Wednesday, October 10, 2012

Underfunded veterans mental-health care channels them into justice system

The Texas Tribune reported on a hearing of the House Defense and Veterans Affairs committee related to mental health challenges facing veterans. Notably:
Studies by the U.S. military have shown an 80 percent increase in suicides since the start of the war in Iraq in 2003. According to testimony by Lt. Col. Alba Villanueva, the director of joint family support services for the Texas Military Forces, which includes the Texas National Guard, there have been 15 suicides among Texas soldiers in the last three years, and two in the last 30 days.

Suicides and the mental health problems that lead to them are often a matter of untreated post-traumatic stress disorder and the lingering effects of military training.
the mental health problems that persist, others said, are serious even if returning soldiers are far from thoughts of suicide. "Sometimes the problems aren't surfacing for three or four months, whether it’s drugs or the criminal justice system,” said Rep. Dan Flynn, R-Canton, explaining that returning soldiers do not want to seek mental health treatment because they just want to get on with their lives. 
“When they come home, they want to go home, they don't want to be involved with the system,” he said.

“We're going to have to figure out some way to close that gap.”

Mental health problems often stem from the process of reintegrating into civilian life, [Military Veteran Peer Network statewide coordinator [Sean] Hanna said, adding that "it's not until they begin to enact their plan for what their life will look like that they start to face these struggles."

Hanna said the problem can be addressed by “more boots on the ground” — more funding for hired professionals to coordinate peer networks of veterans, because he says many returning soldiers will only seek help if they get advice from other veterans, and in rural areas of the state other veterans may not be nearby. 
I reference this discussion to point out how disconnected it seems from the reality facing veterans and others suffering from mental illness: An extremely limited base of providers and little public funding for the levels of mental health services needed to play a preventive rather than a reactive role. In the real world, as opposed to some legislative flow-chart, the criminal justice system is the main location where the system proactively provides services to treat serious mental illnesses. So those who most need treatment too often wait until their behavior deteriorates to the point that they wind up in the county jail or a state penitentiary, where mental health care has also been reduced thanks to budget cuts.

Grits also finds it curious that the Tribune account made no mention of how this subject - as with many corrections-related health matters heading into next year - plays into the debate over the proposed Medicaid expansion under the Affordable Care Act to include adults with incomes up to 133% of federal poverty levels, a matter which Texas must decide in the coming legislative session and which may be informed, one might guess, by the outcome of the national Presidential election.

It's fine to say veterans, the homeless and other special populations should receive mental-health care before they enter the criminal justice system, but the harsh reality of operating those systems doesn't allow for "should bes" but must deal with what actually is. Who will pay for preventive mental health care for the indigent if not Medicaid? Counties? I wouldn't hold my breath. And the state's not likely to pony up. Plus outside the largest cities, there's a stark shortage of behavioral healthcare providers, even if there was money available to pay them. Medicaid would create a market for those services and the hope is providers would follow the dollars.

 My own view is that, if Texas would participate in the mostly federally funded (90/10, when it rolls out completely) Medicaid expansion under the Affordable Care Act, it would have an enormous palliative benefit for the justice system, particularly as it regards creating a funding mechanism to pay for preventive mental health care for at-risk populations, including but not limited to veterans. It would also make much simpler an array of reentry concerns about continuity of care to have a ready insurance plan available for the 70,000+ people released from Texas prisons each year, not to mention the hundreds of thousands more on the probation rolls.

Right now, the state's approach is mostly to ignore mental health issues until they fall into government's lap via the criminal justice system. Part of the reason the Harris County Jail has become one of the largest mental wards in the nation is that front-end care has been under-valued by legislative budget writers while funding for jails and prisons until very recently was considered sacrosanct. Now the budget crisis has become so severe that even sacred cows like prison and jail funding are on the table for potential reductions, which is a marked change in the terms of debate even from just a few years ago. In that context though, it's also difficult for the state to come up with extra money for up-front care.

Though Governor Perry has already announced his opposition to Medicaid expansion, Grits doesn't for a long shot consider that a fait accompli because of the billions of dollars the state's medical industry would be leaving on the table in the wake of such a decision. Economist Ray Perryman has a column making the rounds in several Texas papers declaring that, from an economic perspective, Texas only has "one rational choice" available, which is taking the money under Obamacare and expanding Medicaid. That's certainly been my view and I suspect once the partisan winds of election season have passed, more than a few Texas legislators struggling with issues like veterans mental health care and recidivism reduction will see the same thing and press to accept the much-needed federal dollars for that purpose.

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Anonymous said...

This argument operates under the false premise that the expanded Medicaid funding would be (1) forthcoming (2) adequate and (3) that the services thus provided would be helpful. I think your argument fails in all three points.

Where is a broke United States going to get this money? Oh I get it--we can have a QE4 and QE5 to add more play money to our system as Obama and Bernanke have been doing. Who will want the Medicaid money? It is inadequate funding even now, and the provision of more of it will still be inadequate. No progress there.

Finally our publicly funded healthcare services are a sham even now, only passing out bottles of drugs to some people, converting abusers of illegal drugs into abusers of legal drugs. More government money diverted into Medicaid and mental health services will likely fund only more unqualified practitioners to pass out more pills with no salutary medical effect.

You've been harping on this potential "Medicaid Bonanza" for months--but it ain't coming, and if it does it won't be helpful.

You are correct about the truly alarming rate of suicide and mental disease among returning servicemen, but to be effective such care must come through the military, not through our dysfunctional public mental health system. Continuing to crow about the potential benefits of the "Affordable Care Act" is to put rose colored glasses ahead of harsh reality. I am sure that Dr. Perryman is a brilliant economist but rolling more government money around in a broken system is like observing dung beetles at work.

RSO wife said...

Speaking as the mother of a young man who gave 22 years of his life for his country, the services that are in place to take care of retired servicemen are atrocious.

It is much worse for those young men who chose not to make a career out if it and spent a few agonizing years in the service of their country. They gave their youth, they gave their families, they gave their health and in way too many cases, they gave their lives.

The way we treat those that make it back is unconscionable. If it weren't for them, people like "Anonymous 10:24" wouldn't have the freedom to write the junk they write.

The government got us into a losing battle in the middle east and the government should take care of our veterans when they come home and should take care of their families if they don't make it back, no matter what the cost. It's only money, we're talking lives here!!!!

Gritsforbreakfast said...

10:24, I think your first concern is silly - like telling George W. Bush he couldn't invade Iraq because the US didn't have the money. Once he did it - and the ACA is a done deal - they pay for it. The feds have to learn to pay for their budget, yes, but doing so wouldn't be nearly as difficult as operating with a dysfunctional healthcare system has been.

As for whether Medicaid is adequate, it's far more resources than exist now for these folks so it would be better than the status quo or anything you or other critics can suggest. In any event, even if coverage is less adequate than one might prefer - and nobody knows yet, time will tell - it's hardly "no progress," especially compared with your suggested tack of doing nothing.

Finally, your sweeping claims about "unqualified practitioners," etc., are just intellectual flotsam - the kind of foolishness people only say anonymously because they'd be embarrassed to say in public. It happens, but it's ridiculous to characterize the whole system that way. By and large Medicaid delivers a tremendous amount of real care far more efficiently than any private insurance company could ever imagine.

You may not like the ACA but it exists, it probably isn't going away, and Perryman's right that to refuse the money would be an absurd and unnecessary economic blow to the state.

I realize it's election season so maybe reconsider things once your Obama-hater goggles are removed and the reality sets in next year that the ACA isn't going anywhere. Time, after all, makes more converts than reason.