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Stephen Schnee

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.

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.

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.