Tuesday, January 14, 2014

'Want treatment for mental illness in Houston? Go to jail'

See the excellent story in the Texas Observer by Emily DePrang (Jan. 13) with the same title as this post. Here's a notable excerpt that pegs the lack of mental health treatment resources in the justice system to the state's failure to expand Medicaid under the Affordable Care Act, a factor this blog has previously lamented:
Being untreated makes it harder to stay out of trouble. A six-month study by Harris County’s public mental health authority found that people on the waiting list were three times more likely to end up in the Harris County Jail than their counterparts receiving services.

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.”
There's also a good discussion of the challenges facing a mental-health pilot program approved at the Harris County Jail by the Texas Legislature last year:
In 2011 and 2012, some 920 people were booked into the Harris County Jail five times or more. Formally, they’re known as “chronic consumers,” but behind closed doors they’re called frequent fliers, people who use hundreds of thousands of dollars in public services cycling through jails and emergency rooms for years. Well over half of chronic consumers have a mental illness; almost two-thirds are homeless.

Harris County launched a program in 2009 to identify chronic consumers who had frequent run-ins with police and to connect them with services. It’s been successful; the county has reduced its clients’ contacts with police by about half. A new pilot program, funded by the state, will target 500 chronic consumers and do even more, providing medical, psychiatric, substance abuse and housing services in Harris County during their first weeks out of jail. The goal is to save money in the long run by breaking the crisis cycle, preventing re-incarceration and re-hospitalization. But are the millions appropriated for it well spent?

[Andrea] Usanga, of Mental Health America, is among those with doubts. “If you look at these folks that we’re targeting in Harris County,” she says, “[who have] 20 or 30 years of criminal justice involvement, saying that some months or even a year of case management is going to break that cycle—that’s very, very difficult. The Legislature invests a lot when we’ve already gotten to the point where it’s most difficult to treat something.”

The Harris County pilot program, for example, got $10 million to address the needs of between 500 and 600 chronic consumers for the next two years. That’s about $9,000 per person annually—considerably less than the price of a year in jail, but far more than outpatient care. The problem is that even with the new efforts, Usanga says, chronic consumers are likely to spend time in jail.
“With this program, they’re going to have to determine what success is,” Usanga says. “Again, you can’t say that success is the person’s never going to come back [to jail], especially when you have somebody with histories as complicated as many of these individuals. It may just be like, well, it’s better if instead of coming back after one month, they come back after two.”

Community-based care, however, is downright cheap. In fact, an entire year of outpatient care costs less than the average jail stay of 40 days.

Mental Health America believes that’s where state money should be going. Usanga says that the last legislative session, when lawmakers added $350 million for various mental health programs, was a start, not a solution. “It’s like, we appreciate what you’re trying to do,” she says. “You’re trying to make up for years and years, decades of ignoring us. But we can’t fix it in two years.
 The entire, lengthy piece is well worth the read. Great job, Emily.

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