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The House Committee on Appropriations met on February 15th to hear LBB and agency budgetary presentations. This report focuses on the following topics:

  • Overview of the Texas Medicaid Program
  • Behavioral and Mental Health
  • Transportation, Water, and Flood Mitigation Funding

A video archive of the hearing is available in two parts here (part 1) and here (part 2).

This report is intended to give you an overview and highlight the various topics taken up. It is not a verbatim transcript of the discussions but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

Overview of the Texas Medicaid Program

Claire Stieg, LBB

  • Link to presentation
  • Provides overview of Medicaid, incl. structure, federal regulations, service delivery models, waivers, etc.
  • Primary budget drivers are caseload and health care costs
  • Highlights FMAP, each state has a different FMAP; slide 12 shows TX FMAP from 2012-24 through 2025
  • With passage of Consolidated Appropriations Act 2023, enhanced FMAP no longer tied to end of PHE
  • HHSC will need to conduct eligibility redeterminations for all clients on Medicaid, disenrollments can begin in April 2023
  • $76.9b in all Funds, incl. $30b in GR, for Medicaid; vast majority is at HHSC for Medicaid client services; decrease of 7.9b in All Funds and increase of $1.5b in GR
  • Medicaid funding breakdown on slides 15 & 16
  • Toth – Cost growth rate change, inflation
    • Caseload growth from continuous coverage has contributed greatly to it
  • Toth – Is the federal government paying for those crossing the border illegally?
    • Don’t have that breakdown
  • Toth – So we don’t know?
    • We receive data broken down by client type
  • Toth – Percentage of Medicaid births?
    • Don’t have this number
  • Rose – Great need for additional step down bed programs in my district, can any of the funding be used for this
    • Presentation on behavioral health after the Medicaid presentation
  • Stucky – FMAP is different based on per capita and personal income, where does TX sit compared to other states
    • Can follow up on this

 

Cecile Young, Executive Commissioner HHSC

Stephanie Stephens, State Medicaid Director

  • Link to presentation
  • Provides overview of TX Medicaid, TX serves 5.8m through Medicaid and CHIP & heavily impacts state funding through FMAP
  • Across both programs majority of those served are children; Medicaid is an entitlement, CHIP is not and is funded through set allotment
  • Subject to certain criteria, incl. income level, eligible population category, etc.
  • TX Medicaid income levels align with federal requirements, difference for pregnant women and those with disabilities
  • Growth of managed care on slide 7, breakdown of managed care programs on slide 8, service areas on slide 9
  • Mission statement on slide 10, incl. access, quality, and operational goals
  • HHSC focusing on improving timely access to services, encouraging providers to participate, incentivizing value through VBP, and strengthening partner contracts
  • Wu – Could you explain what continuous coverage means in more detail?
  • Chair Bonnen – Will have a whole presentation on that up next

 

Molly Lester, HHSC

  • Speaking on Medicaid continuous coverage unwind
  • Timeline of continuous coverage:
    • March 2020 – FFCRA set up enhanced FMAP so long as states provided continuous coverage
    • December 2022 – Consolidated Aprons Act passed which separated continuous coverage from end of PHE
    • March 31, 2023 – Continuous coverage requirement ends
    • April 1, 2023 – States can begin to disenroll
    • April 1 – December 31, 2023 – Enhanced FMAP phase out
  • HHSC beginning plan to unwind from continuous coverage over the next year, federal guidelines on slide 3
  • Out of more than 5.9m Medicaid members, 2.7m have extended coverage
  • Goals:
    • Maintaining coverage for people who remain eligible
    • Prioritizing redeterminations for those most likely to no longer qualify for Medicaid
    • Ensuring a sustainable workload for our eligibility system and future renewal schedule
  • Staggering redetermination into 3 cohorts; planning to redetermine eligibility for these cohorts in consecutive months beginning in April
  • If a member has an upcoming renewal in this time period, will try to determine eligibility in normal timeframe; e.g. if it is coming up in October 2023, will do it in October 2023
  • Unwind planned timeline:
    • Feb 18, 2023 – HHSC intends to identify continuous coverage population by this date
    • March 2023 – Begin checking for members of Cohort 1
    • April 2023 – HHSC intends to send renewal packets or requests for info from the Cohort 1, responses due within 30 days
    • May 2023 – Redeterminations to begin for Cohort 2
    • June 2023 – Redeterminations to begin for Cohort 3
  • HHSC has been working to increase workforce, added 1k eligibility workers, increased base salaries, and added 400 to 2-1-1 call center staff
  • Increased efficiencies and access to electronic data, simplified training, and increase stakeholder outreach
  • Started an ambassador program to help spread info to members; also directly reaching out from HHSC to members
  • Current priorities:
    • Continue working with CMS to keep aligned with the latest federal guidance and requirements
    • Complete final checks to ensure systems and workforce are prepared
    • Established a cross-functional agency command center to oversee implementation of the unwinding
    • Develop monthly reports to monitor and track progress on unwinding efforts
    • Continue engaging with contract partners and external stakeholders to build awareness for the unwinding plan and actions members will need to take
  • Wu – During the time of expanded enrollment many who may not have been normally eligible were covered; was HHSC able to see a difference in health results? Was there enough time to determine trends?
    • Stephens – Data currently is primarily utilization so can look at what was accessed, quality measures can have lags up to 1-2 years
  • Wu – Just based off of what services people used, can you see if people are accessing health care more?
    • Saw decreases in utilization initially in the PHE, have seen some of this come back to normal
  • Wu – So data is clouded by the bigger disaster
    • Yes
  • Wu – Medicaid for illegal immigrants?
    • There is info provided during the eligibility process that is verified in different ways
    • Undocumented immigrants are not eligible for regular Medicaid, there is emergency Medicaid
    • If an individual meets Medicaid but for the citizenship, they can receive emergency care; providers are reimbursed
  • Wu – And this is more protecting the hospitals than anything else
    • It is a way for providers to get paid
  • Walle – Do you have percentages of those on Medicaid are elderly versus children?
    • Majority are children, of the 5.8m, about 4.2m are children
  • Walle – And a small percentage of disabled individuals on Medicaid as well?
    • Yes, about 392k who are aged & disabled, about 425 receiving LTSS
  • Walle – Differences in how you pay for subgroups?
    • Usually consider it about 60/40, children could be 60% but 40% of the cost
  • Walle – So even with more children on rolls, cost for children is less than the elderly population?
    • Yes
  • Walle – How do you get on Medicaid?
    • All tied to federal poverty level, about $25k for a family of 3
  • Walle – So a family of 3 has to make less than this?
    • Adjusted a little, but gives a sense of income levels
  • Walle – Not well off at that income level
    • Would agree
  • Walle – Highlights Medicaid for elderly & disabled individuals handbook; contains general qualifications for those that could be undocumented; only for ER services?
    • Yes, undocumented people qualify for Emergency Medicaid only
  • Walle – Already had vacancies, so when you say you hired workers for the redetermination?
    • Lester – vacancy rate about 6%, have an exceptional item for an additional 640 FTEs that will be needed for the unwind
  • Walle – Do you have a breakdown of the cost?
    • $143m total, some items for staffing & 2-1-1 contractor
  • Walle – Had some on the rolls that may not have been eligible?
    • Anyone on continuous coverage was eligible at some point, but at some point they were determined ineligible and coverage was maintained
    • Need to recheck eligibility before we disenroll
  • Walle – 6 month instead of 12 month extension for mothers?
    • Once we resume redeterminations, because we don’t have federal approval for 6 months, current policy is that women will be moved to Healthy Texas Women after 2 months
    • Women who are past postpartum coverage, earliest disenroll would be June 1, if eligible for HTW then will transfer to HTW
  • Walle – Is HTW as comprehensive as Medicaid? What type of benefit do you get?
    • Lester – No
    • Stephens – HTW has a targeted benefit package, covers general women’s services, screenings, etc.; also have HTW Plus for postpartum women addressing morbidity and mortality factors
  • Walle – So they can qualify for those services and there are enough providers?
    • Stephens – Without continuous coverage, women transition to HTW
    • HHSC monitors availability of providers, have network adequacy standards that are part of the waiver
  • Walle – At some point we have to get approval for CMS for 6 months and how to get mothers back on? Do we need another bill?
    • Submitted request to CMS to provide 6 month postpartum coverage in May
    • CMS has not responded at this point
  • Walle – Cost for 12 month extension?
    • $240m All Funds, $90m GR for first year of biennium
  • Toth – In 2014 TX AG sued Xerox for the way they are handling Medicaid disbursements, had a $1b settlement; have announced another contract with them?
    • Stephens – Yes
  • Toth – How are we doing oversight? What level of scrutiny understanding that they’ve been bad actors in the past?
    • Transitioning from having one vendor, now have 3 vendors, Conduent is one
    • Have team with staff from LBB, DIR, etc., have structure in place to oversee the contract
    • Have key performance metrics, deliverables, etc. that HHSC monitors; require corrective actions if not met
    • Can also impose liquidated damages
  • Toth – Thought to bringing in SAO to oversee?
    • I don’t think that has occurred, HHSC has internal audit division
  • Toth – Since 2018?
    • Don’t know that is it new, but is a group that reviews contract practices
  • Toth – Auditing contract practices is different than a forensic audit in the field; what are we doing
    • Responsibility within Medicaid and CHIP Services to oversee the contract, get info from vendors about performance and have various metrics
  • Spiller – How many on Medicaid, how many on CHIP?
    • CHIP is very small at this point because of continuous coverage & children not moving to CHIP from Medicaid
    • 81k CHIP, 4.2m children on Medicaid without disabilities
  • Spiller and Stephens discuss service difference in Medicaid and CHIP, generally cover same types of services
  • Spiller – Shocked that 51% of TX births are covered by Medicaid
  • Howard – Mothers would be in 3rd cohort so they would roll off at a later time?
    • Lester – Different Medicaid categories can be in different cohorts, but postpartum women are generally in Cohort 3
  • Howard – IT requirements to support transition? Due to 6 months postpartum bill passage, HHSC began ensuring structure was in place?
    • Yes, with funding would have ability to implement 6 month in March
  • Howard – So if we used GR, we could start in March giving 6 month postpartum coverage?
    • Yes, with legislative authority
  • Howard – What authority would you need?
    • There is current statute that precludes spending GR on programs with a federal match
  • Howard – If we were able to pass 12 month postpartum, what is timeframe you would need to put infrastructure in place?
    • Would take about 8 months from time we receive direction
  • Howard – So 6-8 months after legislation is passed?
    • Yes
  • Howard – So would still have people disenrolled who would qualify if we implemented sooner?
    • Most likely yes
  • Howard – So even though House supported 12 month, because of Senate we have 6 month; will have people who would’ve qualified for the 6 month but won’t get it because we didn’t pass something in time; people will drop off who we intend to have covered
    • Yes
  • Howard – Would hope we can get emergency legislation to do something sooner rather than later
  • Stucky – You will do all 5.9m+ redeterminations between now and next May, is the staffing support enough? Enough time to do it?
    • Try and renew coverage through electronic databases, if they aren’t eligible, members have 30 days to respond
    • Have data on average time it takes workers to do this; do anticipate needing additional workers and exceptional item reflects this
    • 3 cohorts are staggered & will have others initiated later based on normal renewal dates; expecting peak early
  • Stucky – Exceptional item covers this?
    • 642 via exceptional item is temporary staff to cover, additional 1k built up is filling vacancies at the agency
  • Thimesch – You want to keep the 1k, but 642 will be temporary?
    • Yes, 642 is what HHSC anticipates needing for unwinding
  • Thimesch – Net increase of 1k you’re planning to keep?
    • Within existing authority, can manage through attrition if needed to accommodate regular caseload
  • Walle – Normal wait time for 2-1-1?
    • Under one minute typically
  • Walle – Any issues with 2-1-1 rollout?
    • Had spike in wait times over summer, but has been resolved

 

Behavioral Health

Michelle Alletto, HHSC

  • Significant investment
  • $1.7b through block grant, $1.3m through Medicaid and CHIP
  • Provides overview of behavioral health services, some funding from COVID legislation carries through to 2025
  • Highlights behavioral health services and structure of service delivery, incl. mental health first aid training, community-based services, crisis services, etc.
  • LMHAs are the largest providers of services, 98% of those receiving services through LMHAs remain in community and do not need intensive care
  • 3 types of beds contracted for or provided by HHSC, incl. private psychiatric beds @343 total/20 forensic, community mental health hospital beds @215 total/23 forensic, and state hospital beds @2,900 total/252 are child & adolescent
  • Not all funded beds are online, primarily due to lack of staff; HB 1 provides funding for additional beds
  • Over 60% of state hospital beds support forensic patients
  • Even with investment in mental health, still see great need across the state & gaps; some programs are addressing this like AgriLife Extension, Mobile Mental Health services in San Antonio, etc.
  • Funding and staffing for these services are a challenge, particularly in rural areas
  • Jetton – In November had a report about allowing MCOs to provide alternative mental health services?
    • Ryan Van Ramshorst, HHSC – HHSC have moved forward allowing MCO to cover 3 services, partial hospitalization, intensive outpatient, and coordinated specialty care
    • Expecting plans to send operational plans to HHSC 60 days before they go live
  • Jetton – Reimbursement rates?
    • In-lieu of so there wouldn’t need to be rate changes
  • Jetton – Obstacles?
    • Health plans are very eager to move forward, workforce is an obstacle
  • Jetton – Spoke with County Judge about lack of competency restoration beds; how many beds are not active due to workforce shortages?
    • Alletto – Somewhere between 700 and 800
    • Have invested in workforce salaries, showing great progress currently
  • Jetton – If we are at full capacity, is 2,911 enough to provide services?
    • 2,911 is less than optimal, do have the ability to contract with community beds while forensic beds are built
  • Rose – Did you make a request for additional funding or support for LMHAs? Having the same issues with workforce shortages
    • Have offered capacity building to LMHAs via COVID workforce capacity dollars that can continue through 2025
    • Also have a Mental Health Charity Care program to cover UC costs, $500m pot for FY2022 and LMHAs have claimed $405.9m
    • Still working on some appeals so that number could change slightly
  • Rose – On State Hospitals, did you receive a letter from Dallas County?
    • Yes, letter stated county concern about number in jails awaiting competency restoration
    • Concerned about cost and capacity issues due to those awaiting competency restoration
  • Rose – Some in the Dallas County jail have been there for over 900 days waiting for space, what is HHSC’s position on this? Have people sitting in jail sometimes longer than sentence would’ve been & this is inhumane; Dallas County threatened a lawsuit?
    • Yes
    • HHSC is extremely concerned about waiting list for forensic services, priority to cut down list and get services to people
    • 700 beds and staff is one of the more immediate ways, not something we take lightly
  • Rose – Issue has been going on for many years, at some point state needs to address this; very serious issue and wants to meet with HHSC on this issue
  • C Bell – On construction costs to build state hospitals, cost to build is very high; have we done work to check if contracts and costs are reasonable?
    • Scott Schalchlin, HHSC – Yes, work with architects and engineers to estimate budgets and compare to other states
  • C Bell – Using architect and engineer estimates? Not really good at estimating budgets; are we comparing to other areas? Hawaii cost to construct is cheaper, need to make sure we’re not paying more than what it is supposed to cost
    • Can follow up on HHSC’s methodology to ensure costs are reasonable
  • C Bell – Would also like to see the competitive bidding process
  • Walle – On the Uvalde response, what did HHSC do? Standing up a clinic? Providing dollars?
    • Alletto – Disaster Behavioral Health team went to Uvalde to work with LMHA and local leaders
    • Budget execution order had $625k for multi-systemic therapy
    • HHSC also has exceptional item that includes funding for crisis services center in Uvalde
  • Walle – Highlights Bipartisan Safer Communities Act which provides mental health supports in communities and schools

 

The committee recessed for the House floor session & reconvened after

 

Behavioral Health

Michelle Alletto, HHSC

  • Walle – Asks about the Uvalde facility
    • Sonja Gaines, HHSC – 16 beds for children, 16 adult, multiplex
    • LMHA is not a very good building & need expanded space, will be housing LMHA building on the site
  • Walle – Primarily behavioral health?
    • Yes
  • Walle and Gaines discuss services and response in Uvalde; LMHA and FQHC have done a great job, also established a Uvalde support line, behavioral Health Disaster Team helped coordinated local response
  • Walle – Sustaining support for that community is important for the committee & legislature
  • Walle – How many are waiting for forensic beds in jails
    • Alletto – About 700 beds offline, some could be used for forensic
    • Schalchlin – Just under 2,500 waiting in jails
  • Walle – Those bonded out and waiting to get transferred
    • Waiting for services, have been deemed incompetent and in some cases allowed to leave
  • Walle – Have an issue in Harris County where some could be bonded out but they are having to wait; any info on this?
    • No details on that, Harris County has been very skilled in ensuring people on the waitlist need to be there; have done a much better job than other counties
  • Walle – Highlights how local counties end up paying for people waiting for beds
  • Bryant – Texas is 50th or 51st in mental health care and access?
    • Alletto – Did recently review a report that put TX at 50th
  • Bryant – Do you agree with that ranking?
    • Don’t agree as methodology wasn’t sound, but have a lot of room to improve
  • Bryant and Gaines discuss training and mental health aid for children
    • Can get you numbers on mental health aid for children
  • Bryant – Only $2.5m for mental health first aid seems absurdly inadequate; who made decision
    • Gaines – Only state dollars here
  • Chair Bonnen – Across all articles, spend about $9b, $4.4b in GR, created a Consortium in 2018 that has scaled up funding dramatically; inaccurate assessment
  • Bryant – Which part is inaccurate?
    • Gaines – $2.5m is for Mental Health First Aid
  • Bryant – Was asking about money allocated to preempt mental health inspired violence like in Uvalde, Mental Health First Aid seems to be this initiative; some other program that helps preempt?
    • Alletto – Several programs that are tailored to communities, partner with LMHAs and focus on early detection and treatment
  • Bryant – Could you identify where that is referenced?
    • Only some services are in the PowerPoint, were not able to include all of them
    • Fall into two categories: prevention & services
    • Can arrange all programs and attach dollar amounts to that
  • Bryant – Total funded beds? Some are offline, how long have they been offline?
    • Schalchlin – 2,300+; started seeing large drop off at beginning of pandemic in March 2020
  • Bryant – Couldn’t there have been things done to solve the problem since that time?
    • Yes, did increase pay raises to stabilize staffing
    • Implemented new pay raises across the system this month, expecting staffing levels to rise and to be able to bring beds back online
  • Bryant – 365 people who have been declared incompetent to stand trial but still in Dallas County jails; what happens to a person incarcerated for a year without treatment?
    • They are getting treatment, not the best location for them
    • Working with Dallas County to assist in delivering services, LMHAs also available
  • Bryant – Across the state there are around 2k people, do you regard this as an emergency?
    • It’s concerning, people should be in the best setting
  • Bryant – Have you told Governor and asked him to declare an emergency to solve the problem?
    • Alletto – Working with Governor for getting salaries and working with legislature on constructing hospitals; even with hospitals today, wouldn’t meet need of 2k people
  • Bryant – After we pass budget, what would our mental health ranking be?
    • Would depend on what they are ranking, crisis system would improve, also have funding for additional new beds and community beds
    • Where we can make a difference in rankings is with children and youth, innovation grants are required to target children & youth; grants are a good way to address unique needs in communities
  • Tepper – How do people get services? Hotline?
    • Gaines – LMHAs are required to have a 24 hour call center
    • Also have a 9-8-8 national initiative to contact mental health professionals; 5 locations TX responsible for answering those calls
    • Highlights other avenues like mentalhealthresources.org
  • Tepper – If you had all beds online, and staff, then the new beds, you could probably fill these 8x over; are you overwhelmed?
    • Alletto – Communities are overwhelmed, HHSC is trying to steward funding available
    • Seeing more complex cases recently
  • Tepper – Mental health dollars flowing into public schools at all? Part of the $8b-$9b?
    • Trey Wood, HHSC – A lot goes towards services for children in Medicaid, also goes to SHARS program
  • Tepper – Have more questions offline, vast issue, ranking very low in TX in some studies and seems to be getting out of hand for everyone; seems like dollars increase and problem increases
  • Spiller – Number one issue in counties for LEOs is mental health, wait list is substantial; staff available to address problem?
    • Schalchlin – Applications have risen dramatically since pay raise, hiring at a pace higher than last 3 years
    • Still will probably be short of estimates need by 2024, but have good shot at bringing new beds online
  • Spiller – Bed availability seems to be somewhat impacted by fact that average stay seems to be longer than before, gone from 204 days to 472 days?
    • Have noticed the increase as well, working with forensic director to make sure more consistent processes are in place, e.g. consistent competency restoration
    • Other issue is that getting people back to the county can take time
    • Alletto – HB 1 includes funding for step-down housing as well, transition support back to community
  • Howard – What about transitional housing like what was available for the Austin State Hospital?
    • Gaines – Working on a number of initiatives that will help people move back to community, incl. HCBS, housing initiatives with LMHAs through ARPA dollars
    • Working on initiatives to lower hospitalizations as well
  • Howard – Housing costs are being borne by the counties, trying to figure out how to map this out across the entire state to let all entities work together
  • Howard – How many people are considered long term?
    • Schalchlin – Can follow up, have a large number of people in the long term category
  • Howard – How many diagnosed as IDD waiting for competency restoration in the jails?
    • Wait on IDD side is much shorter, can get exact numbers
  • Chair Bonnen – Supplemental approps act expected to have funding, $2.3b state hospital funding designated in Art. IX that will land at the end of last biennium
  • Jarvis Johnson – How many open position do we currently have?
    • 1,800 vacancies in state hospitals
  • Jarvis Johnson – have we truly identified it is a money problem? Leadership problem? Direction problem?
    • Usually it is not about pay, but started to change in 2020 and 2021 as the private sector competition grew
    • Also had a lot of retirements when COVID started
    • Also working to support work culture, though different areas have different challenges
  • Jarvis Johnson – Would benefit us to have an exit survey or survey of workers, hearing a lot of guessing; need to figure out the actual need, $8b-$9b sounds like a lot of money, but perhaps need is greater
  • Jarvis Johnson – Would you consider expansion of Medicare/Medicaid to possibly help with this?
    • Alletto – Have not looked at those numbers in how it would affect waitlist, 60% in state hospitals would be forensic and not Medicaid insured
  • Jarvis Johnson – Would be the point of expansion
    • Schalchlin – We do survey staff & ask about experience
  • Jarvis Johnson – Would like to see survey results, would help anchor solutions
  • Wu – Do you see the trend is that more mental health issues are popping up or is it that we are now better at diagnosing and see mental health causes?
    • Gaines – So many other factors that play into mental health and a lot more awareness
    • Have done a better job on the stigma piece & more are actually seeking help
    • Also impact of COVID was severe
  • Wu – Build up from COVID going to stay?
    • Research shows trauma events are long term, not something that instantly got better, sometimes there is a delayed reaction, etc.
  • Wu – Some of the difficulties in recruiting is that many Baby Boomers are retiring; do you see  a future where no amount of money will fix the problem? Where staff cannot be sufficient?
    • Alletto – Population growth is an excellent point, need more people to serve more people
    • Would defer to Dr. Lakey from Child Mental Health Care Consortium
  • Thimesch – 2,617 people on waiting list? Adults or children?
    • This is the state hospital wait list
    • Schalchlin – May include some children
  • Thimesch – How many children and where are they?
    • Will need to follow up, in some cases served elsewhere
  • Allison – Do you have much coordination with the Consortium and others? Is it working
    • Alletto – Yes
    • Gaines – Quite a bit of coordination with the Consortium, also have initiatives where LMHAs are involved, interns embedded in LMHAs
  • Allison – Have you had much interaction with TEA and the ESA rollout?
    • HHSC and LMHAs have personnel in the RSCs, has worked very well for mental health first aid training, coordinating efforts
  • Allison – Opportunities for expansion?
    • Have not heard of staffing deficits, think it’s working well
    • Alletto – HB 1 currently has funding for innovation grants which are required to focus on children & youth
  • Rose – Present letter from Dallas County that was sent to HHSC, 382 individuals awaiting transfer to facility for competency restoration, urgent issue; previously discussed LMHA UC funding that was going to go away with DSRIP?
    • Alletto – Is part of 1115 waiver, will be part of waiver after DSRIP goes away
    • Wood – Wanted to protect LMHAs after DSRIP as much as possible, fully covering costs as of now with the $500m pot & exceeds DSRIP funding
  • Rose – Do any funds address workforce shortages?
    • Alletto – It would, but pool pays out for actual costs, LMHAs can apply for increased salary rates that were uncompensated
  • Martinez Fischer – Have 288 individuals awaiting competency restoration in Bexar County, facilities are struggling to find adequate workforce; would like to think about mental health funding needs in a more holistic way & what is actually needed to get beds and facilities online
  • Martinez Fischer – Want to share expertise and best practices between regions, how to operationalize dollars in the best way
    • Alletto – Can discuss practical effect of mental health funding so far
  • Martinez Fischer – Diversion programs all over the state?
    • Not doing these all over the state, many diversion program make a tangible difference
  • Martinez Fischer – Would like to hear more about diversion programs, etc.
  • Gervin-Hawkins – Short and long term solutions are needed, how can we start fixing to see positive outcomes every year? Document that guides this kind of solution?
    • Alletto – With salary increase, should be able to get some of the 700 beds online, state hospitals are very aware of need
    • Construction takes time, but legislature has been generous over several years to see more beds come online quicker
    • Will need to monitor for need beyond the 700 beds
  • Gervin-Hawkins – Want to make sure we’re intentional about recruitment, onboarding, and training, e.g. could look at those released from prisons, light offenders
    • Schalchlin – Sometimes criminal history is a bar to employment
  • Gervin-Hawkins – Could target light offenders, high school students, etc. that could do some work, maybe admin; would love to see a recruitment strategy in writing
  • Chair Bonnen – Do have the Texas Statewide Behavioral Health Strategic Plan
    • Gaines – Have a coordinating group made up of 25 agencies that developed the plan, on 3rd version now
    • Also have a forensic plan that covers this area, working with other agencies
  • Gervin-Hawkins – Want a plan to fill the vacancies
    • Scahlchlin – Just had training from a facility with better success than others, trying to share successful method with others
  • Gervin-Hawkins – Is there a feedback mechanism for funding or assistance where local entities can decide what they need
    • Alletto – Exceptional item process details agency’s top priorities, had a few items related to this issue incl. state hospital salaries
    • Also present info in meetings and hearings
    • See challenges in the differing needs across the state

 

Andy Keller, Meadows Mental Health Policy Institute

  • HHSC is doing everything they can, plan to get more employees is a good one, but state agency cannot get us out of the problem alone
  • TX is not 51st in the nation, considering funding TX is likely in the 30s
  • Most critical limiting factor is workforce, but not just the workforce for state hospitals
  • Not doing anything for the LMHA rate, dollars in the $500m are cost reimbursement dollars and cannot support new hires; can’t have costs with workforce in place
  • Need to recognize that mental issues start in childhood and restructure system around this
  • Recommending full funding for Child Mental Health Care Consortium
  • Youth Mobile Crisis Teams are opportunities to be hospitals on wheels and provide follow up care
  • Multi-systematic Therapy is important, will help prevent tragedies like Uvalde
  • Chair Bonnen – Assertion was made that state spends $2.5m on mental health first aid, so nothing else was done to prevent tragedies, what is your response?
    • Need to look at all programs, Consortium provides more than $300m, should do more, but doing a lot; also have a line item for crisis centers
    • Have a very sound infrastructure
  • Rose – You see nothing for workforce shortages at LMHAs?
    • $500m is for cost reimbursement, doesn’t support hiring of new workers

 

Dr. David Lakey, UT System, Texas Child Mental Health Care Consortium

Dr. Laura Williams, Baylor College of Medicine, Texas Child Mental Health Care Consortium

  • Consortium was built to address other mental health challenges, but getting children needed services and linking professionals is a large part of what it does
  • Highlights functions like Centralizing Operating Support Hub, UT is coordinating entity
  • Mission is to equip providers in Texas to be able to provide care for kids, build workforce, and drive research to improve systems of care
  • $124m was invested in mental health last biennium, $113m additional through ARPA, fully funded request this session
  • Highlights programs included in HB 1, e.g. Youth Aware of Mental Health stood up with ARPA dollars, 8 institutions working in schools to help kids navigate challenges, HB 1 has $19.1m for the program, training programs
  • Provides overview of Child Psychiatry Access Network, helps primary care physicians manage mild to moderate issues; have expanded program to allow for easier communication from PCP, developed web portal
  • Working on program to help PCPs intervene in potentially suicidal youth
  • Chair Bonnen and Williams discuss how program is intended to support PCP with additional tools to help identify potential patient issues; also has recommendations on possible screening for suicidal ideation, etc.
  • Howard – Leading cause of death among children & youth is firearms, is part of intervention to talk about this?
    • Williams – Yes
  • Williams highlights areas of state CPAN teams cover
  • Takes some time to set up the program, but seeing good utilization
  • Tried to leverage what was learned from CPAN
  • Discusses rollout of PeriPAN
  • Provides overview of TCHATT, telemedicine access program for children, only operates with involved and consent of parent or guardian; pandemic focus on remote access boosted adoption and usage
  • Always focus on partnering with local ISDs, do not want to duplicate services
  • Workforce retention and recruitment is a challenge for service delivery
  • In communication with LMHAs to support; believe strong LMHAs are required to meet needs
  • Consortium also working to attract workers from outside of state and focus personnel in key areas
  • Chair Bonnen – 5 or 6 year process to get new professionals trained, Consortium has been operating for less; highlights that it will take time for a graduate class to form
  • Walle – Common theme is sustaining programs so they are clinically meaningful; do you have an opinion on creating schools of behavioral health sciences?
    • Lakey – UT System has a proposal to build a behavioral health school, need to have a workforce that understand modern mental health care; value to have behavioral health schools
    • Williams – Many students have difficulty finding next step, places we can maneuver together to expand training opportunities
  • Spiller – Rural need would be for CMS to fund LPS
  • Chair Bonnen – 2019 Sen. Nelson championed this, had no other program to compare it to & Consortium has been very successful

 

Transportation Funding

Marc Williams, Executive Director TxDOT

  • Speaking on Unified Transportation Program (UTP) & recent actions
  • $66b in state highway improvement, $2b in safety projects, other multi-modal projects
  • Commission approved $85b UTP, 4k highway improvement projects, $14b for safety projects, $14b for rural projects, $32b additional for maintenance; $117b investment in transportation program
  • Prop 1 & Prop 7 funding is very important, more money than TxDOT receives through the traditional SHF
  • 64% of funding is from state sources, federal sources only 36%; many other states are heavily dependent on federal funding & TxDOT can guide its own projects to a greater extent; also allows TX to continue to operate if federal funding is suspended

 

Brandy Hendrickson, Deputy Executive Director TxDOT

  • Provides overview of UTP, 10-year plan updated annually that forecasts transportation planning & projects based on funding estimates, not a guarantee that projects will be built
  • $85b+$34b=$117b in transportation investment over the next decade
  • Highlights UTP process & timeline, 2023 UTP adopted in August 2022, 2024 UTP is already underway; continuous development cycle
  • Draft planning targets were distributed this month, draft 2024 UTP expected June, public involvement open July-August, then final draft and adoption late August
  • 2024 UTP draft includes $95b in funding, also expected $39b in additional funding for maintenance and project dev, so $135b total
  • Highlights timeline for passage of the Infrastructure Investment and Jobs Act, most recent highway funding reauthorization, 21% increase in federal funding, but only 6% impact on TxDOT’s overall budget
  • TxDOT will align & distribute IIJA funding largely through the UTP
  • Around 10% of funding for IIJA is distributed through existing and new federal grant programs selected by USDOT
  • TXDOT has assisted partners in application to secure grant opportunities
  • TXDOT was awarded $25M in raise grants
  • Local entities have been awarded over 400M across several discretionary grants state wide
  • Importance of safety on roadways, set a goal of 0 deaths on roadways by 2050
  • Thompson- Regarding rail highway grade crossings, seems there are not enough funds to provide for match. What can we do to help provide for the match?
    • Williams- The funds that are there for the crossing program is a continuation of a program already in place, about 20M a year goes to critical at rail crossings; when we undertake those projects not looking for locals to provide match for that; we look at supplementing those funds with traffic safety funds; The Legislature could look at capitalizing on the rail relocation and improvement fund
  • Thompson- Other states use Construction Manager General Contracting (CMGC) to award contracts, how would those tools work for TXDOT?
    • The CMGC is utilized in Texas but not for highway projects, its mostly for vertical construction
  • Tepper- Can you elaborate on the Austin I-35 project?
    • We are close to finalizing final environmental for central portion of the project expect it to begin in 2024; both the north and the south projects are beginning construction this year
  • Tepper- What is the status on the I-27 project in my district?
    • We must use our own sources of funds to advance it, it’s been a steady and incremental approach in working with local communities
  • Tepper- Does money affect the speed of the project?
    • A lot of the time the schedule of projects keeps funding in mind, many of the plans must have fiscal constraint
  • De Ayala- Is the I-45 green lighted again?
    • Hendrickson- Happy to report we have come to an agreement with both the county and the city, project does remain on pause at the federal level
  • Toth- Is the Texas High Speed Rail dead?
    • Williams- We haven’t been engaged with them in quite some time
  • Toth- What would the cost to taxpayers be if Texas built a High-Speed Rail?
    • It would be whatever portion of the project can’t be privately funded or financed
  • Ortega- Do you have an expectation how much money the grant program could bring to the state?
    • Hendrickson- It depends on the application, the competitiveness of the project, and the discretion of the USDOT
  • Ortega- Are those application going to be processed for a couple of years?
    • They are authorized through the IIJA which is 5 years
  • Walle- What is the impact of the record letting for the UTP?
    • Williams- We are starting to see an increase in competition in the contracting industry and a better alignment of bid prices
  • Walle- Is the price of raw materials and labor plateauing or on the rise?
    • It appears that the increase of those prices has plateaued
  • Walle- Could you talk about multimodal forms of transportations?
    • It is in our budget and there are several that our LAR, two were $150M for the port capital plan, and the other is $400M that would capitalize the Ship Channel Improvement Revolving Fund; aviation side $94M to help serve general aviation airports across the state; transit side $700M in formula funding for transit districts
  • Martinez-Fisher- Is the federal investment going to be significant?
    • Hendrickson- 21% in federal funds is appreciated, in terms of the overall growth it’s a small portion of our overall budget
  • Gervin-Hawkins- Will the unincorporated areas be able to apply for any of the grants?
    • Yes, our transportation alternatives program addresses some of that

 

Water Development Board

Jeff Walker, TWDB

  • FIF is a constitutionally dedicated fund created to provide financial assistance for flood mitigation projects
  • Have committed $470M in assistance for various flood projects
  • Price tag submitted for regional flood plan is $42B
  • Exceptional item $394M for FIF and update method of financing for FTEs
  • In 2020 board adopted Flood Intended Use Plan to guide entities applying for FIF funds
  • There are 4 categories for funding and the scoring system was designed to match the boards highest priorities
    • Category 1 Flood protection planning for water sheds
    • Category 2 Planning acquisition design and construction
    • Category 3 Matching federal funds
    • Category 4 Measures for protecting life
  • The amount of grant funding was based on project criteria
  • Have received over 280 projects for over $2.3B, have committed $471M and if projects receive funding $137M will remain
  • If inhouse projects get funded, the board will have funded $632M out of $770M

 

Mark Wentzel, TWDB

  • Over the last 18 months Texas has endured worst drought since 2011
  • A year ago, drought was impacting 78% of state and reached 97% of state in Aug
  • As of last week 53%, of the state was still in drought, takes quite about of surplus to get out of drought
  • National weather service seasonal out look through April expects drought to expand and cover all but east corner of the sate
  • Over the long run La Niña conditions are expected to dissipate by the end of April

 

Temple McKinnon, TWDB

  • State has developed water plans to prepare for and respond to draught conditions
  • Plans are based on conditions that would be expected to exist if we had worst recorded drought in states history
  • There are certain instances across the state where no economically feasible water supply could be identified in 2022 state water plan
  • In the event of a severe drought total potential shortages are projected to be 6.9M acre ft. by the year 2070; to address shortages planning groups recommended strategies that if implemented would produce 7.7M acre ft. of water by 2070
  • Implementing these strategies would be estimated to cost $80B
  • Walle- The ones that applied and didn’t make the cut for FIF, would there be a new process for them?
    • Walker- Yes, we’ve learned from this project and we would invite them back and more
  • Walle- The agencies responsibilities have grown over time is that right?
    • Yes we have grown from $6.8B assets managed in 2013 to over $19B today
  • Walle- Is that with the similar number of FTEs?
    • No, most of the FTEs we’ve grown from flood, and we’ve found that that wasn’t enough
  • Bell- Where would you point local municipalities that don’t have the funding for projects?
    • With the exception of FIF the only other source of “free” money would be some FIMA grants we administer; small match of 20%
  • Stucky- Is TWD involved when discussing purchasing water from another state
    • There would have to be a local sponsor involved
  • Toth- Is there anything in FIF that’s also in SWIF
    • No sir, so far we haven’t seen any that have true long term water supply benefits
  • Thompson- NFIP has changed a lot of mapping, how are y’all working with risk factor 2.0?
    • We have flown the whole state with lidar, and we are trying to show where the water levels go; we’ve got most of the state but not all of it

 

Gulf Coast Protection District

Michel Bechtel, Gulf Coast Protection District, Mayor of Morgan’s Point

  • Appreciates funding for Gulf Coast Protection District (GCPD) in HB 1
  • Provides overview of GCPD, selected to the non-federal sponsor of the Coastal Texas and Sabine to Galveston (S2G) projects, sometimes referred to as coastal barrier system or Ike Dike
  • SB 1160 (2021) empowered GCPD to do the following: delivering cost share, work with Army Corps of Engineers for construction, and maintain assets
  • $200m was appropriated in 2019 for S2G program, spent on cost share or for construction projects
  • 2021 SB 1 funds are paid out or encumbered for Coastal Texas and S2G
  • Port Arthur construction for first mile contract completed, design is completed on a further 5 contracts
  • Orange County project has progressed to design phase, Army Corps is working with landowners and stakeholders to minimize impact
  • Reached milestone for Coastal Texas in Dec. 2022, program was authorized to proceed to design & construction; eligible to receive federal funding, but none appropriated yet
  • GCPD has worked with GLO and Army Corps on all aspects of design & planning, have agreements with local agency stakeholders and prioritizing community involvement
  • Launched a website to make info accessible
  • State will benefit from projects as it reduces threat to landscape and safeguards industry in the area
  •  Walle – Intent is to put $500m to this effort, what would this go to?
    • Bechtel – Primarily for the ongoing matching funds for the S2G project
    • Coastal Texas was just authorized on Dec 23, balance will go there; federal ask was $600m
  • Walle – So this will allow us to draw down dollars, get reimbursed for ongoing work?
    • On inherited S2G project, federal gov would’ve financed those, but with funds from legislature have been able to pay as we go to avoid deficit
  • Walle – Total cost?
    • $34.4b in today’s funds for Coastal Texas project, incl. Ike Dike
    • GLO is non-federal sponsor for the areas down the coast
    • S2G was originally a $4b federal total
    • 65% federal/35% local match for these projects; TX is responsible for 35% of $34.4b and existing $4b
  • Chair Bonnen – $500m in HB 1, $200m unencumbered, $300m contingent on the match; though while there is federal approval for the project, there is no federal funding yet
  • Chair Bonnen – State has paid for expenses so far, question is when we will get the federal match; working now to understand what the timeline and expectation would be
  • Chair Bonnen – If TX applies more capital, would that expedite the federal funding
    • Question of what comes first; working on it, expecting the funding
  • Chair Bonnen – Corps has a budget and has projects around the country; to the extent they already have projects and funding allocated, even without additional funding the question is if we could work with Corps and if they would look favorably at the project with TX capital; if we invested more capital would that allow us to leverage resources
  • Chair Bonnen – Also understand that even with $34.4b today, it will take some time to construct
    • Met with Army Corps recently and tried to make point that TX has shown with participation in S2G that state is committed and ready to go; trying to leverage this to push federal appropriations
  • E Thompson – Started out as a $7b-$8b project, but was expanded by the Army Corps of Engineers; $34.4b is a huge number, but that’s not where it started
    • Agree, like many projects once it starts rolling people start adding to it
    • With authorization we can now start preliminary engineering and design phase so numbers will become more concrete
  • Chair Bonnen – Concept that started right after Hurricane Ike, sense that we started off with a specific mission and doing everything but that & it has been more than a decade; not a criticism, but some would like to see focus back on the original point
    • GCPD Board reflects that opinion
    • Some of the things proposed will never come to be, but this is how proposals develop
    • Board would like to concentrate on building the beach on Bolivar Peninsula & Galveston, could probably achieve 65% of the protection with that alone
    • End phase things 35 years from now are included in the authorization
  • Gervin-Hawkins – Have received authorization to proceed but no dollars?
    • Correct, received authorization two days before Christmas
    • Had tremendous support in Congress for the authorization
  • Gervin-Hawkins – You have pre-development dollars?
    • Can go into PED phase now
  • Gervin-Hawkins – How does this impact us this biennium, holding dollars in hopes of federal funding?
  • Chair Bonnen – Have $500m in the introduced bill this biennium, strong likelihood that this money will be used and federal dollars will come down; question is how much further we can go and draw down funding
  • Gervin-Hawkins – So a phased plan?
  • Chair Bonnen – Will take decades
  • Gervin-Hawkins – Does this stop other projects?
  • Chair Bonnen – No, approach is measured and expect $500m to be utilized, if we get more from the federal government, question is if we’re ready to follow up and if more dollars would incentivize the federal government to act; not overextended
  • Gervin-Hawkins – That’s helpful

 

Closing Comments

  • Chair Bonnen – Schedule for subcommittee work will be out by the end of the week