The Mental Health and Mental Retardation Authority of Harris County

The story goes like this: An older gentleman is walking down the beach. The tide has gone out and the beach is covered with thousands of starfish. As he walks, he sees a young man down the beach. The young man bends down, picks something up, runs to the water, and throws something out, then runs back, doing this over and over as the older fellow approaches. In a few minutes, the older man comes up to where the young fellow is and asks of the younger one: “What are you doing, young man?” The young fellow stops, and says, “The tide has gone out, leaving all these starfish on the beach where they will die. I’m throwing them back in so they may live.” The older fellow asks “Young man, there are thousands of starfish on this beach, what difference can you make?” The young man reaches down, grasps one, runs to the water, and throws another starfish into the water. He then turns, and says to the older fellow: “It makes a difference to that one.”

Many have heard the starfish story before, which I think is so applicable to those of us who work hard day in and day out to provide the services and supports so necessary for some of the most complicated and involved persons in Texas with mental disabilities. Often we feel overwhelmed with the enormity of the numbers in need of services and the scarcity of resources. Sometimes it feels like we can’t get our heads above water.

As this article is being written and goes to print, the Conference Committee is in the process of reconciling the difference between the House and Senate versions of the Appropriations Bill for FY 2002-2003. Ten appointees, five from the House and five from the Senate, literally hold the budget of Texas government in their very hands. As in the past, these 10 key representatives and senators will struggle over the significant, critical needs of the state’s various agencies, institutions, and organizations, doing the best they can to spread the limited resources projected for the next biennium by the State Comptroller as fairly and appropriately as possible. Constitutionally, they can’t create a deficit budget — having to live within the revenue estimates certified by the Comptroller. In many past sessions, as the final hours of the session neared, the Comptroller made a final projection of funds available, certifying additional revenues above the levels previously identified. This year we have a new player in the mix, the stock market decided to “right” itself in response to indicators of an economic slowdown. With the significant market adjustment, even with the federal government dropping the prime interest rate again, there may be too much softness in the Comptroller’s indicators to forecast much in the way of additional revenues. If that is so, then the current revenue estimates are what there is. And, if the current certified revenue estimates are all there is for the Conference Committee to allocate — there isn’t enough money to make a meaningful dent in the real, worthwhile needs of Texas government. The one possibility above certified revenues is to tap into the Rainy Day Fund (a special fund established some years back by the Legislature to be available in hard financial times.) The Senate, convinced about the critical issues facing Texas, approved its Appropriations Bill above certified revenues, allocating monies from the Rainy Day Fund to make those increases they believed to be justified. The House did not, placing those significant, justified increases into Article XI — The “Wish List” — to be funded if the Comptroller certified additional, sufficient income. The House Leadership has, supposedly, rejected tapping into the Rainy Day Fund. The Conference Committee will decide what to recommend within the final bill.

So here we sit, the Conference Committee poised in the first week in May to take up Article II — where the TDMHMR budget items reside. This session has probably been one of, if not, the most successful in terms of advocacy efforts on behalf of the service and support needs of Texas residents with significant mental disabilities. The efforts of the Texas Coalition of advocates were truly outstanding. Speaking with a loud, unified voice, many members of the Texas Legislature were convinced — the needs are real — the services and supports are eroding — people who should have access are being placed on waiting lists, or worse, “lost.” People are ending up in jails and prisons in large part because they can’t obtain the supports, intensity, and wraparound level of services that would enable them to become more productive members of our community. Many members of both the House and Senate want to respond — members of the Conference Committee want to respond — but will they, can they?

The “elephant” in the room this session has clearly been Medicaid. The state general revenue match for federal Medicaid is way, way over estimated levels. Over $600 million is needed to balance this biennium (FY 2000-2001). The $600 million plus an additional $690 million, we were recently told, is needed for FY 2002-2003, which will only be enough to maintain current levels of care. In addition, serious concern exists within the Legislature over people who are eligible for Medicaid, but due to the “barriers” that exist, don’t have access to this health insurance. The answer, Medicaid “simplification.” The cost, estimated at more than an additional $300 million. And, due to the current Medicaid rates of reimbursement, the Legislature has become seriously concerned over the erosion of the provider network throughout the state (providers are dropping out of Medicaid, capping caseloads, or going out of business). The Legislature wants to adjust rates, which is estimated, potentially, to cost more than $500 million. Medicaid is the “elephant” this session, with a potential additional cost of $2 billion, which overshadows everything else.

So what about the other needs of Texas — the service and support needs of the mentally disabled, the pay raise for state employees, the pay raise rider for Community MH/MR Centers, the teachers’ health insurance costs, the projected increases in the prison population, public education, the infrastructure of a myriad of state agencies and institutions (deteriorating buildings, vehicles becoming unusable, information systems requirements, etc.) The needs are huge — the revenues simply are not there to adequately address them. The Texas tax structure, as it currently exists, cannot fund the array of truly worthwhile needs.

Texas residents are, supposedly, taxed at a level which ranks 40th per capita in the nation. Our mental health services are ranked 43rd per capita and our mental retardation services ranked 41st per capita in the nation. With the impending Medicaid Rehab rate adjustment coming Sept. 1, 2001, it is estimated that more than $17 million per year in existing Medicaid revenue will be taken out of the funding mix for mental health services in FY 2002. Significant medication cost increases and other inflationary pressures are reducing the buying power of available general revenue — taking other millions of dollars out of the mix. Depending on how the Conference Committee makes its decisions, the public mental health and mental retardation system may have less revenue, rather than more. Thousands of Texans are currently waiting for services — thousands more may have to be added because of the lack of revenue as well as the erosion in the “buying power” of existing resources.

Hopefully, the efforts of the Texas Coalition will have a positive outcome — even in this tight session. We are not waiting on the chance that additional revenue will be forthcoming. We, as a system, are in the process of “scrubbing” ourselves, inside and out. We are looking at the ways we spend our resources, and what “bang” we get for them — are we achieving the kind of results our consumers deserve? Tough decisions will have to be made: what general revenue is really available to provide services for the uninsured (separate from the general revenue needed to match the Medicaid services)? What services, how much, and for how long? How do we deploy our staff resources to maximize their productive value at a reasonable cost? How do we work smarter to better meet the needs of our consumers and the payers of their services? One thing is clear, we cannot — cannot — do business as we have been. We have to be clearer as to what we are able to do — then do it well — within the limits imposed by the resource limitations that exist. Each and every consumer we clinically “touch” will have to understand these limitations but then experience a positive and productive interaction, both for the consumer and his/her family. We may have less, we certainly won’t have enough. Each dollar must count — each contact must count. The people who turn to us — either because they believe we can help — or because they have no other place to go — deserve it! It does make a difference to that one — to each and every one of them. Thank you — for them — from them.