Indiana is on the cusp of mental health reform. But what about paying for it?
Rev. Rick Spleth, regional minister of Christian Church (Disciples of Christ), speaks during a Faith in Indiana press conference on March 7, 2023, inside the Statehouse. (Credit: Ryan Martin)
- Mobile crisis teams visit people at their homes in a new approach being hailed as transformative
- Advocates worry whether lawmakers will still consider fully funding the crisis system
- $1 cell phone surcharge floated as a possible way to fund an expanded system
A woman in rural Indiana wanted to harm herself. Without friends or family, she felt alone, like no one cared.
But on that day in February, a Logansport behavioral health clinic sent two members of its mobile team to the woman's home. They convinced her to return to the clinic with them. She spoke with a therapist and learned about ongoing help available across Cass, Fulton, Miami and Pulaski counties.
"She started crying and said, 'People really do care,'" recalls Bev Garrett, 54, who runs the mobile team at 4C Health. "That is the one thing that saved her life that day."
Indiana has struggled to provide adequate care for people in crisis for years. As a result, suicides have remained above the national average. Indiana's life expectancy, meanwhile, is lower than the national average and has been rapidly worsening over the last decade, fueled by excessive substance use.
It has grown so dire that drug overdoses have increased by more than 100% over 10 years, according to an analysis by an Indiana demographer, and the nonprofit Mental Health America last year said Indiana ranked 42nd in treatment.
So when Hoosiers reach a crisis point — whether they're suicidal, experiencing delusions or desperate to shake the demons of addiction — Indiana provides the thinnest of a safety net. Two common destinations? An emergency room or a jail cell, both of which are costly.
Some parts of Indiana, though, are charging into a new frontier of delivering mental health services. Like 4C Health, they're launching mobile teams to visit people at their homes. They're establishing crisis stabilization units for people who can't wait weeks for an appointment and are providing the services 24/7, regardless of anyone's ability to pay.
The new ways of providing mental health services are being hailed as transformative.
"They are the single greatest developments in several decades of doing this work," said Dr. Carrie Cadwell, CEO of 4C Health, which is funding the new services through temporary grant funding.
Now a collection of legislators, policymakers, providers, law enforcement, faith leaders and advocates are hoping to spread the crisis system across Indiana. By connecting the system with the state's fledgling 988 hotline, Indiana could have a replica of 911, shifting mental health care away from law enforcement and into the hands of medical professionals and peers.
But in Indiana, there's always a question about lawmakers' appetite for adding an ongoing expense to the state budget. That's especially true in a year when they are also considering significant investments into county public health departments.
Without help, the mental health system will undoubtedly continue to struggle. And worse, advocates say, new services provided by 19 clinics will recede as temporary grant funding runs dry.
Indiana lawmakers are grappling with a few questions: Will the state's revenue forecasts in April reveal enough money to pay for the expansion? Should they instead pursue an option of adding a $1 surcharge on cell phone bills to generate new revenues? Should they increase the cigarette tax instead?
Or should they spend less and therefore save the problem for another day?
Creating a three-part crisis system
Just about everybody inside the Indiana Statehouse says that the state's mental health system needs dramatic improvements. The price tag, though, begins at roughly $130.6 million per year.
According to a 2022 estimate by the Indiana Family and Social Services Administration (FSSA), that's how much it would cost each year to fully fund the three-part crisis system: the 988 hotline, mobile teams and crisis stabilization units.
If Indiana wants to gradually expand the number of clinics throughout the state, the price would increase in future years.
The push to fully fund the mental health system is led by some strong voices, including Sen. Michael Crider, R-Greenfield. He is a member of Senate Republican leadership and also serves on the Senate Appropriations Committee, which plays an outsized role in forming the state budget.
After the Behavioral Health Commission released its recommendations last fall, Crider filed Senate Bill 1 in an attempt to overhaul the system. The bill has already passed the Senate and has more than two dozen House sponsors.
But Crider will also need money in the budget to have a lasting impact.
A new model for mental health care
SB 1 would move Indiana from one model of mental health services — community mental health centers — to another: certified community behavioral health clinics (CCBHC).
To the layperson, the words may sound like a bureaucratic thesaurus. The impacts, however, have proven significant for clinics that have made the switch.
Put simply, the new model provides all-encompassing care. Among the more than 60 pages of federal criteria, for example, are requirements to provide access 24 hours a day. Waiting times have dropped and more people have received help in other states that have moved to the new model.
The new model also is expected to reduce overall spending in the state because, for example, a crisis stabilization unit is less costly than an emergency room. (Researchers say untreated mental illness accounts for $4.2 billion in annual costs in Indiana.)
4C Health in Logansport is witnessing the benefits. Funded by state and federal grants, the mobile team launched in September 2020 and has responded to nearly 3,000 calls for help across four largely rural counties.
On average, the mobile teams arrive within 25 minutes of calls. About 65% of the time, the mobile teams are stabilizing a Hoosier in crisis, which allows that person to remain safe at home.
The crisis stabilization unit — where someone can stay up to 23 hours — has accepted 228 voluntary admissions since it opened in February 2021. Some are walk-ins; some are dropped off by law enforcement or friends. None have required admission into a secure psychiatric facility.
As a result, the costlier psychiatric facility is now seeing a 24% drop in usage, which has amounted to about $1 million in savings, according to the clinic. And that doesn't include any savings accrued by diverting people away from jails and emergency rooms.
Crider's bill this session seeks to replicate those successes in every Indiana clinic.
"Those services can be developed in all parts of the state," said Zoe Frantz, CEO of the Indiana Council of Community Mental Health Centers. "This is really an infrastructure bill for this whole state."
Advocates say the new model is also more sustainable because the funding works differently. Right now, every service requires separate billing, and the state Medicaid reimbursement rates were set decades ago, which is a big contributor to the state's difficulty in finding and retaining enough professionals to work in the mental health field.
But under the new model, clinics would be reimbursed by Medicaid for each patient per day and the scope of services would expand. That would allow patients to be treated no matter where they are: in their homes through mobile services, at a school or somewhere else.
Biden administration doesn't do Indiana any favors
The new CCBHC model started taking root over the last seven years. Federal grants have helped specific clinics in several states, including some in Indiana, to begin providing the additional services found in the new model.
But those are patchwork and have limited funding.
The federal government, meanwhile, has approved 10 states to participate in what's called a demonstration program. Those states are receiving a greater Medicaid reimbursement.
When Congress last year enabled an expansion of the demonstration program, several leaders in Indiana began preparing. Crider's bill contained a provision encouraging Indiana FSSA to apply.
As a first step toward applying, Indiana sought a $1 million planning grant from the federal government.
Then last week, the Biden administration broke the hearts of a collection of Hoosiers. Not only did the federal government deny Indiana's application for the grant, it also announced that 15 other states were under consideration for the demonstration program next year.
Indiana didn't make the cut this round.
Without the federal funding, Indiana lawmakers could consider waiting until the next phase three years from now before seeking a mental health overhaul. But advocates say lawmakers need to act now.
"People are in crisis in Indiana today. And the state has already invested so much in planning their CCBHC implementation," said Rebecca Farley David, senior advisor at the National Council for Mental Wellbeing. "There are still options remaining to them. They can still do this."
Crider's bill would allow FSSA to pursue those other options. Indiana could apply for what's called a Medicaid state plan amendment, as a handful of other states have done. It would still transform Indiana's mental health system and allow for greater services through the use of Medicaid, but the option does not carry additional federal funding — at least not until Indiana is accepted into the demonstration program.
Advocates and providers, meanwhile, remain worried. Will lawmakers still consider fully funding the crisis system?
A federal grant enabled Southwestern Behavioral Healthcare in Evansville to launch a mobile team and develop a crisis stabilization unit in early 2022. Southwestern has seen more than 4,200 interventions, including calls to its crisis line.
"The hope is that there'll be some continuous, sustainable, reliable funding that can fund this crisis system in Indiana. Because my grant will run out, and then what?" said Katy Adams, CEO of the center. "We just have to believe that people are going to back it. If they don't, it'll be catastrophic."
Voices calling for change
Supporters of the new crisis system are uniting around SB 1 while urging lawmakers to include funding for the three-part crisis system.
Lt. Gov. Suzanne Crouch, who is running for governor, took the rare step of testifying in front of a Senate committee in January. She spoke about members of her family who have faced depression, alcoholism, bipolar disorder and suicide.
"I know that we're in a position here in the General Assembly where we can make a difference and we can help Hoosiers," Crouch told State Affairs afterward. "And that's what Senate Bill 1 will do."
More recently, on WFYI's show "Indiana Lawmakers," Crouch said she wanted to see the full $130.6 million in the budget.
Dr. Jerome Adams, the former Indiana health commissioner who served as U.S. surgeon general under former President Donald Trump, wrote an IndyStar op-ed in support of the bill. He wrote about a family member struggling with substance use disorder.
Law enforcement leaders are also on board. Indiana Sheriffs' Association Executive Director Stephen Luce testified before the Senate and sent a letter of support to community organizers at the nonprofit Faith in Indiana: "For years, the jails have been the dumping ground for those in need of mental health services. It is time to fund mental health properly in our communities for those in need to have access to treatment."
Faith in Indiana leaders held a rally in February that attracted several hundred supporters, including a bipartisan group of Indiana lawmakers. They have followed up with multiple meetings and press conferences inside the Statehouse.
They see what's been promised by Indiana officials so far. Gov. Eric Holcomb plans to pilot four mobile crisis teams to cover 15 counties in 2023, and he aims to fund multiple crisis centers to pilot that approach, too.
But advocates are growing tired of pilot programs.
"This system requires full funding so that our people have the help they need when they are in crisis," several Faith in Indiana leaders wrote to Holcomb and lawmakers in a March 7 letter. "We are looking to you to provide the leadership we need to have safe and caring communities."
$1 cell phone surcharge to pay for it?
How to pay for expanded mental health care remains up in the air.
Citing a Behavioral Health Commission recommendation, Crider suggests a monthly $1 surcharge on cell phone bills. FSSA estimates it would raise roughly $90 million, covering nearly 70% of the costs associated with an expanded mental health system.
Crider likes it, in part, because the surcharge contains federal restrictions that require the money to be spent specifically on 988 calls and responses to those calls.
Most supporters and advocates seem to agree with the surcharge — noting that 911 is funded similarly — but some are looking to other options.
The Indiana Chamber of Commerce is urging lawmakers to consider an increased tax of $2 per pack of cigarettes and similar taxes on other tobacco and vaping products. The Chamber, which has unsuccessfully pushed for similar increases for years, estimates the taxes would fund the mental health and public health systems.
House Speaker Todd Huston, R-Fishers, said he doesn't think the state needs new revenues to meet the funding goal, though he has yet to publicly specify what amount he would support.
"I don't think we need to go find an alternative funding source," Huston told reporters March 9. "I think we can find the money."
In the Senate, President Pro Tempore Rodric Bray, R-Martinsville, has yet to publicly endorse a specific number or way of paying for it. He has repeatedly noted that the mental health program is a priority for his caucus, so much so that they agreed to highlight it as this session's first bill.
"We have long been trying to find a way to get some revenue to support those programs, which I think are super, super important," Bray told reporters March 16. "Part of it is going to be what the final [revenue] forecast looks like. And we are really fortunate in Indiana; Hoosiers are hard at work and that's creating revenue through the income tax, sales tax, and all the avenues that we have. So is it possible that we could do that without a new revenue source? I'd love that."
The version of the budget that passed the House did not contain funding to support the crisis system. Huston and the top budget writer, Rep. Jeff Thompson, R-Lizton, said they wanted to give their Senate colleagues an opportunity to request the amount they find necessary.
They did, however, set aside $10 million in grants to provide mental health services for incarcerated Hoosiers — a priority of House Republicans this year to help alleviate the state's jail overcrowding crisis.
Budget negotiations between the two chambers could last weeks. The House's proposed budget is now in the hands of the Senate Appropriations Committee, which includes Crider and other supportive voices.
"I'll be in there at the end," Crider told State Affairs, "fighting for funding."
If you or someone you know is in crisis, please call the 988 Suicide and Crisis Lifeline, which has trained listeners standing by and ready to help. Visit 988lifeline.org for crisis chat services or for more information. Visit the Indiana Suicide Prevention website for resources.
Contact Ryan Martin on Twitter, Facebook, Instagram, LinkedIn, or at [email protected].
Twitter @stateaffairsin
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LinkedIn @stateaffairs
Header image: Rev. Rick Spleth, regional minister of Christian Church (Disciples of Christ), speaks during a Faith in Indiana press conference on March 7, 2023, inside the Statehouse. (Credit: Ryan Martin)
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The debt ceiling, a lack of integrity and the possible fallout
In the coming days, the United States again confronts our statutory debt ceiling. This is a 1917 law (increased every year or so) establishing a cap on federal government debt. The law itself runs up against the 14th Amendment to the Constitution, which was intended to reassure bondholders that we pay our Civil War debts. That means the debt ceiling may be unconstitutional, giving the Biden administration the option of simply printing money to cover the debt.
The debt ceiling law is politically convenient because it offers an opportunity for members of both parties to engage in a bit of political theater. It is important to remain focused on the real issue of debt rather than the political shenanigans. I expect some sort of compromise, but that is more hope than actual analysis.
Neither the Republicans nor Democrats have performed satisfactorily on this ballooning public debt. The GOP showed zero concern about debt when a Republican president was in office. Not a single Hoosier Senator or member of Congress voted against the Trump administration’s Tax Cut and Jobs Act (TCJA) or the CARES Act. These bills fall in first and third place in terms of recent contributions to the debt.
The Democrats, who voted almost unanimously against the TCJA, voted unanimously for the American Rescue Plan, which came in second place for debt loading. There’s not a clean hand in Congress on the current debt. Insofar as I can tell, the sole Republican speaking honestly about the GOP’s profligate history is Mike Pence.
As I wrote at the time, each of these large spending bills had some merits, and there remain reasonable arguments for each. The problem is that so many now in office want to remake themselves as thoughtful budget hawks, but when it mattered, they were nothing of the sort. It is the lack of integrity that highlights the real problem. No one can be honest about the root of the problem.
In 1946, right after winning World War II, our debt-to-GDP ratio stood at 119%. Today it sits at 121%, down from 127% two years ago. But, there is no peace dividend. Our spending problems are not about our military spending, which is today at near historical lows as a share of GDP.
The big-budget items driving our deficit are spending for Medicaid, Medicare, Social Security, and federal government and military retirements. And yes, I know Social Security and Medicare are supposed to be separate budget items. They are not.
If we cut all foreign aid (including Ukraine defense), housing subsidies, environmental remediation, research, discretionary education spending, immigrants, parks, and clean air or water, we wouldn’t make a dent in our debt. Altogether, these spending items wouldn’t even cover the interest payments on our debt.
In order to reduce our debt in the coming decades, we are going to have to do two very unpopular things: raise taxes and cut spending. We are going to have to do more of both than almost anyone really imagines.
On the revenue side, we are going to have to sunset the TCJA and raise marginal income tax rates on middle- and high-income households. By middle, I mean everyone who pays an income tax. Also, we probably must extend the Social Security taxes (FICA) across all earned income types.
On the spending side, we are going to have to extend retirement age, probably to 70 years or so for younger workers. We won’t have to means-test benefits, because we will have higher taxes on more affluent households. But, we will reduce retirement benefits for younger workers, and end the practice of increasing Social Security for older adults who work. We are also going to have to reduce the rate of inflation adjustments for Social Security recipients.
If all of that sounds distasteful to you, too bad. What I have just outlined is probably the easiest resolution to our current debt problem. But, what if we choose a different path?
We could cut defense spending. I’d vote to eliminate the entire Marine Corps. If we did that, it would only take another 117 years to eliminate today’s debt, though that wouldn’t come close to balancing the current budget. So, we’ll have to cut something else. If we cut our foreign aid, we could pay off the current debt, not counting interest, in 600 years. Alternatively, we could reduce overall Social Security costs by 10%, through later eligibility, and extend FICA taxes to a further 10% of earnings, and retire the debt in 60 years.
It is probably wise to ignore the political talking points about our debt and focus on the arithmetic. Still, many might wonder what if we ignore all this and blow off our debts, and default. After all, many Americans declare bankruptcy. Well, that step would be somewhere between a crisis and a full-blown economic catastrophe.
The United States borrows money like every other government does. We have treasury bills notes, bonds, inflation-indexed securities, floating rate notes, domestic series bonds and the like. Altogether this is about $31.5 trillion in borrowing. About 13 cents on every federal tax dollar collected goes to paying interest on these debts (or about twice the annual cost of the entire Marine Corps).
The reason the U.S. can borrow all this money is simply that everyone believes we will pay it back. Our creditworthiness ensures a reasonably low rate of borrowing and keeps our currency as the world’s reserve currency. So what happens if we default?
Well, there will be a flight away from U.S. securities. This will lead to financial markets devaluing our bonds, leading to higher borrowing rates on futures. Since our bonds turn over all the time, that would mean an almost immediate increase in the share of taxes we have to spend to service the debt.
If the U.S. defaults on our debts, the stock market will decline precipitously. It would strengthen China and Russia, while weakening the U.S., perhaps sliding our economy into recession along with most of our allies. The worst forecast I have seen suggests that an extended default would result in a Great Recession-level shock to the global economy.
I think this is an unlikely scenario, only because the domestic political backlash would be so severe we will come to some compromise. But, I’m a notoriously bad political forecaster. Rather than risking default, we’d be wise to heed the rare wisdom of then-President Donald Trump’s advice on the debt ceiling: “That’s a sacred element of our country. They can’t use the debt ceiling to negotiate.”
Michael J. Hicks, Ph.D., is the director of the Center for Business and Economic Research and the George and Frances Ball distinguished professor of economics in the Miller College of Business at Ball State University. He can be reached on Twitter @hicksCBER.
Header Image: Debt ceiling (Credit: Douglas Rissing / Getty Images/iStockphoto)
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