How the Texas vision for seamless mental health care fell apart over 60 years

Elizabeth Ramirez, mother to three children, sits at home in El Paso. After her eldest child experienced a mental health crisis, Ramirez navigated through the confusing and under-resourced Texas mental health system in search for professional help. (Credit: Emily Kinskey for The Texas Tribune)

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For 24/7 mental health support in English or Spanish, call the Substance Abuse and Mental Health Services Administration’s free help line at 800-662-4357. You can also reach a trained crisis counselor through the Suicide and Crisis Lifeline by calling or texting 988.

It was in early 2020, a few months into the COVID-19 pandemic, that the world Elizabeth Ramirez knew – filled with her three kids’ activities and a job as a human resource specialist – came to an abrupt halt.

A teacher had called from her son’s El Paso school. Her 13-year-old, Orlando, mentioned suicide during a virtual class, sending Ramirez into a desperate search for an in-patient mental health facility.

Ramirez’s son hadn’t been the same since his friend died in an ATV accident. Since then, he had met with mental health professionals, but more severe depressive behavior and suicidal ideation were causes for serious concern.

Ramirez had found counseling for her son when he was 5 years old and diagnosed with ADHD, so she thought it wouldn’t be hard. But it proved nearly impossible.

None of the four nearest in-patient psychiatric facilities had a bed for her son. She left her job with the U.S. Department of Homeland Security to take care of her son full time, moving all three of her children onto Medicaid. That shrank her options even more, as providers told her they didn’t accept the federal and state health insurance program for the poor.

Ramirez even tried to reach out to university research trials for help, but she was told there were no spots.

“In every facility, every clinic, and even the main hospital in town, the answer was always the same. No availability and not enough providers,” she said.

What Ramirez discovered was that she was wading into a Texas mental health system that was confusing, lacking resources and sometimes inaccessible. It’s a system that doesn’t have enough trained professionals. A system where the local health centers set up by the state are so overwhelmed by needy patients that they can serve only a small portion of the communities they were designed to support. A system where even people with health insurance often can’t find the help they need — or can’t afford it because practitioners have resorted to only taking cash.

And for the 3,347,000 adults in Texas who have a mental health condition, there are few directional cues about how to navigate it: Do patients just go to a primary care doctor, or is this a medical specialty with direct contacts, like gynecology or orthopedics? Or should they head to an emergency room or straight to a private psychiatric hospital, if there is one in the area? Can anyone access the 39 regional community mental health centers in Texas, or are those only for patients without insurance? Why do so many counselors and psychologists refuse Medicaid? And why are there so many waitlists?

For people in a mental health crisis, these questions can’t be answered soon enough and they point to a growing unequal mental health care system where cash payments, not insurance coverage, is the quickest way to treatment if a provider can be found.

Elizabeth Ramirez's son, Orlando, likes to draw to help de-stress. When he experienced a mental health crisis 3 years ago, Ramirez struggled to find resources through their Medicaid insurance. "And while you are waiting, you are seeing your child crumble in front of you," she said. (Credit: Emily Kinskey for The Texas Tribune)

“When it comes down to meeting a psychiatrist or meeting a therapist or any kind of provider, it’s, ‘Come back tomorrow, or we will give you a call next week,’ and that phone call never comes,” Ramirez said. “And while you are waiting, you are seeing your child crumble in front of you.”

For those in Ramirez’s position, it’s not surprising to learn Texas ranks last when it comes to access to mental health care, according to the advocacy group Mental Health America. For child mental health care, it’s not much better: 41st.

Today, 251 of Texas’ 254 counties are wholly or partially designated by the federal government as “mental health professional shortage areas,” and that’s in a state where roughly 5 million people do not have health insurance.

A Kaiser Family Foundation survey found that 36.8% of adults in Texas reported symptoms of anxiety or depressive disorder. Among adults in Texas who reported experiencing these symptoms, 30% reported needing counseling or therapy but not receiving it.

The need for these mental health services is only rising. Texas 988 centers in 2021 answered 60,000 calls, a 92 percent increase compared to 2018. The average state call line receives 3,300 calls per month; Texas gets 14,000 calls per month. In May of this year, the 988 Suicide and Crisis Lifeline answered 11,502 total contacts from Texas. According to a 2021 survey by the federal Substance Abuse and Mental Health Services Administration, 8.22% of Texans 18 or older had a major depressive episode, 5.33% had serious thoughts of suicide, and 1.78% made suicide plans in the past year.

“Texas is supposed to be this great state, but this great state has a mental health crisis, and they don’t see that,” Ramirez said. “We’re worried about other things like border issues and other things that aren't as important as the rate of kids and adults killing themselves because they can’t find hope.”

State-funded centers are strained

Mental health treatment in Texas wasn’t supposed to be this threadbare and challenging.

Nearly 60 years ago, Texas officials — encouraged by President John F. Kennedy’s 1963 Community Mental Health Act — envisioned an extensive mental health care system at the local level that would offer services to everyone.

“First-rate psychiatric care and comprehensive mental health services should be available to all Texas citizens,” proclaimed the writers of the Texas Plan for Mental Health in 1964. The 250-page document provided an optimistic blueprint for what would become the state’s community mental health districts.

As originally imagined, those districts were supposed to reduce the need for repeated appointments because they would offer a single entry point for services and then smoothly move a patient from intake to appropriate treatment. The 1964 plan leaned heavily on the idea of multi-agency collaboration and “non-psychiatric” counseling services offered by school teachers, ministers, and others.

Today, there are 39 local mental health authorities, but their mission has changed dramatically. Demand has so outpaced the staffing at these centers, funded primarily by the state through performance contracts, that they almost exclusively cater to the uninsured. It’s these 39 districts that many residents turn to first to locate counseling services, yet all report having a wait list that is weeks or months long.

In downtown Fort Worth, a steady stream of people walk in and out of one of four outpatient clinics operated by My Health My Resources of Tarrant County. This one clinic provides treatment to over 1,300 people a month with only three licensed mental health providers.

Those providers each see about 10 to 15 patients a day. The patients come for substance abuse assistance, therapy programs or to fill a prescription from the onsite pharmacy. They can receive counseling services, pre-admission screening for nursing homes, housing and employment help, substance abuse assistance, and case management, among other services.

“We are the safety net for the state,” said Susan Garnett, the center’s CEO. “We fill in the gaps.”

The state says that anyone in the community should be able to get help there. But Garnett said her center, like most facilities across the state, only has the resources to serve the neediest people.

“Our number one obligation is to the uninsured and those on Medicaid,” Garnett said. “Until we can say that we got all those people nailed down, then we won’t branch out to others.”

Sharon Forbes, a nurse at My Health My Resources of Tarrant County, one of 39 local mental health authorities in Texas. The center provides treatment to over 1,300 people a month with only three licensed mental health providers. (Credit: Azul Sordo for The Texas Tribune)

Even then, some community mental health centers are forced to turn away recipients of Medicaid, the health insurance for low-income Americans, due to staffing issues.

Limited funding means pay is low. When Garnett found out this summer that the local Taco Bell was offering to pay their employees’ college tuition, she cringed. The mental health center was given only enough funds to pay their intellectual or developmental disability direct care employees $10.06 per hour compared with the $12 per hour the average Taco Bell employee can make, and now fast food restaurants have benefits they couldn’t match.

“I was just sitting thinking, ‘Oh no, I can’t compete with that,’” she said.

Through fundraising, My Health My Resources of Tarrant County hopes to pay their direct care employees an additional $5 an hour. It’s the only hope the center has to hire more employees, Garnett said.

Because they work for nonprofits that are contracted by the state, local health authorities employees did not get pay raises that state-employed health workers received in the budget approved by lawmakers this year, frustrating some center leaders.

“We are contractors. They took care of state employees,” Garnett said. “I applaud them for that, but I hope they think that through a little better next session.”

More in need, fewer to provide help

The state’s mental health care shortcomings have been apparent for years.

“Since fiscal year 2012, the number of adults served by local mental health authorities has increased,” the Legislative Budget Board, which prepares policy recommendations for state lawmakers, reported in 2019. “However, the challenge remains to serve individuals that attempt to access services adequately.”

Since the pandemic began, the need has grown.

The stress of isolating for months at a time, navigating constant school and work interruptions not to mention income and job losses, took an enormous emotional toll on people in Texas and nationwide.

The World Health Organization reported last year that the global prevalence of anxiety and depression increased by 25% following the first year of the COVID-19 pandemic.

“The information we have now about the impact of COVID-19 on the world’s mental health is just the tip of the iceberg. This is a wake-up call to all countries to pay more attention to mental health and do a better job of supporting their populations’ mental health,” said Dr Tedros Adhanom Ghebreyesus, the director-general for the World Health Organization in a 2022 news release.

The Centers for Disease Control and Prevention reported in 2022 that since the pandemic started, mental health-related visits to hospital emergency rooms rose 24% for children ages 5-11 and 31% for children ages 12-17 compared with data from 2019.

There are not nearly enough practitioners to serve that growing need. Experts have been raising the alarm for more than a decade about mental health workforce shortages being at crisis levels.

“Texas has historically underinvested in mental health and substance abuse services, leading to gaps in communities accessing needed care,” said Alison Mohr Boleware, policy director for the Hogg Foundation for Mental Health. “Community-focused care has received less investments, and at the same time, Texas population has incrementally been increasing each year.”

The Statewide Health Coordinating Council in 2022 reported in their State Health Plan that 173 counties in Texas had no psychiatrists, and the workforce shortage is only expected to worsen.

A waiting room in the My Health My Resources of Tarrant County Youth Center in Fort Worth. Mental health-related visits to hospital emergency rooms rose for children since 2019. (Credit: Azul Sordo for The Texas Tribune)

“Given the nationwide mental health workforce shortage, it is unlikely that Texas can meet its staffing needs by recruiting providers from other states,” the report stated.

The Texas Department of State Health Services projects a shortage of 1,043 psychiatrists by 2032.

Providers’ struggles

The shortages aren’t just being felt by the community health centers; the private sector is struggling to keep up just as much, resulting in lopsided coverage because Texans, even those with insurance coverage, struggle to find a provider taking on new patients. In the Rio Grande Valley city of Alamo, home to around 20,000 people, Angela Salinas is the only in-person mental health provider. She has been forced to give out sporadic free sessions for the past few months just to address the dire need in her town.

“I try to give as many free sessions as I can. But I get to the point where it’s like how can I continue to survive and support my family if I continue to give away free sessions,” she said. “I work from nine in the morning to sometimes nine at night, with each session being 45 minutes. I work on Saturdays too, just to be able to help people out because there is nobody else.”

Salinas has been waiting for one of the largest insurers in the state to credential her since January because it takes 90 to 120 days to complete the process, and any mistake means the entire thing starts over again. This has left Salinas, like a majority of private providers, contemplating if taking insurance is even worth it.

Ana Y. looks through jewelry and drawings at My Health My Resources of Tarrant County. (Credit: Azul Sordo for The Texas Tribune)

“That is why you have providers saying they are done taking insurance; they can’t wait that long without payments,” she said. “On top of that, insurance [providers] can always come back and reverse what they gave you based on any little thing. It’s just too much of a hassle to take for some people.”

A large segment of private mental health providers in the state have switched to an out-of-pocket model these past few years because of low reimbursement rates from insurance companies.

Federal and state lawmakers have been trying to figure out how to put mental health coverage on the same footing as physical health for decades.

In 1996, Congress passed the Mental Health Parity Act, which prohibited large,group health plans from placing dollar limits on mental health benefits that were lower than those for medical and surgical benefits.

Texas lawmakers in 2017 passed House Bill 10, a law that strengthens existing federal protections for mental health and substance use care provided through private insurance. In 2021, the Texas legislature passed House Bill 2595, designating October as Mental Health Condition and Substance Use Disorder Parity Awareness Month, but more importantly, created a complaint portal where Texans can report problems with coverage to the state Department of Insurance.

In its annual report, the Texas Department of Insurance told lawmakers that between June 1, 2022, and May 31, 2023, the agency received 83 complaints about mental health and substance abuse benefits. Of those, 27 were confirmed as an insurance carrier’s error.

By law, if your health plan covers mental health or substance use services, those services must be provided at the same level as other medical services. Parity laws, however, do not require insurance companies to cover mental health or substance abuse services, and insurance companies have found it easier to question the necessity of treatment when it involves mental health inpatient care.

A national study published in 2013 found that only 55% of psychiatrists accepted private insurance compared with 89% of other medical professionals. Providers say the situation has only gotten worse since then, as the National Alliance on Mental Illness reported last year that Texans are over five times more likely to be forced out of network for mental health care than for primary health care.

“I believe people don’t want to take it because it’s like $30 to $45 a session for a session that is normally $110 or $120, and providers are saying I can’t live off of that,” Salinas said.

This has led to a significant gap in services for the majority of Texans who don’t qualify for the low-income or uninsured services found at local health authorities but don’t have the cash on hand to pay for mental health services.

Even fewer mental health providers deal with Medicaid because it’s not even viewed as worth the paperwork due to the low amount Texas provides for treatment.

About 15% of Texans are covered by health plans the Texas Department of Insurance solely regulates, explained the Hogg Foundation’s Boleware. About 50% of Texans are actually covered by their employer, and then about 20 to 25% are on a Medicaid-type plan.

No matter the payment method, right now, most places are either completely full and not taking new clients, or they don’t take insurance. “That is the huge challenge,” Boleware said.

This is a specific problem in rural communities that are usually older and low-income and might only have one private mental health provider in their region.

“I say in my heart, I want to cry. I get so emotional. When I know of all these people that need help, but we can't help them because you can only do so much,” Salinas said.

ERs and jails become a last resort

The result for many patients is a desperate search for help.

Jennifer Antwine's daughters had been seeing a family therapist in Fort Worth for several years after their father left them on Christmas Day almost four years ago. But when the family therapist told Antwine that her 13-year-old daughter, Ashlyn, had told her sisters she was thinking about suicide, it caught her off guard.

“I reached back out to the therapist and was like, ‘OK, what do we do now? Where do we go? How do we get her the help that she needs?’” Antwine recalled. “The first thing she told me was to go to our primary care doctor because that is the fastest option.”

This response surprised Antwine. She thought she should take her daughter to a psychologist or some type of mental health professional. But the therapist assured Antwine the quickest way to help her daughter was to go through primary care instead of dealing with the lingering mental health provider waitlists across the state.

Ashlyn Mosley, 13, "bedazzles" her stuffed animals with her mother, Jennifer Antwine, in Fort Worth. Antwine found it difficult to locate intensive mental health care for Ashlyn, facing the lingering mental health provider waitlist. (Credit: Azul Sordo for The Texas Tribune)

For two weeks, all Antwine could do was watch her daughter almost every moment of the day because there was no place to take her at the time.

“We were watching her like a hawk,” Antwine said. The mother of three lived in one of the largest cities in Texas, had Blue Cross Blue Shield health insurance through her job, and her child was already seeing a family therapist. None of it seemed to help.

It took a chance health scare, a drop in Ashlyn’s blood sugar, that inadvertently helped the family locate intensive mental health care. The low blood sugar triggered a seizure and Antwine's daughter was rushed to Cook’s Children’s Medical Center in Fort Worth. There, the nurses told Antwine about a telehealth intensive outpatient program for adolescents run by a virtual mental health clinic called Charlie Health. This program allowed Ashlyn to stay with her sisters and mom while receiving much-needed treatment.

“It wasn’t ideal to have to go to the ER for such a situation, but without it, we would have never learned about the telehealth program, and she wouldn’t have gotten the help she needed,” Antwine said. “I think that is what is so frustrating and irritating. There was such a long wait to get her to see somebody, and I knew she needed something, but I couldn’t help her. I feel like the main problem is nobody seems aware of what resources are available.”

The number of children showing up in emergency rooms with mental health problems is rising. Cook Children’s Medical Center reported this year that an average of 330 children with mental health complaints show up in their emergency rooms every month — a 36% increase from three years ago.

It’s part of a trend across the state as Texas Children’s Hospital in Houston reported in 2022 that 400 to 450 children a month are going through a behavioral health crisis. This was a significant leap from the 50 kids per month the hospital was seeing in their emergency rooms in 2019.

Ashlyn Mosley peeks through a window in her grandmother's home. A trip to the emergency room inadvertently helped Antwine find a telehealth intensive outpatient program for Ashlyn. (Credit: Azul Sordo for The Texas Tribune)

Hillary Wylie, director of clinical outreach for Charlie Health in Texas, said their organization works closely with emergency rooms across Texas for this very reason.

"Texans and young people all across the nation are increasingly seeking behavioral health support, and local health care services stand as the front line for so many of these folks,” she said.

But ERs are a costly last resort.

“Many emergency departments lack sufficient personnel, capacity, and infrastructure to triage and treat patients with mental and behavioral emergencies,” wrote Mohsen Saidinejad, an emergency room pediatrician, researcher and lead author of a policy statement issued by American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association. In it, the groups called for communities to step up and increase access to mental health services to prevent them from reaching the emergency room.

Relying on ER for urgent mental health care only “increases the likelihood of lengthy wait times, crowded facilities, and other challenges that compromise patient care,” the statement reads before conceding: “In many cases, an inadequate mental health infrastructure gives families nowhere else to turn but the emergency department. It’s a dilemma we’re experiencing more often since the COVID pandemic began.”

Texas Legislature fix

Texas lawmakers have poured $11.68 billion into the mental health system this year, an increase of more than 30% from the previous session.

Of that, $24 million is earmarked for additional mental health services to the Uvalde region in response to the mass shooting at Robb Elementary, $158 million to increase salaries for the state’s mental health workers, and $195 million for locally driven grant programs to encourage health care providers and nonprofit groups to offer mental health treatment.

“The state doesn’t always have to do this. There are great nonprofits doing wonderful work out there. We have local mental health providers doing wonderful work,” said state Sen. Lois Kolkhorst, R-Brenham, when her bill that created a $30 million “Innovation Grant” program received approval from lawmakers. “This is an opportunity of a lifetime to be able to help and direct our community in a time that we really do need it — and post-pandemic, we need it more than ever.”

Kolkhorst’s bill also requires the state to audit local mental health authorities once every 10 years and publish online data related to mental health care. It will also create a discharge and transition program to help people in state hospitals gradually make their way into the community.

The program by mental health providers has been universally praised as a potential solution to all the confusion surrounding the Texas mental health system.

“We have long maintained that the state should be collecting data about the extent to which individuals are in a lower level of care than what they are clinically recommended for,” Greg Hansch, executive director of the nonprofit National Alliance on Mental Illness of Texas, said. “Getting the right services at the right time matters.”

The Pottsboro library in Pottsboro, a little lake town of about 2,700 people near the Oklahoma border. Rural parts of the state are usually left with a limited number of mental health providers. (Credit: Azul Sordo for The Texas Tribune)

Rural mental health care challenges and one solution

The problems will not be easily fixed.

There are overwhelmed state mental health hospitals and county jails forced to house a large number of those with mental illness. Substance abuse treatment centers, particularly those that provide residential services, are closing their doors due to a lack of funding.

The unequal distribution of mental health providers in Texas exacerbates the workforce shortage issues as the limited number of providers tend to stay in metro areas, leaving entire counties in the rural parts of the state without providers. In fact, a state report in 2014 found no clinical psychologists in rural border counties, and more than two-thirds of the state’s licensed psychologists practice in five counties: Harris, Dallas, Tarrant, Bexar and Travis.

In some places, local officials are getting creative in their search for solutions.

About 80 miles north of Dallas, teeming skyscrapers give way to farm fields and hay bales. It’s here in Pottsboro, a little lake town of about 2,700 people near the Oklahoma border, where both mental health care and even high-speed internet is a challenge.

“We have an urgent care [facility]. We have a couple of dentists, and that's it,” said Kacie Galyon, Pottsboro city manager. “I would love for some sort of mental health, whether it be even like, you know, a licensed psychologist or psychiatrist in one of the existing offices. That'd be great. But unfortunately, we have nothing in the city.”

Pottsboro city manager Kacie Galyon says the small rural town has been rejected to receive a mental health facility. "We are just too small," she said. (Credit: Azul Sordo for The Texas Tribune)

Most patients have to travel elsewhere in Grayson County, to Denison or Sherman for specialized care.

Galyon said Pottsboro has made multiple attempts over the years to get a mental health facility, but each time, they are rejected for being a small rural town.

“They look at us on paper, and they say, ‘Oh, that’s all you got? Then it’s not worth it financially for us to be there.’ That is the hurdle that we can’t seem to get over. We are just too small,” she said. “It indirectly ends up translating to my people that live in my town aren’t worth it. But I understand from a business model it doesn’t make sense.”

Some people have decided to stop waiting for help to come to them. Instead, they’re finding better ways to connect the town to providers elsewhere.

Pottsboro librarian Dianne Connery turned a storage room into the home of an innovative telemedicine program. She used a $20,000 COVID-19 grant that she received from the National Library of Medicine’s South Central Region to equip her storage room with a reliable internet connection, web cameras, blood pressure readers, better ventilation, and even an iPad for patient check-ins.

Pottsboro librarian Dianne Connery used COVID-19 grant money to convert a storage room to a place where patrons can login for telemedicine appointments. (Credit: Azul Sordo for The Texas Tribune)

(Credit: Azul Sordo for The Texas Tribune)

(Credit: Azul Sordo for The Texas Tribune)

From this tiny room, the Pottsboro Area Library provides mental health services from the University of North Texas Health Science Center in Fort Worth.

“It was a situation of if I wasn’t going to do it, then nobody was going to,” Connery said. She says the people who use it often don’t have a good internet connection in their home.

The Pottsboro Library receives no funds from people using the telehealth service, and the entire thing is built on grant money Connery can dig up for herself.

“I love to do innovative stuff. But at the same time, we don’t want this to be an unfunded mandate that five years from now libraries are expected to do this without any additional funds,” Connery said. “We have to look at the sustainable funding.”

The Texas Tribune is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity (CPI), and newsrooms in select states across the country.”

Disclosure: Hogg Foundation for Mental Health and University of North Texas have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

Correction, Jan. 2, 2024 at 11:52 a.m.: A previous version of this story misspelled Hillary Wylie's name.