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Smart Justice: Texas Needs More Effective Alternatives Than Jail to Treat Mentally Ill

Wednesday, May 27, 2015
Andy Keller, PhD., Executive Vice President for Policy and Programs

For decades, a best practice of health care systems reform has been to reduce higher-cost emergency health care by promoting more cost-effective primary care aimed at prevention and early intervention of illness and disease. It is time to eliminate the stigma of mental illness and understand it for what it is, a physiological disorder in the brain, and apply the same best practice to improve Texas’ mental health care.

Across the vast majority of our state, access to community and preventive mental health services is limited. Consequently, too many Texans with behavioral health problems do not receive the help they need until hospital emergency departments, child protective services, social services agencies or the criminal justice system intervene with services that are often more costly and less effective.

The Meadows Mental Health Policy Institute partnered with the Texas Conference of Urban Counties to study outcomes of the Texas mental health system. Counties representing more than half of Texas’ population provided data on jail related costs, including large and small counties (21 total). Using county level prevalence estimates, they determined the relationship between the number of people with serious mental illness and the cost of housing and treating individuals with mental illness in county jails. Their conservative estimates of the local burden of unmet mental health needs add up to a heavy price tag for our communities:

  • $450 million in jail costs for individuals with mental illness.
  • $230 million in juvenile justice costs for youth with serious emotional disturbances.
  • $940 million in psychiatric emergency department costs.
  • $445 million in alcohol and substance abuse emergency department costs.

When you consider that one half of all mental illnesses begin by age 14, and that adults with untreated mental health conditions are eight times more likely to be incarcerated than the general population, earlier screening and intervention need to be part of a comprehensive, integrated primary and behavioral health care system in Texas.

Each year, 175,000 Texas children suffer from severe mental health needs. Of those, 50 percent will drop out of high school and face double the risk for substance use. Despite the availability of Medicaid, the stigma and lack of public education surrounding mental illness is a barrier that prevents families from seeking early care. As a result, many Texas children in need receive their first mental health services through foster care, juvenile justice or special education. Research has consistently documented that approximately 70 percent of youth in the juvenile justice system have a diagnosable mental health disorder; of those youth, over 60 percent also suffer a substance abuse disorder; and 27 percent have serious disorders that require immediate and significant treatment.

Untreated mental health disorders in children will follow them into adulthood with potentially greater consequences and cost to our communities. It is estimated that 34 percent of the inmate population in Texas have mental health disorders. Youth and adults in our criminal justice system are not the only concern. Texas is home to 17 million veterans. Approximately eight percent experience severe mental health and substance abuse needs and approximately three percent suffer severe and persistent mental illness in a given year, putting veterans with inadequate access to care at higher risk of contact with the criminal justice system.

The concept of Smart Justice is to divert the treatment of mental illness away from our criminal justice system by ensuring Texas has a comprehensive, integrated primary and behavioral health care system to prevent, screen and intervene early through lower-cost and more effective programs. To do that, we need to de-stigmatize mental illness and join in supporting our state and community leaders and organizations who are working on this issue in your community.


70% of youth in the criminal justice system suffer from mental disorders.
17% of adults entering jails and state prisons have a serious mental health issue.


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What I Learned About the Price of Mental Health Issues for Texas Taxpayers

Sunday, May 17, 2015
Representative John E. Davis (R), 76th through 83rd Legislative Sessions, and former Chair of the House Appropriations Subcommittee on Article II – Health and Human Services

During my tenure in Austin representing Houston’s House District 129, I had the privilege of serving as Chair of the House Appropriations Subcommittee on Article II for the 78th, 79th, and 80th Legislative Sessions. As the committee worked on budget recommendations related to Texas’ Health and Human Services agencies, one thing hit me that few people realize – the tentacles of mental health issues run through all parts of our state budget. Beyond health care and social services, mental health costs touch criminal justice, education, housing – everything.

That was a big take away for me. What I want legislators and taxpayers to understand about mental health is, “you can pay now or pay later, but you will pay a price.” It is not only the cost of mental health services. There is a family price, and a social price. Speaking strictly from a dollar-wise perspective, it is smarter to pay at the front end because mental illness touches every part of our public services, and the cumulative price is far greater.

Throughout my time in office, I have advocated for access to health care, including mental health care, for all Texans. The point is people need to know where to go, and there shouldn’t be a wrong door. Here is where we took large and significant steps during my time in the House.

Reorganize the System

While not fully implemented, HB 2292 (76th session) was the first to begin the restructuring and streamlining of 12 state agencies into four under the Health and Human Services umbrella to provide services in a more client-responsive and cost-effective manner.

The 80th Texas Legislature appropriated $82 million to the Department of State Health Services (DSHS) for mental health and substance abuse crisis services. This funding allowed the local mental health authorities to provide recommended crisis services to Texas communities and is still being funded today.

SB 1 (83rd session) promoted more efficient use of health and human services dollars and prioritized preventive health services for women, mental health, and programs to assist abused and neglected children. SB 58 (83rd session) sought to improve outcomes for mental health care and reduce costs by better coordinating services through Medicaid and in the managed care setting.

Promote Collaboration

In addition, The Healthy Community Collaborative (Rider 90, 83rd session) allocated up to $25 million to fund grants for programs serving the homeless with mental illness. This legislation recognized that
1.) programs have to be scalable and tailored to the community,
2.) public/private partnerships are necessary for sustained outcomes, and
3.) collaboration between local agencies is essential to holistically treat an individual with mental illness whether he or she is in health care, social services, criminal justice, or education setting.
Two positive examples of that came out of Rider 90 are the Haven for Hope in San Antonio and The Bridge in Dallas. Both programs utilize case managers to help navigate individuals to the right path for care and fit in those communities the way they envisioned it should. This success can be replicated.

Next Steps

Those legislative accomplishments were needle movers, but improving mental health services across a state as vast and diverse as Texas is complex. We have to keep chipping away at this issue, educating people, and be willing to talk about mental illness.

The 84th Legislative Session is continuing that effort by making mental illness a priority. The Sunset Review recommendations have sparked new bills taking on mental illness issues on multiple fronts – from further streamlining Health and Human Services to fully integrating mental health services. Legislation is moving to address workforce shortages, help veterans, and ensure the mentally ill in our criminal justice system get the help they need.

Overlaying all of this is a rider in the Senate version of HB 1 that brings all of the state agency players together to create the first coordinated mental health strategic plan. If all of the state’s resources acted in unison, I think we’re going to see remarkable results.

It may not all be perfect, but from my perspective, it is wiser to pass and adequately fund these direct measures now rather than lose the opportunity to do so in the next session. As I have learned, mental health issues touch every part of our state’s budget, and the price we will pay later on are its greater, hidden costs.