What's Medicaid Got to Do with It?

illustrationMedicare-vs-Medicaid-5.15.11by Dawn Thames

For good or ill, recent events have cut across partisan divides to ask why mental illness was not identified and treated. Mass shootings in Aurora, CO, and Newtown, CT, have prompted debate about automatic weapons, large capacity magazines and, secondarily, mental illness. Should there be a national database for assault weapons owners? Should there be a national database of all gun owners? Should there be a national database of persons with mental health diagnoses?

National debate began to feel wearily familiar except for the small window of discussion on mental health issues. "Who can watch the sad images of the last several weeks, who can see the pictures of those young faces and honestly say that we are doing enough?" asked Gov. Martin O'Malley (MD-D) Democrat in his State of the State address in January, urging state lawmakers to "ban the sale of 'military-style assault weapons,' require licenses for buying handguns, bolster mental health treatment and information sharing, and spend more on school security."

The February 4 death of Navy Seal sniper Chris Kyle removes all questions of gun registration or appropriate setting for carrying a weapon. Apparently, in the middle of therapeutic peer outreach to a young veteran, Chris Kyle and Chad Littlefield were shot to death. This shooting took place on a firing range, all guns were licensed, all three men were armed and highly capable. One of them, the confessed murderer now held on bond, had reportedly been diagnosed with PTSD. A veteran at just 25 years old, Eddie Ray Routh was old enough to do real damage without the marksmanship that made Chris Kyle a legend. Two simple truths can be assumed in this situation: 1) untreated trauma can make psychic pain violent and deadly; and 2) traumatized people tend to over-react in perceived stressful situations.

Out of the attic and into the public sphere, the taboo mental health needs of the "criminally insane" are no longer limited to once-a-decade sensational stories. The daily headlines portray shootings by the "people next door." The still-polarized discussion of public health care might find new alliances around providing better mental health care services to those seriously affected. Even violent criminals have human faces. As sons of teachers, brothers of firefighters, or the lonely student, these people in the headlines have reduced the comfortable distance between ourselves and danger. Labels like sociopath can no longer cover the huge gaps in our mental health care system. Can we move the discussion to address this aspect of the national crisis over gun violence?

Mental health care needs in Texas have grown exponentially in the past decade according to Theresa Daniels, Dallas County Commissioner. "There just are many fewer dollars per person to spend on mental health services in Texas." One of the large, identified underserved populations in Texas is a group identified as "individuals with severe mental health disorders… data suggest people may be presenting in crisis having not received appropriate care through a specialty provider network." Also listed are the presumably overlapping populations identified as, "Special populations including jail and prison inmates, juvenile justice residents, child welfare recipients and homeless people." The recognition of juvenile justice residents as an underserved population is especially concerning since the statistics on mental health care needs among these populations are alarmingly high. One 2012 study estimates that 50-75% of juveniles in the Texas system qualify for with at least one diagnosed mental health disorder.

Poverty and serious psychiatric disorders combine forces to make ordinary social interactions into major challenges.

Persons with serious psychiatric disorders (SPD) demonstrated social disadvantage in the 2001–04 NHIS. Persons with SPD were more likely to be poor (live below the federal poverty line) than persons without SPD. Persons with SPD were much less likely to be married or have finished their high school education than persons without SPD. The higher rate of poverty among seriously mentally ill persons is a common finding (33–34). In a series of three papers describing the social consequences of psychiatric illness, Kessler and colleagues (35–37) demonstrated that early-onset psychiatric illness is associated with lower educational achievement, higher risk of teenage pregnancy, and inability to find or maintain a relationship leading to marriage.

Imagine this further exacerbated by incarceration, homelessness, or juvenile detention when mental health services are unavailable or inadequate. There are numerous advocacy organizations in Texas that have had a positive impact on juvenile justice practices. There are yet other forces for educational reform focused on interrupting the school to prison pipeline by diversion.

Probation-Based Diversion: Texas has developed a pre-adjudicatory, specialized mental health diversion program in four juvenile probation departments—in Dallas, Lubbock, Bexar and Travis counties. The Front-End Diversion Initiative (FEDI) is a specialized mental health probation program for juveniles that diverts youth with mental health needs from adjudication using Specialized Juvenile Probation Officers (SJPOs) who receive intensive, specialized training and maintain lower caseloads. SJPOs coordinate services by providing quality case management and link youth and their families to formal and informal community resources and support. Key FEDI program elements include.

Mobile Crisis Intervention Teams (MCIT) were formed to respond immediately to youth in emotional crisis at schools or other locations before arrests are made. Efforts are made to de-escalate the teen's response and provide a positive response to the underlying emotional needs of the teen before detention becomes a reality. This process is staffed by specially trained juvenile probation officers as mentioned above. In other states law enforcement officers are the point persons for these therapeutic interventions.

Sound extravagant? Indulgent? In fact, Texas has become notorious for an extravagant level of school security spending! Texas spent 227 billion dollars on school discipline and security in 2012 according to a Texas Tribune report. Front End Diversion of students away from secure detention sites and into therapeutic community-based programs and alternative therapeutic options for youth in trouble could radically change the fiscal picture as well as rerserve this precious human capital. The availability of Medicaid dollars for funding mental health resources could not come at a better time for Texas youth.

"We recognize that many Texas school districts are struggling as a result of the $5.4 billion cut in state funding for public education approved last year to help address a state budget shortfall," Texas Appleseed's Deputy Director Deborah Fowler said. "We are releasing this report, not to point a finger at spending in the surveyed school districts, but to open a dialogue with schools about different approaches to student discipline that are more effective and less costly to implement."

Ruben Austria, Founder of Community Connections for Youth notes:
When you move a kid 200 miles from his family in a system that has no long-term interest in loving and … helping that kid get to the next step. You send that kid back to our communities worse off than he was in the first place. These kids are getting pushed deeper into the system.

Unfortunately, without front-end diversion, kids are not being counseled and evaluated for some more positive solution. In fact, they are isolated from family and community resources and, incidentally, racking up a big bill! Texas Criminal Justice Coalition estimates a daily cost per youth from $75 to $209/day x an estimated average daily population in pre-adjucation facilities of 1,720 in 2011. Millions of dollars could be saved by this estimate.

The MCIT and the FEDI (front-end diversion initiative) have been lauded by the counties in which they have been introduced, because they brought new funding to an overwhelming problem in their communities, and in the least restrictive environment. Counties with community-based diversion programs are eligible to receive a state reimbursement of up to 80% of the cost of services whereas counties employing secure detention facilities to treat youth are only eligible for a state reimbursement of up to 50% of the cost of services.

In an atmosphere of fiscal conservatism, appropriation of funding for reform in each of these discreet budgets has been severely restricted. Yet there has been a new coalition of forces to highlight the role of health, specifically mental health for children and adolescents which adds a third dimension to relatively flat presentations of this complex matrix of social problems.

Despite the contentious healthcare environment, the Medicaid expansion debate in Texas may actually show some openings for better options. While Texas has been pouring massive funds into juvenile detention, proactive funding for mental health just makes sense. Proactive interventions for teenagers make even longer-term sense for the human being, for society, and for our fiscal well-being as a state.

Call or write your State representativeCALL FOR MEDICAID EXPANSION, and mention the importance of FRONT-END DIVERSION in JUVENILE JUSTICE! It works for all of us.

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