After Sandy Hook: The state of Tennessee's mental health system

Thursday, December 27, 2012 at 1:06am

In the wake of the Sandy Hook Elementary School massacre, the national discussion has focused largely on gun control and access to firearms.

The other side of the issue, though, is mental health. Much of the conversation surrounding mental health issues at the state level begins with a 1975 Supreme Court decision — O’Connor v. Donaldson — that resulted in the massive deinstitutionalization of mental health patients nationwide.

As a response to this, Congress passed the Mental Health Systems Act of 1980. The aim of this legislation was not only to eliminate the warehousing of mental health patients, but also to fund services, research and training professionals. Stated simply, the act worked to eliminate reliance on expensive nursing homes, jails and prisons.

In 1981, changes to funding mechanisms were made as the federal government announced it would curtail the budget of the National Institute of Mental Health and phase out training of clinicians and eliminate services, among other cutbacks. Then the Omnibus Budget Reconciliation Act of 1982 merged money for mental health programs into block grants. States were given the discretion to use the funds however they saw fit.

In the years since, those funding mechanisms have met with consternation from mental health advocates.

Organizations like the National Alliance on Mental Illness urge states to better fund mental health initiatives and periodically issue reports on how states rank against each other. While it would seem that looking at their data or simply how much money is spent by the Tennessee Department of Mental Health and Substance Abuse Services would answer the question, it isn’t that simple. While that department does tackle mental health issues, TennCare pays for mental health services as well and thus does not show up in some budget comparisons of other states.

In Tennessee, the Department of Mental Health operates four mental health hospitals in the state: Nashville, Memphis, Chattanooga and Bolivar. A fifth facility
in Knoxville closed down earlier this year, but department spokesman Michael Rabkin said most of the money that had been used to operate that facility is now being used to fund mental health programs in the Knoxville community.

Rabkin detailed the department’s funding: “In Fiscal Year 2012, the Department of Mental Health received $291,929,600 in total funding. Of that, about $186 million was from the state, about $63 million was federal, and about $42 million was from other sources. In Fiscal Year 2011, we received $275,943,700 in funding (the FY 2012 number was higher because of new federal grants that we received). That broke down as about $182 million from the state, about $49 million from federal and about $44 million from other sources. In FY 2010, we received $295,178,600 in funding — about $177 million from the state, about $64 million from federal and about $53 million from other sources.”

Rabkin also noted that the department licenses more than 2,000 facilities in
the state that deal with mental health and substance abuse issues.

As for how the money is spent, he laid out the state’s system.

“The department is divided into two functional areas: Administrative Services and Mental Health and Substance Abuse Services,” he said. “The MHSAS division provides community services for individuals suffering mental illness or a substance-related disorder through a comprehensive network of service providers, including the state’s four regional mental health institutes.

“A key area in which we work is with the Behavioral Health Safety Net of Tennessee,” he added. Via that program, the department “helps Tennesseans with serious mental illness who are poor and uninsured by working with community mental health agencies across the state to provide key mental health services.”

The safety net was installed for those individuals who need of mental health services but are denied TennCare coverage, a byproduct of the changes former Gov. Phil Bredesen made to the TennCare program during his administration.

As for what TennCare spends on mental health, department spokeswoman Sarah Tanksley said, “TennCare spent approximately $365 million in FY 2012 on inpatient and outpatient mental health services. This does not include pharmacy services.”

“Psychiatric inpatient hospitalization, 24-hour psychiatric residential treatment, outpatient mental health services, partial hospitalization, day treatment, crisis services (available 24 hours), crisis stabilization unit (adult only), mental health case management, applied behavioral analysts, psychiatric rehabilitation services (adult only), medication management, ECT, and psych testing. On substance abuse we have provided for inpatient hospitalization for rehab and detox, residential treatment for rehab and detox, outpatient treatment and detox.”

She added, “All services are available to children under 18 and adults 18 and older unless indicated differently. These services are covered as part of the TennCare managed care program and covered as medically necessary. In addition, TennCare provides funding to the Crisis Services program which is part of the Department of Mental Health and Substance Abuse Services.”

So, what steps might Tennessee take after Sandy Hook?

Earlier this week, Gov. Bill Haslam was asked whether the school massacre would make him reconsider how much money he gives to the Department of Mental Health. He said he’s still considering whether “there are real things we can do. Everybody’s
always going to have their hand up saying, ‘If you fund us more, we’re doing this.’ Because there’s such a surplus of demand over available funds, we have to think, ‘Where do we know we can make a difference?’ ”    

12 Comments on this post:

By: Ask01 on 12/27/12 at 6:22

Just because I'm in a contrary mood this morning, let me make a suggestion which should appeal to few people.

We can fully fund an effective mental health system in this country by increasing exponentially taxes on firearms, ammunition, reloaders and all the accessories associated with guns.

Additionally, a settlement with firearms and ammunition manufacturers similar to the tobacco settlement could be reached and that money also used to improve mental care facilities in America.

We receive an excellent mental health program and the gun advocates can have all the guns they can still afford from manufacturers who stay in business.

I must now take my leave and go to work, stimulating the economy and lining the pockets of the corporate overlords.

By: treehugger7 on 12/27/12 at 8:03

Ask, you know that's an intelligent solution. that would never fly in Tennessee! I find it very reasonable, which means it will never happen here.

By: InTheRaine on 12/27/12 at 10:24

Not so sure why firearms and related components should be taxed any more than they are? Firearm manufacturers are nothing like tobacco companies, as in their products aren't the cause of mental health issues.

By: InTheRaine on 12/27/12 at 10:31

How going after things that actually do contribute to the mental health issues? Poor mental healthcare for Soldiers, toxins in the food (GMO and pesticides), long term substance abuse, prenatal damage, hereditary contributions, childhood psychological trauma, neglect....

By: Ask01 on 12/27/12 at 5:53

Well, InTheRaine, (please come in out of the weather) all those issues you address could be addressed with funding derived from the taxes levied upon firearms and their accessories.

I further suggest licensing such as used for drivers licenses, with renewals, (for a hefty fee, of course) every four years using the system once required for drivers of passing a written test on all firearm regulations, a shooting test to demonstrate skill, and a physical and mental exam to be sure the applicant is physically and mentally capable of handing a firearm.

It is a win win situation for everyone. Gun enthusiasts can have all the wapons they can afford and the state developes another revenue stream.

This idea might have actually appeal to our money hungry legislators.

By: InTheRaine on 12/28/12 at 12:25

You haven't given a valid reason for taxing them. Once again, firearms didn't cause mental problems. Go after Montsanto, companies that sell Chinese products that introduce deadly products, companies that sell/make products with all the preservatives... these are the real contributors to the poor mental health status of the United States, along with hereditary contributions and things listed in my previous post.

Why are you going to penalize law abiding citizens? Why are you penalizing companies that legally manufacture weapons? Why are you suggesting to make an already difficult and expensive process even more unobtainable? The sarcasm was noted when you said, "...have all the guns they can still afford from manufacturers who stay in business." What you are suggesting will make firearms unaffordable, and unrealistic. Basically, from what you stated above, everyone can deduce that you don't give two hoots about firearms. I can respect that. I can respect your preference to not carry, to not own, but you should respect our preference to carry. You can't methodically carve out part of the Constitution just because you don't like it. Please remember that my right to carry stands between a right that you value more and those hackers.

Realistically, cars kill more people than guns, as do doctors... so instead of jumping on the bandwagon to disarm Americans, why don't you take a step back and look at the bigger picture. Disarming Americans falls hand in hand with other elements to further bring the American people into submission.

By: Ask01 on 12/28/12 at 5:05

Guns have only one reason for existing. To kill. End of story.

Cigarettes kill as an unintended byproduct as do automobiles. (I really can't believe you used such an asinine overplayed example as cars. Really?)

Alcohol is legal but heavily taxed to discourage use, which done at home away from a car is a persons private affair, and no concern to anyone else. Yet we don't question the high taxes on this product.

Insurance is often said to be high to cover uninsured motorists, not because insurance companies are greedy pigs, but it is still legally high.

The bottom line, you wish to own a product which has no other use but to kill, you need to pay for the privilege to exercise your rights.

As noted before, the constitution can be changed or less broadly interpreted so as to narrow the right signifcantly while still leaving the right intact.

The other bottom line is gun enthusiasts need to come to the table ready to accept controls on certain classes of weapons, ammunition, and accessories in return for a more expansive and comprehensive mental health system.

The alternative is to alienate the public to the point that people like me, who really do not advocate total confiscation, but rather better controls, are over ridden by those who want every firearm melted down and made into plowshares.

Now, with which group would you rather deal? The reasonable or unreasonable? The alternatives I mention are what could happen if gun advocates don't calm down and be reasonable.

By: JeffF on 12/28/12 at 4:40

Long post, but still not seeing how weapons use can be tied to mental illness and can be used as a legal justification for funding via taxes. Your hatred for all things gun may be leading you to miss out on the logic that our legal system and government are supposed to be based on.

Gun owners own a product that kills so they should fund mental health services? The underwear gnomes would be awe of that plan. They like plans that go from A to C without any idea of what B looks like.

Luckily the Supreme Court has ruled in recent years that the 2nd Amendment means what it says so the unnamed persons in your next-to-last paragraph (the ones wanting to melt down the guns) really are just as helpless and impotent as they want to be. The flower child generation is reaching retirement age and we do not have much more of their nonsense to deal with. Maybe they can have one more ban-guns drum circle just to show they mean business?

By: Ask01 on 12/28/12 at 6:16

Another who totally misses the point.

Am I being too obtuse? Need I spell everything out directly? Perhaps including stick figures and simple early reader style phrasing?

I don't support the idea of banning all guns as other posting on this site.

I do believe there are certain classes of weapons the average person has no need of owning, as they have but one purpose: to kill large numbers of people in as an efficient manner as possible. That said, I would not mind owning some of these types as a display due to their historical and technological significance, but since we cannot know who among the other wannabe owners is a closet basket case just waiting for the spark to light the fuse, I resign myself to reality.

I suggest some of the ideas I have heard bandied about for the purpose of attempting to educate the gun enthusiasts on the possible dangers of coming across as a gun nut, turning huge numbers against you.

Think such an event will never come to pass? Don't fool yourself. If firearms are given enough of a bad rap and gun enthusiasts become extremely agitated and spew forth hateful language, average people will become concerned and perhaps frightened, If enough people become scared and in turn scare enough politicians, they might do anything.

Am I losing anyone yet?

All I am trying to get across is the spirit of compromise and not shooting yourself in the foot. Realize certain classes of weapons may need to be given up as part of a compromise.

At least I'm not like another poster on this site who advocates a total gun round up, prying them from the cold, dead, fingers of the owners who resist, if need be.

Now again, since no one have answered me yet, which group would you rather deal with, the reasonable, willing to make concessions for concession, or the one who wants all your guns, even if they must kill you to take them?

That was the point of all my posts which no one seemed able to catch.

By: bfra on 12/31/12 at 2:50

Ask01 - I catch your point & agree 100%. IMO it is foolish to even think of banning ALL guns, but assault weapons and the ammo for such should be banned. If that should happen, anyone caught with either should face stiff penalities & big fines.

By: ancienthighway on 12/31/12 at 3:22

Surtaxes on firearms, firearm related equipment, and ammunition may not be a bad idea. I'm sure Ask01's suggestion that the tax be used to fund mental health programs is based on the rhetoric that mental health is the primary concern in mass shootings. Even the NRA states this.

Alcohol, tobacco products, and gasoline are all subject to surtaxes at the federal and state levels and all are legal to purchase and use. One of the reasons for the high surtaxes is to discourage use. Lawsuit settlements with big tobacco companies have been levied because their product was linked to peoples death.

I don't see a firearm surtax as being unreasonable, and I could even see reason for class action lawsuits against gun and ammunition manufactures whose products were linked to causing death. It can be used to discourage purchase of specific types of weapons while not infringing on rights granted by the 2nd Amendment. (There is no right to cheap affordable guns.) The tax money could be used in programs to educate and warn of the dangers just as their are similar programs alcohol and tobacco use. In fact, gun manufacturers should be tapped with part of that cost, too. All fingers point to mental health as being a major problem in mass shootings so tax and manufacturing funding of mental health programs wouldn't be unreasonable, either.

Naturally gun advocates would be up in arms, so to speak, about this proposal, just as professional drivers, and tobacco and alcohol users are every time the surtax increases. The gun owner still has access to his or her gun for protection and, if they felt it warranted, vigilante-type protection of others and better funding is made available for mental health programs to help reduce mass shootings.

By: EDUNITED on 1/1/13 at 11:12

It's interesting that many comments focus on guns, not mental health and treatment. The Newtown child did not receive treatment. His mother was trying to put her son, an adult, in state custody. He was angry; they were HER guns. State custodianship requires considerable time, legal work, court hearings, etc. Then, the state is responsible. Is there any better outcome? Does the state care any more for the person than his or her family?

Compulsory mental health treatment, especially in adults, is a complicated, difficult, and controversial issue. It is one that few politicians of either party want to address in a substantive manner. In this case, it is easier to identify the agent as cause and to pursue a non-solution believing in the good intentions.

An issue with even voluntary mental health treatment is complicance. A lot of chronically mentally ill persons resist or stop treatment. This is not unlike many (more) people who do not follow their doctor's recommendations: lose weight, exercise, eat a healthy diet, get medical tests, take their prescriptions, etc.

Here's one. Getting flu shots. In an average year, 36,000 people die from influenza. Then, should we make flu shots compulsory? They are proven to save lives. How about banning bicycles? There are lots of bicycle deaths, mostly resulting from violating traffic laws according to the NHTSA. Or should we just ban bicycles?

Let's address the mental health issue first. Take on the tough problem. It's a challenge.

Ed vanVoorhees