and access to medication (along with supervision to ensure they took their meds) and job placement counseling and so on and so forth. If we had these things, these so-called “frequent flyers” would likely not intersect with the justice system much more than the rest of the population, and in addition would likely be a lot more productive and self-sufficient. They’d be net contributors rather than primarily consumers of public services. I absolutely agree with Scott that in the long term, this would be vastly less expensive for the county, the state, and the federal government.

But we don’t have these sorts of programs or facilities. Anyone who proposed such a thing today would be ridiculed as a reckless spender at a time when belts must be tightened. And so, in the name of austerity and “fiscal responsibility”, we spend a ton more money dealing with these poor souls by putting them in a system that can’t help them, which ensures they keep coming back. Hell of a thing, isn’t it? It’s not how things have to be, it’s our choice it’s this way.

I don’t know what the best answer is. I’m sure some combination of federal, state, and local money would be needed for stuff like this, but I don’t even know how you’d get started. I don’t know what infrastructure already exists and needs to be utilized, and what doesn’t exist and needs to be invented. What I do know is that what we have now isn’t working, and that if I had a choice I’d prefer to see more of my tax dollars go to solutions outside the criminal justice system. The Sheriff’s proposal, which won’t be on the ballot this year anyway, is an improvement over the status quo, and it may be the best we can do until such time as we’re ready to try something truly different. Grits thinks there are still problems and that what’s been proposed is still a de facto expansion of the jails. You should read his piece for his argument; at this point I can’t say I disagree. For sure, we’re still not doing nearly enough to reduce the overall inmate population, which would ameliorate those concerns. If we can take those steps, I’ll be very happy to continue that conversation. If this is the best we can do, let’s do the best we can with it.

Grits on the jail czar

When I blogged about the creation of a “jail czar” position in Harris County whose job it will be to deal with overcrowding in the local jails, I said hoped that Scott Henson would comment on it. He did leave a comment in the post, which he has since expanded on at his own blog.

From my perspective, the two biggest drivers at the Harris County Jail of both overcrowding and cost are excessive pretrial detention and the evolution of the jail into the county’s main mental health treatment facility, both of which will require more than “coordination” by a “czar” to fix.

That said, the solutions, at least, are fairly clear: 1) Convincing judges to expand the use of personal bonds instead of requiring bail for low-level offenses, and 2) expanding outpatient mental health services, housing and specialized community supervision through the probation department (including making sure they take their meds) for mentally ill offenders, particularly those who are frequently in and out of the jail on low-level offenses.

The first is almost purely a political problem of convincing local elected judges to change their bail decisions; the second is mostly an issue of resources, with responsibility lying chiefly at the feet of the county commissioners court and the local MHMR authority to provide community-based alternatives to jail.

I’ve asked the Harris County Sheriff’s PIO office for a copy of the consultant’s study that recommended creating the “czar” position, so I’ll have more on this subject after I finally review that document. The same consultant analyzed the Harris Jail four years ago and this Grits series adumbrated at that time many of the same recommendations about which the county is finally (apparently) getting serious now.

Perhaps having a former member of the judiciary (Caprice Cosper) as the czar will help to convince the current judges that a change in their bail-setting policies is needed. And since Commissioners Court hired Cosper in the first place, perhaps they’ll listen when she tells them to do something about mental health and mental retardation issues. I can hope, right?

Our local mental health crisis

Today’s must-read is this op-ed by Dr. Stephen Schnee, the executive director of the Mental Health and Mental Retardation Authority of Harris County, about mental illness and the Harris County jails.

The Harris County Jail is now the largest mental health facility in Texas. Approximately 2,400 inmates a day are now diagnosed with a psychiatric illness that medically justifies the provision of psychiatric medications. There are almost as many psychiatrically ill inmates in the jail on psychiatric medications as there are patients in all of the Department of State Health Services hospital beds across the entire state.

Let that reality sink in.

How is this occurring? Several critical factors contribute to this disturbing trend. First, many individuals with a serious mental illness need early access to appropriate professional diagnosis and treatment and, often, supports to achieve and maintain stability in their psychiatric condition. These conditions aren’t, as a general rule, cured by medication. Stabilized, yes — cured, no. These individuals need education about the condition, available treatment options, impact on personal capabilities, stability and maintenance over time, etc. — all of which are made more difficult by the nature of these disorders affecting the information-processing organ of the body — the brain. These are neuro-chemical — disorders of the brain. And, if one throws into the mix that many untreated or undertreated folks with mental illness self-medicate with street substances, alcohol or both to ease the internal pain, one has a recipe for people recycling in and out of the criminal justice system because their behaviors run afoul of the law.

The discrepancy between the funded treatment capacity (8,500 per month) for only the three eligible diagnoses of schizophrenia, bipolar disorder and major depression (let alone all the other serious psychiatric conditions for which people end up in jail) is huge. A conservative estimate of the incidence/prevalence of these three diagnoses in Harris County is 170,000.

There is a growing awareness among our key county officials that the county simply can’t afford to continue housing this growing population in the jail. More cost-effective options for certain misdemeanor offenses by people with mental illness are under active consideration. This will require literally building out an array of services and supports that don’t currently exist in the form or quantity necessary to effectively impact this subpopulation.

Yes, he’s talking about an expansion, probably a big one, in government services. I realize words like those will get knees jerking in certain quarters, but let’s face it: We’re already expending vast public resources on this problem, and it’s getting worse. We need to do a better job of it, and that’s going to require a different approach, for just as using the emergency room is the least efficient way to deliver health care to those who can’t otherwise afford it, using the jails to deal with the mentally ill has got to be the least efficient way of handling that problem. Perhaps if we were already doing something different, we wouldn’t have such severe and longstanding problems with the jails, and we wouldn’t feel the need to spend millions of dollars to build a new jail to house all the inmates we can’t current squeeze in. Point is, we’re paying for all this now. We may as well get a better return on our expenditures.