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Indiana is on the cusp of mental health reform. But what about paying for it?
- 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.
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)
Your questions answered: Why the state is feuding with Tippecanoe County over water for the LEAP District
Editor’s note: This article is part of a State Affairs and Fox59/CBS4 series looking at how decisions get made at the Indiana Economic Development Corp. and how it impacts economic development in the state. The IEDC has faced increased scrutiny due to its involvement with Boone County’s LEAP Lebanon Innovation District and because two gubernatorial candidates are former IEDC leaders. Read our first story here.
The Indiana Economic Development Corp. is banking on the success of the LEAP Innovation and Research District, a tech hub in Boone County.
But, the state agency is missing a crucial resource it needs to enable more high-tech industries to call the hub home: enough water. The IEDC, the state agency tasked with driving economic development, hopes to funnel water from the aquifer that sits adjacent to the Wabash River in Tippecanoe County roughly 40 miles away, if studies go as planned.
Opposition to the plan has bubbled over among Tippecanoe County residents and their elected leaders, concerned about what siphoning water away from their community could mean for them long term.
What was once an often-ignored topic in Indiana has become one of the most contentious, bi-partisan issues ahead of the 2024 legislative session.
“I’ve never seen an issue like this that united everybody,” said Sen. Spencer Deery, R-West Lafayette.
Here’s what you should know about the water fight.
What is the LEAP District
The LEAP District will be a 9,000-acre “hub of global innovation” in Lebanon. The land is already ready for the IEDC’s use whenever high-tech companies show interest.
The LEAP District was created in order to allow the state to move more quickly to land deals, said Secretary of Commerce David Rosenberg. Back in 2021, the IEDC lost a bidding war against Ohio for Intel, a chip manufacturer. One reason Indiana lost, Rosenberg said, was because Indiana didn’t have readily available land for use, and wasn’t able to move as quickly as Ohio.
Indiana-based drug manufacturer Eli Lilly and Company was the first to announce it would be building two manufacturing sites in the LEAP District, investing $3.7 billion and creating up to 700 jobs. Indiana is in the running for other companies as well.
“LEAP is not in any way or shape designed to compete against what other Indiana cities are doing,” Rosenberg said. “LEAP is designed to compete against international locations that are playing for the same types of companies of the future and other places throughout the United States, like Nashville or Austin, Raleigh, Phoenix.”
Why does the IEDC say Lebanon was chosen for the LEAP District?
Location, location, location. Lebanon is located 45 minutes from Purdue University and Rosenberg said it was relatively easy to piece together enough acreage in the city. Plus, unlike other areas of the state, it’s located within a 30-minute drive to an international airport and can pull from the central Indiana population center for talent.
Why does the LEAP District need outside water?
The IEDC already has a central Indiana source in place to provide 10 million gallons of water a day to the LEAP District. That’s enough to handle the current needs of the district, including those of Eli Lilly.
But, Rosenberg said that won’t be enough water should a high-water user decide to move to the LEAP District, which is the state’s goal. In June, the IEDC announced that Indiana is a finalist for a $50 billion semiconductor plant, the type of industry that depends on large amounts of water.
Rosenberg added that should a high water user not decide to settle in the LEAP District, the IEDC will no longer be involved in water discussions. Regardless, he said water scarcity in central Indiana is an issue that will have to be addressed in the future, even if a major water user doesn’t choose Indiana to expand in.
“Even outside of anything happening at LEAP, this is a problem that is staring the state in the face over the next few decades,” Rosenberg said. “Our premise was can we use economic development to unlock the resources to not only provide additional water for potential companies coming into these areas, but really solve a regional, generational water issue that everyone has identified and known about for decades and decades.”
An Indiana Finance Authority central Indiana water study released in 2021 estimated that the daily water demand in central Indiana would increase by more than 100 million gallons by 2070.
What is Indiana’s water solution?
The IEDC is looking at the Wabash Alluvial Aquifer as a likely solution to its water woes.
IEDC signed a $9 million contract with Black & Veatch Corporation earlier this year to manage water infrastructure. The contract itself outlined a plan to “convey raw water from a series of collector wells and pump stations located adjacent to the Wabash River” for the LEAP district.
But, Rosenberg emphasized the pipeline is not a done deal. At the request of the IEDC, INTERA Inc., has started testing how much water can sustainably be withdrawn from the aquifer adjacent to the Wabash River.
How much extra water does the LEAP District need?
Rosenberg said the IEDC has not placed a number on how much water it would need to pull from the aquifer. That would depend on which companies choose to move to the LEAP District, he said.
Intel in Ohio, for example, is expected to use 5 million gallons of water per day. That’s the kind of water usage Indiana should expect to see if the IEDC lands a chip manufacturer.
Preliminary results from the INTERA study show that two collector wells at the site will sustainably produce more than 30 million gallons of water per day. That’s the equivalent of more than 40 Olympic-sized swimming pools.
The actual amount of water withdrawn could be much larger. Water from the aquifer could be used for other central Indiana uses outside of just the LEAP District, to help address the expected 100 million gallons a day increase in water needs for central Indiana over the next 50 years.
There’s not yet an estimate of the maximum amount of water that could sustainably be moved from the aquifer.
Why are Tippecanoe County residents concerned?
Elected leaders and Tippecanoe County residents are worried that if the IEDC takes water from the aquifer adjacent to the Wabash River, it could negatively impact the county’s water supply and its own ability to expand economically in the future.
“The concern is once you develop that pipeline, Indiana doesn’t have any real rules in place to determine how much can be moved,” Deery said.
Plus, the LEAP District is located well outside of Tippecanoe County, which means the benefits to the community aren’t as obvious as they would have been had the IEDC chosen a location closer to the Wabash River for the development.
Does Tippecanoe have enough water to share?
That’s what the IEDC has been studying.
The preliminary results from the INTERA, Inc. study show that two wells on the site will sustainably produce more than 30 million gallons per day, with “minimal impact on home-owner wells” according to the IEDC.
Those opposed to the project, however, aren’t confident that the IEDC will be able to provide an unbiased look at what the impact on the Wabash River would be.
“Typically, you research before you buy,” Deery said, “and there’s been a sense around here that the decision has been made. And now it’s in search of the evidence to support that.”
What did Holcomb propose to ease concerns?
Last month, Gov. Eric Holcomb directed the Indiana Finance Authority to take over oversight of the INTERA water supply study.
“I am confident that these new efforts led by IFA will provide the necessary data to gain a greater understanding of the amount of excess water that is truly available to support all the surrounding region’s growth prior to any action being taken that could inadvertently jeopardize this needed resource,” Holcomb said in a statement. “ No entity is better suited to lead this overall pursuit than the IFA which will approach this study in the same methodical, collaborative, and transparent manner the organization has conducted in the past.”
Moving oversight of the water study to a different agency was praised by some critics of the project as a step in the right direction.
IFA will also start a comprehensive regional water study for north-central Indiana, expected to be completed in fall 2024.
What is Tippecanoe County doing to try to stop the pipeline?
Last month, Tippecanoe Commissioners unanimously advanced a nine-month moratorium on “high volume water export(s).”
Rosenberg said the commissioners’ moratorium would have no impact on the IEDC’s plans because the agency would not be in a place to pump water from the aquifer in the next nine months.
“I think the action was unnecessary and it was playing to some of the rhetoric and misinformation,” he said.
How will state lawmakers address water during the 2024 legislative session?
Republican legislative leaders say they want to avoid legislating on the water issue until they get the data. That means they have no plans to finance such a pipeline yet.
“We’re not going to take any other steps until we have an opportunity to study to make sure that there’s ample water for the projects that we’re trying to bring into the state of Indiana,” Senate President Pro Tem Rodric Bray said last month, “and we understand just how much is too much to take away from a particular community.”
Those who represent Tippecanoe County, such as Deery, hope to implement some guardrails “that would help protect all communities against any potential harm of large water transfers to another community,” he said in a press release.
The INTERA water supply study is expected to be completed in early 2024. Rosenberg said it’s “too premature” to say whether a water pipeline would move forward without the blessing of Tippecanoe County, should studies show the capacity to move large amounts of water is there.
“We’re not going to in any way inhibit Lafayette from their ability to to grow economically,” Rosenberg said, “because they’ve had so much success already.”
The legislative session convenes on Jan. 8 and must wrap up by mid-March.
INDIANAPOLIS — Last August, Anne Hathaway’s phone lit up with a call from Gov. Eric Holcomb. Nearly a quarter-century before, Hathaway had recruited the future governor to run for an Indiana House seat in the only race he lost.
With the resignation of Indiana Republican Chairman Kyle Hupfer in hand, Holcomb asked Hathaway to lead the Indiana Republican Party, and in doing so was tapping the first women to hold the role.
For the past 15 years, Hathaway had led the Richard G. Lugar Excellence in Public Service Series, an organization inspired by U.S. Sen. Richard Lugar and created by Teresa Lubbers and Judy Singleton to develop a gender bench for the GOP.
“I encourage women every day to take a risk, be willing to lose; go out of their comfort zones and run for office or serve on a board or commission,” said Hathaway, who serves as Indiana’s national committeewoman on the Republican National Committee, during a recent, exclusive Howey Politics/State Affairs interview.
“I couldn’t continue to do that unless I was willing to do that myself, willing to take the risk, willing to lead by example,” she said, adding, “When the call came for me, I jumped. Yeah, I’m in. Let’s go.”
Holcomb said in making this historic nomination: “Here are several key reasons I believe Anne is the right person at the right time for this role. Anne’s resume of service to the Republican Party is as extensive as just about anyone’s in the country, having served with distinction at the local, state and national levels throughout her entire career. Furthermore, with experience in running campaigns at every level of government, she has the knowledge and relationships to not only keep our party moving forward, but to continue to take it to the next level.”
Hathaway’s roots are in the tiny Illinois town of Galva just north of Peoria. After graduating from high school with a class of 77, and then from the University of Illinois, she decided to spend a year in Washington, D.C., where she began as a typist at the Department of Treasury.
Hathaway served in the White House as assistant and director of scheduling for former Vice President Dan Quayle, was program director for the 2012 Republican National Convention, and was executive director of the Indiana House Republican Campaign
Following Hathaway’s resume is a lesson in stewardship and power.
“Sen. Lugar would be more excited about me being state chair than I am just because, Judy Singleton and Teresa Lubbers were ecstatic,” said Hathaway.
She now helms the party at (or nearing) its historic apex. The Indiana GOP holds all the state constitutional offices, nine of 11 congressional seats, maintains General Assembly super majorities, more than 90% of county offices, and as of the municipal elections earlier this month, 76 mayors. If a Republican is elected governor in 11 months, the party will increase its historic dominance to five consecutive terms.
Hathaway will lead the party through the five-way gubernatorial primary. Following next June’s Indiana Republican Convention, she will head to Milwaukee, where Republican National Chairwoman Ronna McDaniel tabbed her to head the RNC’s Arrangements Committee.
Hathaway has committed to serve only through the May primary. “At that time, she will work together with the gubernatorial nominee and you all to decide who is best to finish out the remainder of the term,” said Holcomb.
Asked if there was a chance to continue as chair beyond the May election, she said, “That’s a conversation to be had.
“I have agreed to stay at least through the state convention. I believe the gubernatorial nominee should have his or her own political partner here. I’m just focused on the time between now and then, she said.
Senior reporter and columnist Brian Howey sat down for a 45-minute, wide-ranging interview with Hathaway where she discussed what it means to make history as the first female state Republican chair, how her work at the Lugar Series prepared her for this new role, the Republican party’s diversity programs and other topics. Read the full conversation on State Affairs Pro here.
Gov. Holcomb taps Boone County Council president to serve out remainder of Comptroller Tera Klutz’s term
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