Texas lawmakers budgeted funds for inmates waiting for psych beds. Critics wonder if it was enough

From KERA News:

The years-long waiting list for state mental hospital beds got money and attention at the Texas Legislature this year. But serious questions remain about whether people will actually get the care they need.

“There’s way too many people that are jailed … with mental health issues that aren’t getting the care that you would want them to get,” Denton attorney Sarah Roland said. “To see how they are existing just on a human level, I think, is abhorrent.”

In response to the crisis, lawmakers approved billions of dollars for the state’s mental health system.

If Gov. Greg Abbott signs the state budget into law, some experts say as many as 1,000 beds could either come back online or be created by the new funding.

“There is a very significant investment being made in in-patient care,” said Greg Hansch, executive director of the National Alliance on Mental Illness of Texas (NAMI Texas).

But no one thinks 1,000 additional beds is enough to meet the need, and the state is still struggling to deal with a shortage of workers.

Funding was also increased for programs that would divert mentally ill people from jail, although the legislature passed on other promising strategies.

The forensic waitlist

One of Roland’s clients had already been in a North Texas jail for almost a year when he was declared incompetent to stand trial in early 2022. With that designation, the man joined thousands of other pre-trial inmates waiting for a state hospital bed where he could have his competency restored.

Sarah Roland, a criminal defense attorney in Denton, has represented people waiting to have their mental competency restored before they stand trial.
Bret Jaspers / KERA News

Roland said her client was looking at more than 700 additional days in jail before the state would accept him because of a lack of staff, space, and the fact that he was accused of a violent offense.

And his condition was deteriorating.

“He was self-harming in that concrete jail cell. Banging head against the wall, all sorts of things,” Roland said, looking at a photograph she took of her client curled up on the floor of his cell. “Just horrific things you don’t do if you’re in your right mind.”

Roland said she pushed the court to order the state to fulfill its obligation of care, even subpoenaing the head of the state health commission. Later, a doctor asked the judge to mandate medication for her client. He’s now considered mentally competent and is awaiting trial.

Even though Roland’s client has achieved some level of stability, there are thousands of others who continue to languish.

Texas’ so-called “forensic waiting list” stretched to 2,364 people earlier this month, according to the state. This is a group of inmates that needs persistent and costly mental health treatment.

A big question heading into the recently concluded legislative session was what lawmakers would do to reduce the size of the list, since inmates are seeing no movement on their cases and counties have been forced to absorb the significant cost of their health care.

“If we’re not going to take those inmates, we should at least pay for them,” said Texas Rep. James Frank (R-Wichita Falls).

Frank and others proposed bills to force the state’s health and human services commission to reimburse counties when a mentally incompetent inmate waits more than 45 days for placement in a state hospital.

Those bills never got off the ground in the State Senate.

Lawmakers did, however, spend significant money on the problem:

⋅ About $200 million on operational costs, including salaries for workers, at state mental hospitals.

⋅ More than $300 million on contracting mental health beds at private or community-based hospitals.

⋅ More than $2 billion to help build, refurbish, or replace state mental hospitals in Dallas, Lubbock, Amarillo, San Antonio, Uvalde, Terrell, Wichita Falls, El Paso, the Rio Grande Valley, and elsewhere.

⋅ $38.7 million to upgrade the electronic medical records system in state hospitals

⋅ Millions for educational incentives to increase the number of mental health providers, money for crisis services, and other items.

Hansch said this level of investment should “substantially reduce the forensic waitlist when these new facilities are up and running,” although it would not eliminate it.

Is it enough?

Completing the planned expansion of the state mental hospital system should take several years. Future hospital space would have been of little help to Roland’s client when he was put on the forensic waiting list.

“The beds [were] needed yesterday. Not in 2025. Not in 2026, when something may be available and built,” Roland said.

The planned Dallas hospital, for example, is expected to complete construction in 2025. In the meantime, a county lawsuit against the state is pending in state court over the cost of caring for people on the forensic waiting list.

According to county data, an average of 359 people in the jail in April were waiting for a state mental health bed for competency restoration. The average time a man spent waiting for a maximum-security bed was 729 days. For a woman needing a maximum-security bed, the average wait was 564 days.

The county said sheltering one inmate costs $66.16 per day. Caring for 359 people for an entire year yields an estimated $8.7 million bill for the county.

The beds funded in the recently passed state budget, said Beth Mitchell of Disability Right Texas, likely won’t be enough even when construction is complete. Mitchell pointed to a 2014 report commissioned by the Health and Human Services Department that estimated 3,335 state-operated hospital beds would be needed by 2024. That estimate accounted for population growth and the increase in criminal defendant patients.

“Even based on the beds they’re going to get, that … still does not get them to the beds that they need,” Mitchell told KERA News.

Mitchell’s organization is currently suing the state in federal court for violating the rights of defendants who wait an unreasonably long time for a state hospital bed.

The Texas Health and Human Services Commission said they did not have anyone available for an interview about the budget.

A staffer for Representative Toni Rose, a Democrat who represents Dallas and serves on both the Human Services and Appropriations committees, said she was not available for an interview.

Workforce issues

Lack of workers is a major reason why so many state hospital beds are offline. At the end of April, state hospitals had about 1,220 of their 7,808 full-time equivalent positions unfilled, roughly 15%.

The budget tries to address that with approximately $200 million over two years for state mental hospitals, with about $35 million for salary increases “to address staffing challenges.”

But tellingly, the state budget includes this fallback:

“If by December 1, 2023, the Health and Human Services Commission (HHSC) is unable to hire enough staff to allow offline state hospital beds to be utilized, HHSC may instead allocate the funding to contract for additional competency restoration beds.”

In short, increasing salaries does not necessarily mean the workforce will materialize, as the commission learned in the recent past.

In 2021, the department received a boost of $400 million from the Legislature, only to take beds offline soon after that session ended. Several experts said this was due to staffing.

“This is not a new issue,” said Hansch. “The money being appropriated but then not having the workforce to provide care in those settings.”

As Frank put it, “there is nothing that makes them do it. There’s nothing that makes them go out and hire people. They can just say, ‘we just can’t hire people.’”

An HHSC spokesperson said 436 mental health beds were offline due to staffing as of June 5 of this year, out of a total of 2,354. An additional 181 beds were offline because of construction or maintenance. This doesn’t include beds operated by private health care entities that the state contracts for.

Thinking proactively

There is also funding in the budget to boost care for people with mental health issues before they end up in jail, like tens of millions for crisis services and money for judges, prosecutors, and defense attorneys to learn about mental health and pre-trial diversion.

Yet there were opportunities to address the crisis that lawmakers passed on, experts said.

The biggest may be no expansion of Medicaid under the Affordable Care Act. Texas is one of a dwindling number of states — ten — yet to take advantage of federal Medicaid dollars to insure a larger group of low-income residents. The state has the highest uninsured rate in the nation.

Hansch said community-based mental health providers, who also have workforce challenges, only received a fraction of the funding they hoped for.

And other preventative measures also failed, like a phone fee to fund the 988 mental health crisis line and require insurance plans to cover first episode psychosis care.

“We can’t over-focus on beds, beds, beds,” Hansch said. “There has to be a more concerted effort in other areas because all of these segments of the mental health system are related to one another.”

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