Earlier this year, I started my clinical rotations. In addition to seeing many of the things we learned about in the classroom, I have been able to witness patient-physician interaction and the important role physicians have in empowering, supporting, and providing hope for their patients who may be suffering from severe medical issues. I have seen many physicians comforting their patients by holding their hands and have tried to capture this through my painting.
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By: Jasmine Liu-Zarzuela, Emily Liu, and Justin McCormack
Asian Americans are the fastest-growing ethnic group in the United States, with Texas ranked 3rd in overall population and 2nd in an increase in population over the past 20 years.1 While this group is often referred to and perceived as a monolith, the label of Asian American and Pacific Islander (AAPI) encompasses over 50 ethnic groups speaking over 100 languages.2 With such a variety of ethnicities and language barriers within one group there also comes a variety of unique healthcare problems this population faces. AAPI individuals have been shown to face health disparities in cancer screening and mental healthcare, amongst many others, despite the population being relatively understudied compared to others.3 Thus, it is paramount for healthcare providers to be aware of AAPI health disparities to ensure access to adequate resources and outreach for proper screening, preventative care, necessary follow-ups, as well as proper research and study of this population to ensure disparities can be prevented.
The AAPI community is composed of distinct ethnic subgroups which differ significantly by socioeconomic status, educational attainment, cultural background, amongst other major social determinants of health. For example, Asian Americans are the most economically divided racial group,4 and access to healthcare can depend on factors such as insurance coverage and interpreter access, which vary wildly based on subgroup.5 Thus, disaggregation of demographic data is paramount in order to identify within-group disparities in health outcomes and representation in medicine. The disaggregation of AAPI data will also aid in helping determine necessary initiatives to decrease disease burden in subgroups within the AAPI community.
According to the National Alliance of Mental Health, AAPIs have the lowest rate of seeking mental help of any minority group, with just under a quarter of AAPI adults with mental illness receiving treatment.7 Several barriers contribute to difficulties seeking care, ranging from language barriers, stigma, the model minority myth, and alternative treatments, amongst others.8 The COVID-19 pandemic has increased xenophobia against Chinese Americans and the AAPI community as a whole, and these experiences have been associated with an increased level of depressive and anxiety symptoms.9
In the US, incidence and death rates for liver cancer are second-highest in Asians compared to other ethnic groups (after Hispanic), reaching as high as twice the rates of other racial or ethnic groups.10 Liver cancers have been attributed to Hepatitis B (HBV) and C virus (HCV), which are often silent infections.11 Compared to other demographics, Asian Americans have the highest rates of HBV infection and are least aware of their HCV status.11,12 However, AAPIs with Hepatitis infection do not engage in established risk factors for HCV in other populations, and hence are often under-diagnosed.13
TMA Policy
Currently, TMA policy 260.126 supports the Texas Department of State Health Services efforts in addressing racial/ethnic healthcare disparities and the funding needed to lessen such disparities. However, there are no current TMA policies that acknowledge disparities in healthcare specifically among the AAPI population. TMA does support AMA policy H-350.954, which advocates for the restoration of web pages on AAPI initiatives that address disaggregation of health outcomes concerning AAPI data.
Recently, the medical student section (MSS) of the TMA have submitted several resolutions to address the health disparities within the AAPI population. One of the proposed policies calls for the TMA to support the disaggregation of demographic data regarding AAPIs to reveal the within-group disparities that exist in health outcomes and representation in medicine. A second proposed policy calls for the TMA to support legislation for the funding and promotion of HBV screening, treatment, and education among the Asian American and Pacific Islander population. Lastly, a third proposed policy urges the TMA to support raising awareness and educating providers about the discrepancies in mental health among AAPI populations.
Advocacy Goals/MSS Perspectives
Advocacy goals on increasing HBV screening and education among the AAPI community would improve health outcomes, education, and treatment for HBV and HCV screening, while decreasing the prevalence of liver cancer among one of the most commonly impacted racial and ethnic groups in Texas and the United States. Similarly, advocacy goals on increasing mental health screening and education among this population would improve health outcomes and quality of life. By bringing awareness and policy to decreasing the prevalence of liver cancer, HBV, HCV, and mental illness among the AAPI community, the TMA-MSS has an intricate and influential role in building a stronger screening program and culturally specific interventions to improve the livelihoods and health outcomes in the AAPI community.
Current Bills
Stop Mental Health Stigma in Our Communities Act (H.R. 3573) (7) is a current bill that instructs the SAMHSA to provide outreach and education strategies for the Asian American, Native Hawaiian, and Pacific Islander (AAPI) community.14
Call to Action
It is imperative that medical professionals and students acknowledge the health disparities that exist within the AAPI community and further spread awareness and policy to ultimately improve the health outcomes of this community.Â
References
Asian Americans are the fastest-growing racial or ethnic group in the U.S. (2021, April 9). Pew Research Center. https://www.pewresearch.org/fact-tank/2021/04/09/asian-americans-are-the-fastest-growing-racial-or-ethnic-group-in-the-u-s/
Lee, S., Martinez, G., Ma, G. X., Hsu, C. E., Robinson, E. S., Bawa, J., & Juon, H.-S. (2010). Barriers to health care access in 13 Asian American communities. American Journal of Health Behavior, 34(1), 21–30. https://doi.org/10.5993/ajhb.34.1.3
Misra S, Le PD, Goldmann E, Yang LH. Psychological impact of anti-Asian stigma due to the COVID-19 pandemic: A call for research, practice, and policy responses. Psychol Trauma. 2020;12(5):461-464. doi:10.1037/tra0000821
Duh-Leong C, Yin HS, Yi SS, et al. Material hardship and stress from COVID-19 in immigrant Chinese American families with infants. J Immigr Minor Health. Published online 2021:1. doi:10.1007/s10903-021-01267-8
Cheah CSL, Wang C, Ren H, Zong X, Cho HS, Xue X. COVID-19 racism and mental health in Chinese American families. Pediatrics. 2020;146(5):e2020021816. doi:10.1542/peds.2020-021816
Ho, E. Y., Ha, N. B., Ahmed, A., Ayoub, W., Daugherty, T., Garcia, G., Cooper, A., Keeffe, E. B., & Nguyen, M. H. (2012). Prospective study of risk factors for hepatitis C virus acquisition by Caucasian, Hispanic, and Asian American patients: Ethnic differences in risk factors for HCV. Journal of Viral Hepatitis, 19(2), e105-11. https://doi.org/10.1111/j.1365-2893.2011.01513.x
Kim, H.-S., Yang, J. D., El-Serag, H. B., & Kanwal, F. (2019). Awareness of chronic viral hepatitis in the United States: An update from the National Health and Nutrition Examination Survey. Journal of Viral Hepatitis, 26(5), 596–602. https://doi.org/10.1111/jvh.13060
Products – data briefs – number 361 – march 2020. (2020, June 26). Cdc.Gov. https://www.cdc.gov/nchs/products/databriefs/db361.htm
The onslaught of anti-LGBTQ+ legislative proposals continues to rise among Texas lawmakers amid already skyrocketing negative rhetoric and violence towards the LGBTQ+ community1. Some legislation calls for book bans in school libraries, questions the legality of gender-affirming care for transgender youths, and paints drag shows as grooming children for sex.
The United States Department of Health and Human Services defines gender-affirming care as a supportive form of health care which can include medical, surgical, mental health, and/or non-medical services for transgender and nonbinary people2. This early gender affirming care is essential to overall health for transgender or nonbinary children, allowing them to focus on social transitions which can increase their confidence while navigating the healthcare system.
LGBTQ+ people are more visible in their communities than ever before. A Public Religion Research Institute (PPRI) survey found that 70% of Americans report that they have a close friend or family member who is gay or lesbian, while the number of Americans who say they personally know someone who is transgender has nearly doubled, from 11% to 21%3. Texas is home to approximately 7 million youth under 18, and holds the second largest LGBTQ youth population in the U.S., according to an analysis by Williams Institute at the UCLA School of Law and Gallup Daily4.
LGBTQ+ Demographics in Texas:
% of Adults (18+) who are LGBTQ+
Total LGBTQ+Population (13+)
% of Workforcethat is LGBTQ+
Total LGBTQWorkers
% of LGBTQ+ Adults (25+) Raising Children
4.1%
1,053,000
5%
647,000
29%
As of February 2023, the American Civil Liberties Union (ACLU) has identified 23 anti-LGBTQ bills in Texas– 10 of which directly target access to healthcare5. Many of the healthcare bills seek to limit or ban gender-affirming care for transgender youth by declaring gender-affirming care as “child abuse” and target medical providers with threats losing licensure and pressing criminal charges, and removing state funds for gender-affirming care. Other bills attempt to limit classroom instruction on sexuality and gender identity. Introduction of legislation like this affects the emotional and physical well-being of this historically marginalized patient population.
Key Bills this Session:
Senate Bill 1029, filed by Texas Republican Bob Hall, would ban public funding for gender modifications and treatments, which includes castration, vasectomy, and hysterectomy regardless of age6. It would also bar some health plans from providing “gender modification procedure” and increase legal liability for medical professionals who offer the care.
Senate Bill 1082, filed by Texas Republican Bob Hall, relating to the definition and use of the terms “male” and “female” for purposes of certain government documents7. This would restrict all government-produced communications that request or provide information on someone’s sex to only use “male” and “female.”
The proposed Texas legislations are a direct insult to the mental-well being of LGBTQ+ people and their quality of life. Transgender and gender nonbinary adolescents are already at increased risk for mental health issues, substance use, and suicide. The Trevor Project, a suicide hotline for LGBTQ youth, reported that LGBTQ youth of color reported higher rates of attempting suicide than their white peers in 2022, and that for 86% of respondents in Texas, recent politics further negatively impacted theirwell-beings8.
A safe and affirming healthcare environment is critical in fostering better outcomes for transgender, nonbinary, and other gender diverse children and adolescents. Medical and psychosocial gender affirming healthcare practices have demonstrated lower rates of adverse mental health outcomes, increased self-esteem, and improvement in overall quality of life for transgender and gender diverse youth9.
As future healthcare professionals, it is our duty to ensure equitable healthcare for all individuals, regardless of gender identity. Furthermore, it is our duty to take actions of non-maleficence, avoiding doing any harm to individuals. If bills that restrict the healthcare for these individuals are put into place, this population will not have the same opportunity to advance their mental health and physical health as their non-transgender counterparts. Their mental health will undoubtedly undergo negative impacts as a consequenceThese pieces of legislation decry appreciation for LGBTQ community members and the autonomy and dignity these individuals deserve and are inappropriate for any policy, especially those pertaining to the healthcare legislature .
TMA Policy
The LGBTQ Health Section of the TMA is charged with addressing important issues of interest to LGBTQ medical students, residents and fellows, and physicians. The goal is to advance the association’s leadership role in providing physicians and patients with evidence-based, scientific information on care for lesbian, gay, bisexual, transexual, and queer/questioning individuals. TMA specifically wants to protect the patient-physician relationship. Below are policy examples.
60.008 Rejection of Discrimination: The Texas Medical Association does not discriminate, and opposes discrimination, based on race, religion, disability, ethnic origin, national origin, age, sexual orientation, sex, or gender identity. TMA supports physician efforts to encourage that the nondiscrimination policies in their practices, medical schools, hospitals, and clinics be broadened to include “race, religion, disability, ethnic origin, national origin, age, sexual orientation, sex, or gender identity” in relation to patients, health care workers, and employees. (CSPH Rep. 1-A-18)
60.010 Opposing Legislation that Mandates Physician Discrimination: The Texas Medical Association (1) supports the removal of “opposite sex” as a requirement for affirmative defense to prosecution within the Texas Penal Code, and (2) opposes legislation or regulation that mandates physicians and other health professionals discriminate against or limit access to health care for a specific patient population (Res. 111-A-19).
265.028 Improving LGBTQ Health Care Access: The Texas Medical Association recognizes that lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) individuals have unique health care needs and suffer significant barriers in access to care that result in health care disparities. TMA will provide educational opportunities for physicians on LGBTQ health issues to increase physician awareness of the importance of building trust so LGBTQ patients feel comfortable voluntarily providing information on their sexual orientation and gender identity, thus improving their quality of care. TMA also will continue to study how best to reduce barriers to care and increase access to physicians and public health services to improve the health of the LGBTQ population. (CSPH Rep. 8-A-18)
For LGBTQ mental health support, call the Trevor Project’s 24/7 toll-free support line at 866-488-7386. You can also reach a trained crisis counselor through the Suicide and Crisis Lifeline by calling or texting 98810.
Sources
Legislative Bill Tracker 2023: Equality Texas. equalitytexas.org. https://www.equalitytexas.org/legislature/legislative-bill-tracker-2023/. Published March 13, 2023. Accessed March 31, 2023.
Lesbian, gay, bisexual, and Transgender Health. Centers for Disease Control and Prevention. https://www.cdc.gov/lgbthealth/index.htm. Published November 3, 2022. Accessed March 31, 2023.
How social contact with LGBT people impacts attitudes on policy. PRRI. https://www.prri.org/spotlight/lgbt-pride-month-social-contact-gay-lesbian-transgender-individuals/. Published October 13, 2021. Accessed March 31, 2023.
The Williams Institute. https://williamsinstitute.law.ucla.edu/visualization/lgbt-stats/?topic=LGBT&area=48#density. Accessed March 31, 2023.
Mapping attacks on LGBTQ rights in U.S. state legislatures. American Civil Liberties Union. https://www.aclu.org/legislative-attacks-on-lgbtq-rights. Published March 28, 2023. Accessed March 31, 2023.
2022 National Survey on LGBTQ Youth Mental Health by State. The Trevor Project. https://www.thetrevorproject.org/wp-content/uploads/2022/12/The-Trevor-Project-2022-National-Survey-on-LGBTQ-Youth-Mental-Health-by-State-Texas.pdf. Accessed March 31, 2023.
Tordoff DM;Wanta JW;Collin A;Stepney C;Inwards-Breland DJ;Ahrens K; Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA network open. https://pubmed.ncbi.nlm.nih.gov/35212746/. Accessed March 31, 2023.
For young LGBTQ LIVES. The Trevor Project. https://www.thetrevorproject.org/. Published February 27, 2023. Accessed March 31, 2023.
Maternal mortality continues to be one of the more pressing public health issues in Texas. In December 2022, Texas’ Maternal Mortality and Morbidity Review Committee released a report reviewing pregnancy-related deaths in Texas since 2019 1. The review found that despite policies implemented to prevent these cases, there has been little improvement in rates since 2013, with Texans continuing to experience above-average rates of pregnancy- & childbirth-related deaths – about 12 deaths per month with 89% of cases being preventable 1. The report also found that 19% of pregnancy related deaths were attributed to discrimination, with people of color, particularly Black patients being at the highest risk of pregnancy related discrimination and subsequently the highest risk for maternal mortality.
So what gaps remain to be addressed? In a recent issue of Texas Medicine, TMA announced that “women’s reproductive health” and “Medicaid coverage for women and children” amongst its priorities to address in the 2023 legislative agenda 2 . The federal administration has developed a Maternal Health Blueprint specifying policies on Extending Postpartum Medicaid Coverage; A Maternal Mental Health Hotline; Investments in Rural Maternal Care; No More Surprise Bills; and Better Trained Providers (addressing implicit bias), and in February, Dr. Jackson Griggs testified on behalf of TMA at the Texas Senate Finance meeting seeking adequate state funding for maternal & child health – the written testimony highlights similar issues regarding maternal mortality in Texas (more below) 3. Currently, there are a number of bills proposed this legislative session to address some of these issues:
Medicaid coverage
In the last session, House Bill (HB) 133 requesting extension of coverage for 12 months postpartum was passed by Texas’ House of Representatives – but the Senate reduced this to 6 months, causing the expansion to be stuck requiring waiver approval by the federal government 4
Due to this, despite Medicaid covering half of births in Texas, insurance still only extends coverage to 2 months postpartum – with nearly one-third of maternal deaths in Texas occurring after this coverage ends 5
Medicaid will undergo further “unwinding” this year as Texas restarts disenrollments – currently, a pregnant woman earning up to 198% of the FPIL can be covered by Medicaid through 60 days after pregnancy 6; but on day 61, she must earn less than 17% to maintain her coverage ($3,733 for a family of three), leading to loss of coverage for many 7. In Texas, rates of delayed and foregone preventive care for children and adults have increased, resulting in potentially missed and delayed diagnoses.
Gregg Abbott has even stated that one of his budget priorities is to request funding for 12 months of Medicaid postpartum services 8.
Bills proposed this session to expand Medicaid coverage to 12 months postpartum include House Bill (HB) 56 (currently still in Health Care Reform committee) & Senate Bill (SB) 73 (currently still in Health & Human Services committee).
Racial disparities
Nationally, Black people giving birth are three times more likely to die than their white counterparts – and twice as likely in Texas.9
Bills proposed this session addressing racial disparities include:
HB 663: Creating an unbiased maternal mortality and morbidity data registry for Texas.
Passed vote in the House, now in the Health & Human Services committee in the Senate.
HB 1164: Obtaining funding to conduct a study specifically investigating maternal mortality and morbidity among Black women in Texas.
Passed vote in the House, now in the Health & Human Services committee in the Senate.
HB 1162 & 1165: Establishing requirements for medical provider licensing should include hours for cultural competency and implicit bias training.
Both still in the Public Health committee
Life-saving care
Maternal death rates have been found to be 62% higher in contraception-restriction states like Texas 10
In two Texas hospitals, 57% of patients were reported to have significant maternal morbidity as a result of state-mandated management of obstetrical complications (like access to life-saving medication) compared to 33% in states without such legislation. On average, patients were withheld life-saving care for 9 days, simply being observed instead as their conditions worsened – before they eventually developed complications severe enough to be qualified as an immediate threat to maternal life for physicians to legally take action under Texas law. 11
Bills proposed this session addressing life-saving care include:
SB 79 & HB 3000: Ensuring that current restrictions will not negatively impact pregnant patients requiring termination for their care, including not being susceptible to criminal penalties.
Both still in the State Affairs committee.
HB 1953: Establishing exceptions to current restrictions to ensure that physicians are able to provide life-saving care to high-risk patients in their third-trimester.
Currently still in the Public Health committee.
Mental health resources
84% of pregnancy-related deaths were preventable – leading underlying issues varied by race & ethnicity, including: mental health conditions (23%) (suicide and overdose/poisoning) disproportionately affecting Hispanic & non-Hispanic White people. 12
In Texas, rising rates of drug abuse, suicide, and domestic violence reflect the mental anguish and distress so many patients face – suicide and homicide represented 27% of pregnancy-related deaths with homicides most often perpetuated by the individual’s partner 1
Establishing funding to allow PCPs to provide up to 4 postpartum depression screens in the year following delivery, especially given the current shortage of both adult & child psychiatrists, may help address these issues. 8
Bills proposed this session addressing mental health resources include:
HB 3724: Establishing a maternal mental health peer support pilot program for perinatal mood and anxiety disorder.
Currently still in the Health Care Reform committee.
HB 2873: A strategic plan for improving maternal health, including improving access to screening, referral, treatment, and support services for perinatal depression.
Passed vote in the House, now awaiting vote in the Senate.
Maternal health deserts
Texas leads the country in maternal health deserts – communities with limited or no local prenatal and maternity care services, even for insured women – jeopardizing the health of expectant mothers and their unborn babies.8
Bills proposed this session addressing maternal health deserts include:
HB 3626: Implementing a public outreach campaign to increase the number of maternal health care professionals in rural areas.
Currently still in the Health Care Reform committee.
HB 617 & SB 251: Establishing a pilot program for providing telemedicine and telehealth services in rural areas.
HB 617 passed & signed into law by Governor Abbott, effective 9/1/2023.
SB 251 passed vote in the House, now in the Jurisprudence committee in the Senate.
HB 1798 & SB 663: Developing a strategic plan for providing home and community-based services under Medicaid to children and mothers, especially in low-resource settings.
HB 1798 passed vote in the House, now in the Health & Human Services committee in the Senate.
SB 663 currently still in the Health & Human Services committee.
In summary, please consider the following goals for advocacy this session:
Ensuring safe access to life-saving procedures.
Extending Medicaid coverage to 12 months postpartum for all mothers in Texas.
Increasing access to evidence-based community and crisis mental health and substance abuse services.
Addressing gaps in medical education to prevent the impact of racial discrimination on maternal mortality, including cultural competency & implicit bias.
Improving access to comprehensive healthcare in rural settings and maternal health deserts.
Since most of these bills are still being discussed within committees, it is an especially pertinent time to speak with the representatives sitting on these committees and urge them to move the bills forward to be voted on and signed into law. Stay informed about issues pervading your communities, reach out to your local representative to ask for their support on proposed bills, and engage in this legislative session by joining physician advocates at the Capitol!
Resources
Texas Maternal Mortality and Morbidity Review Committee and Department of State Health Services Joint Biennial Report 2022. Accessed January 26, 2023. https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Joint-Biennial- MMMRC-Report-2022.pdf
Texas Medicine March 2023. www.qgdigitalpublishing.com. Accessed April 1, 2023. https://www.qgdigitalpublishing.com/publication/?m=55178&l=1
House TW. FACT SHEET: President Biden’s and Vice President Harris’s Maternal Health Blueprint Delivers for Women, Mothers, and Families. The White House. Published June 24, 2022.https://www.whitehouse.gov/briefing-room/statements-releases/2022/06/24/fact-sheet- president-bidens-maternal-health-blueprint-delivers-for-women-mothers-and-families/
Klibanoff E. Texas health agency says its plan to extend maternal Medicaid coverage is “not approvable” by feds. The Texas Tribune. Published August 4, 2022. Accessed April 1, 2023. https://www.texastribune.org/2022/08/04/texas-medicaid-postpartum-application/
Waller A. Maternal health care advocates applaud new state law to extend Medicaid coverage, but say it doesn’t go far enough. The Texas Tribune. Published August 27, 2021. https://www.texastribune.org/2021/08/27/texas-medicaid-maternal-mortality-health
Comments on the Status of the Texas Maternal Health Coverage Bill. Texans Care for Children. Accessed April 1, 2023. https://txchildren.org/posts/2022/5/4/comments-on-the- status-of-the-texas-maternal-health-coverage-bill
Maternal deaths are public health and health equity problems. They’re also preventable. | Kinder Institute for Urban Research. Kinder Institute for Urban Research | Rice University. https://kinder.rice.edu/urbanedge/maternal-deaths-are-public-health-and-health-equity- problems-theyre-also-preventable
Texas Medical Association. Senate Finance Committee – Senate Bill 1, Article II Hearing Texas Health and Human Services Commission. TMA; 2023
Salahuddin M, Patel DA, O’Neil M, Mandell DJ, Nehme E, Karimifar M, Elerian N, Byrd- Williams C, Oppenheimer D, Lakey DL. (2018) Severe Maternal Morbidity in Communities Across Texas. Austin, TX: University of Texas Health Science Center at Tyler/University of Texas System.
Declercq, E., Barnard-Mayers, R., Zephyrin, L., & Johnson, K. (2022, December 14). The U.S. Maternal Health Divide: the Limited Maternal Health Services and Worse Outcomes of States Proposing New Abortion Restrictions. Www.commonwealthfund.org. https://www.commonwealthfund.org/publications/issue-briefs/2022/dec/us-maternal-health- divide-limited-services-worse-outcomes
Nambiar, A., Patel, S., Santiago-Munoz, P., Spong, C. Y., & Nelson, D. B. (2022). Maternal morbidity and fetal outcomes among pregnant women at 22 weeks’ gestation or less with complications in 2 Texas hospitals after legislation on abortion. American Journal of Obstetrics & Gynecology, 0(0). https://doi.org/10.1016/j.ajog.2022.06.060
CDC Newsroom. (2016, January 1). CDC. https://www.cdc.gov/media/releases/2022/p0919- pregnancy-related-deaths.html
Medicaid is a program established by the federal government in 1965 as a solution to the coverage gap that many marginalized groups faced due to the inaccessibility of private health insurance.Âą Funded jointly by the federal and state government, Medicaid became an option for health insurance for low-income, older, and disabled members of society. While partly federally funded, the program criteria, benefits, eligibility, etc all falls under the ruling of each state.2
In 2010, passage of the Affordable Care Act developed an even more comprehensive reform, with the goal of making insurance coverage and healthcare access accessible to a greater population. The ACA called for Medicaid expansion,3 which if adopted by each state would allow for more flexible eligibility- addressing the existing coverage gap that continues to remain an issue. Expansion of Medicaid would allow for individuals to be eligible to receive benefits through Medicaid on an income-basis, as long as household income did not exceed 138% of the established Federal Poverty level.4
How would Medicaid Expansion help Texans?
Texas leads the nation in the number of uninsured individuals in the state, with a reported rate of 18% according to data collected in the 2021 Census.5 For many who do not qualify for Medicaid or receive employer-sponsored health insurance, the barrier to insurance lies in the high cost of marketplace plans. With over 5 million uninsured individuals in Texas, Medicaid expansion would allow for increased access to care and improved health outcomes by expanding eligibility to include underserved and vulnerable populations above the poverty line.6
The pivotal 2002 report: Care without Coverage released by the Institute of Medicine has since been strengthened by findings that continue to show a direct relationship between mortality risk and the lack of health insurance.7 A literature review by the Kaiser Family Foundation showed that ACA expansion was correlated with better health outcomes and was specifically related to improvements in areas of cancer diagnosis and treatment, transplants, smoking cessation, behavioral health, and treatment of opioid disorders.8 Health insurance and health outcomes are undeniably interconnected, making Medicaid expansion a necessary legislative agenda to improve the health of Texans and address existing health inequities.9
A current bill to specifically advocate for is: Bill SB 343- Relating to the expansion of eligibility for Medicaid to all individuals for whom federal matching money is available. This bill was introduced by Nathan Johnson in January, and it was read in April and referred to the Health and Human Service Senate Committee for review.
How has the TMA advocated in the past?
The TMA for many years has advocated for the expansion of medicaid through the promotion of articles that show the health benefits of medicaid expansion in Texas. In 2019, 2020, and 2021 the TMA published articles showing public support, public health benefits, and fiscal benefits of allowing medicaid expansion in Texas.10 Furthermore, former TMA President Dr. Doug Curran testified in support of HB 565 introduced by Representative Coleman in the 2019 legislative session, although the bill did not make it past committee.11 TMA Policies 190.032 (Medicaid Coverage and Reform) and 190.036 show the TMA’s support in accepting additional funds from the federal government for increasing Medicaid access while also urging the government to develop new, more sustainable systems than the current Medicaid expansion plan.12,13 TMA Policy 190.037 (Medicaid Work Requirements) also states that the TMA opposed any lifetime limits or reduction in access for Medicaid enrollees.14 Through medical student advocacy, it is important to support these lobbying efforts by the TMA in passing Medicaid expansion. It is important for the MSS to increase knowledge about the coverage gap between Texas’ current Medicaid system and the income needed to afford health insurance from the Affordable Care Act marketplace to decrease our state’s uninsured population.The federal government is slated to pay 90% of the total costs of Medicaid expansion,15 greater than the normal 50-78% that the federal government pays for current enrollees. This expansion will not only make healthcare more accessible for low-income Texans who fall in the coverage gap, but also increase the fiscal stability of safety-net hospitals that currently have to pay for people in this coverage gap through increased local property taxes.
Fast Facts
Medicaid expansion in Texas would provide health insurance coverage to approximately 2 million low-income Texans who are currently uninsured.16
States that have expanded Medicaid have seen improvements in health outcomes, including lower rates of mortality, better access to preventive care, and improved management of chronic conditions.17
Expanding Medicaid in Texas could help address health disparities by providing access to healthcare for low-income and minority populations who are disproportionately uninsured. 18
Medicaid expansion in Texas would also save taxpayers money by reducing the amount of uncompensated care provided by hospitals and other healthcare providers.19
Expanding Medicaid in Texas would result in significant net fiscal benefits for the state. According to a report by the Urban Institute, the federal government would cover 90% of the costs of expansion, and the state would save money on healthcare and other programs that currently serve uninsured individuals.20
The Texas Hospital Association has estimated that Texas hospitals would see a $34 billion reduction in uncompensated care costs over a 10-year period if Medicaid were expanded.21
Expanding Medicaid in Texas would generate more than $100 billion in economic activity and create 200,000 jobs over 10 years, according to a study by the Perryman Group.22
References
Center on Budget and Policy Priorities. (n.d.). Introduction to Medicaid. https://www.cbpp.org/research/health/introduction-to-medicaid.
HealthCare.gov. (n.d.). Affordable Care Act (ACA) – Glossary. https://www.healthcare.gov/glossary/affordable-care-act/.
Kaiser Family Foundation. (2023). Status of State Medicaid Expansion Decisions: Interactive Map. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/#:~:text=The%20Affordable%20Care%20Act’s%20(ACA,FMAP)%20for%20their%20expansion%20populations.
Mykyta DCand L. (2022). Decline in share of people without health insurance driven by increase in public coverage in 36 states. Census.gov. https://www.census.gov/library/stories/2022/09/uninsured-rate-declined-in-28-states.html
Rachel Garfield, K.O. (2021). The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid – Issue Brief – 8659-10. KFF. https://www.kff.org/report-section/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-issue-brief-8659-10/#endnote_link_508791-3.
Kilbourne AM. (2005). Care without Coverage: Too Little, Too Late. J Natl Med Assoc. 97(11), 1578.
Guth, M. (2023). The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020 – Report. KFF. https://www.kff.org/report-section/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-report/.
Sommers BD, Baicker K, Epstein AM. (2012). Mortality and access to care among adults after state Medicaid expansions. New England Journal of Medicine. 367(11), 1025-1034. doi:10.1056/nejmsa1202099.
Center on Budget and Policy Priorities. (n.d.). Medicaid Expansion: Frequently Asked Questions. https://www.cbpp.org/research/health/medicaid-expansion-frequently-asked-questions.
Kaiser Family Foundation. Medicaid in Texas. Retrieved from https://www.kff.org/medicaid/state-indicator/texas/
Kaiser Family Foundation. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. Retrieved from https://www.kff.org/medicaid/report/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/
National Academies of Sciences, Engineering, and Medicine. Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors. Retrieved from https://www.nap.edu/catalog/23635/accounting-for-social-risk-factors-in-medicare-payment-identifying-social
The Commonwealth Fund. The Cost of Not Expanding Medicaid in Texas. Retrieved from https://www.commonwealthfund.org/blog/2019/cost-not-expanding-medicaid-texas
Urban Institute. The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis. Retrieved from https://www.urban.org/sites/default/files/publication/32696/413136-The-Cost-and-Coverage-Implications-of-the-ACA-Medicaid-Expansion-National-and-State-by-State-Analysis.PDF
Texas Hospital Association. The Economic Benefit of Expanding Medicaid in Texas. Retrieved from https://www.tha.org/Public-Policy/State-Federal Issues/Medicaid-Expansion
The Perryman Group. Economic and Fiscal Benefits of Medicaid Expansion in Texas. Retrieved from https://www.texmed.org/Template.aspx?id=47027
The history of graduate medical education (GME) funding is complex with many competing interests, from teaching hospitals and government agencies that foot the bill to faculty physicians and residents themselves. The establishment of Medicare in 1965 marked the beginning of significant federal subsidization of residency training.1,2,3 Initially uncapped, financial support from Medicare was meant to be a temporary measure until more permanent systems of GME funding could be established.4 Today, Medicare remains the single largest monetary contributor to residents’ education. Direct graduate medical education (DME) covers resident and faculty salary and benefits, plus administrative overhead.5 Indirect graduate medical education (IME) was established to help alleviate the additional costs of running a teaching hospital related to a more complex patient panel and research expenses.4 However, concerns about inflating healthcare costs and the looming threat of a physician surplus in the 1980-90s prompted the curtailing of GME spending. Thus, the formulas used to calculate a hospital’s DME provided full funding for each “Full-Time Equivalent” (FTE; employed resident) only for the duration of the initial residency period or 5 years, whichever was shorter. PGY-6+ residents comprised only a fraction of an FTE, and the hospital received less money per senior resident.6 Additionally, the Balanced Budget Act of 1997 limited the number of residents at a given hospital that were eligible for DME, limiting a hospital’s maximum DME by the number of residents it employed in 1996.7
As indications for a national physician shortage emerged in the early 2000s, the conversation surrounding GME began to change. The focus became how to reconcile the myriad of funding streams and best support the growth of the next generation of physicians while eliminating excess spending. Even as the American Association of Medical Colleges (AAMC) was calling for expansion of medical school seats across the country, the 2010 Simpson-Bowles Commission recommended a reduction in average GME compensation, an attempt to reign in government spending in the midst of the economic recession.6 More recently, the US Department of Health and Human Services aimed to integrate GME funding streams from Medicare, Medicaid, and the Children’s Hospital into a single consolidated program, distributed jointly by the Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services Administration.8
The Texas Medical Association (TMA) was established to lobby on behalf of physicians at the state and federal levels to promote physician autonomy, protect the patient-physician relationship, and minimize regulatory intervention in the practice of medicine from insurers and other nonmedical entities. Created in the late 1970s, the Medical Student Section (MSS) is a voice for medical students within the TMA with the goal of improving medical education and advocating for the future of medicine.9 In the saga of GME, one of the TMA’s primary objectives has been to retain graduates of Texas medical schools in Texas. TMA advocacy has focused on supporting the growth of GME, both financially and in terms of the total number of seats.10,11,12 The acuity of the physician shortage was emphasized with the national population growth rate and was again highlighted during the COVID-19 pandemic, as patients experienced long wait-times and shortage of resources. In response, six new medical schools have opened in Texas since 2016, and some of the established nine medical schools have increased their class sizes.
However, even as the number of Texas medical school graduates is rising, the number of residency positions available remains stagnant.13 More positions are necessary to increase the physician workforce, which calls for an increase in GME funding. The TMA postulates a target ratio of 1.1:1 first-year GME slots per medical school graduate.14 Not only does this ratio provide enough residency spots for every medical student in Texas, it also gives graduates from out-of-state schools a reason to consider Texas when deciding where to bring their talents. Conversely, allowing the number of positions to dwindle provides a catalyst for a mass migration of graduates out of the state, taking with them a substantial revenue stream. It is thus imperative that GME remains a top priority for lawmakers. The consequences of allowing funding to fall by the wayside are too drastic to ignore. For the sake of the nation’s health, legislators must ensure that medical school graduates have the opportunity to take that necessary next step toward becoming a physician.
Fast Facts
The $2.3 trillion Consolidated Appropriations Act of 2021 authorized relief funding for community development financial institutions. It provides funding for 1,000 new Medicare-supported GME slots beginning FY 2023, adding up to 200 positions annually.15 In 2021, Texas graduated almost 2,000 medical students.16 Texas needs to stabilize the physician workforce by allocating additional funds to the 2024-2025 Texas Higher Education Coordinating Board’s (THECB) physician development programs. Health related institution formula funding recommendations for the 24-25 Biennium provide the lowest percent increase for both Instruction and Operations (18.8%) and GME funding (19.3%). 17 These areas directly impact the ability of the state to attract faculty and residents to fill the much needed and growing physician workforce gap.
The 84th Texas Legislature, Regular Session, consolidated the Unfilled Residency Position Program, the New and Expanded Residency Program, and the Resident Physician Expansion Program into the single GME Expansion Program. The funding allowed the new positions created in 2014 and 2015 to be maintained and to provide enough funding to support the addition of approximately 130 new residency positions.
The 86th Texas Legislature, Regular Session, provided $157.2 million to support GME Expansion Programs. As a result, an estimated 2,000 residency positions received funding support in FY 2020 and FY 2021.
While adding new residency positions and programs is admirable and will contribute to the state’s 1.1 to 1 ratio goal, it is also important that the state’s existing residency programs receive adequate funding and support.
The closing of two family medicine residency programs resulted in reduced access to health care in the communities of Wichita Falls and Corpus Christi, further contributing to physician distribution challenges.
Funding Requested
Additional funding requested: $34 million for the State GME Expansion Grant Program to maintain residency positions created through the program to date, and to maintain the1.1:1 state target ratio. GME Expansion Program funding has supported the creation of 472 new first-year residency positions between 2014 and 2021 to accommodate the increase in the number of medical graduates resulting from the opening of new medical schools.
Additional funding requested: $20.5 million to replace recent budget cuts to the Family Practice Residency Program and enable annual grants of $15,000 per family medicine resident.18
$1 million to activate the State Rural Training Track Grant Program for creation of rural residency training programs (HB 1065 passed in 2019 but was not funded).
$30 million one-time endowment to sustain the State Physician Education Loan Repayment Program and recruit physicians to the state’s most underserved areas.
$2.14 million for the Joint Admission Medical Program so it can keep pace with recent increases in medical school enrollments.
Related Bills (congress.gov)
No currently proposed Texas Legislature (capitol.texas.gov).
H.R. 9424 – 117th Congress Introduced in House (12/05/2022) Creating Access to Residency Education Act of 2022 Sponsor: Castor, Kathy [Rep.-D-FL-14] (Introduced 12/05/2022) Cosponsors: (0) Committees: House – Energy and Commerce This bill requires the Centers for Medicare & Medicaid Services to award matching funds to teaching hospitals or other graduate medical education training programs for medical residency training programs in states where there are fewer than 44 medical residents per 100,000 people. Recipients must cover one third of the costs for primary care residency training programs and one half of the costs for programs in other fields. Latest Action: House – 12/05/2022 Referred to the House Committee on Energy and Commerce.
H.R. 3671 – 117th Congress Introduced in House (06/01/2021) Doctors of Community Act or the DOC Act This bill reauthorizes and provides mandatory funding for graduate medical education programs operated by teaching health centers. The bill sets out funding levels through FY2033. Funding for FY2034 and beyond equals the preceding fiscal year’s amount adjusted for medical inflation. Latest Action: House – 06/02/2021 Referred to the Subcommittee on Health. S.1958 — 117th Congress (2021-2022) Introduced in Senate (06/07/2021) Doctors of Community Act or the DOC Act DOC Act Sponsor: Murray, Patty [Sen.-D-WA] (Introduced 06/07/2021) Cosponsors: (8) Committees: Senate – Health, Education, Labor, and Pensions This bill reauthorizes and provides mandatory funding for graduate medical education programs operated by teaching health centers. The bill sets out funding levels through FY2033. Funding for FY2034 and beyond equals the preceding fiscal year’s amount adjusted for medical inflation. Latest Action: Senate – 06/07/2021 Read twice and referred to the Committee on Health, Education, Labor, and Pensions
H.R.8508 – Rural Physician Workforce Production Act of 2022 – 117th Congress (2021-2022) Sponsor: Rep. O’Halleran, Tom [D-AZ-1] (Introduced 07/26/2022) Committees: House – Ways and Means; Energy and Commerce Latest Action: House – 07/26/2022 Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
H.R.949 — 117th Congress (2021-2022) There is one summary for H.R.949. Bill summaries are authored by CRS. Introduced in House (02/08/2021) Expanding Teaching Health Centers Act of 2021 This bill provides funding through FY2023 to the Department of Health and Human Services to establish and expand medical residency training programs at teaching health centers. Latest Action: House – 02/09/2021 Referred to the Subcommittee on Health. (All Actions)
Sources
House report number 213, 89th Congress, 1st session. https://www-govinfo-gov.foyer.swmed.edu/app/details/STATUTE-79. (1965), Accessed 13th February 2023.
Guss D, Prestipino AL, Rubash HE. Graduate medical education funding: a Massachusetts General Hospital case study and review. J Bone Joint Surg Am. 2012;94(4):e24. doi:10.2106/JBJS.K.00425
Stevens R. American medicine and the public interest. New Haven and London: Yale University Press; 1971.
Schuster BL. Funding of Graduate Medical Education in a Market-Based Healthcare System. Am J Med Sci. 2017;353(2):119-125. doi:10.1016/j.amjms.2016.11.027
Solomon IH, Normandin E, Bhattacharyya S, et al. Neuropathological Features of Covid-19. N Engl J Med. 2020;383(10):989-992. doi:10.1056/nejmc2019373
He K, Whang E, Kristo G. Graduate medical education funding mechanisms, challenges, and solutions: A narrative review. Am J Surg. 2021;221(1):65-71. doi:10.1016/j.amjsurg.2020.06.007
Iglehart JK. Medicare, graduate medical education, and new policy directions. N Engl J Med. 2008;359:643-50.
HHS.gov. FY 2019 Budget & Performance. https://www.hhs.gov/about/budget/fy2019/index.html?language=es. Published 2019. Accessed February 13, 2023.
TMA House of Delegates. “TMA 2025 Goals.” TMA 2025 Goals, Texas Medical Association, 10 Apr. 2019, https://www.texmed.org/goals.aspx.
Texmed.org. 200.016 Graduate Medical Education. https://www.texmed.org/Template.aspx?id=43064. Published 2016. Accessed February 15, 2023.
Texmed.org. 200.045 Needed Growth in Graduate Medical Education Programs. https://www.texmed.org/Template.aspx?id=43093. Published 2017. Accessed February 14, 2023.
Texmed.org. 205.022 Federal Title VII Graduate Medical Education Grant Program. https://www.texmed.org/Template.aspx?id=43034. Published 2022. Accessed February 14, 2023.
Price, Sean. “Unfreezing GME: A Boost to Federal Funding for Residencies by Sean Price Texas Medicine October 2021.” Texmed, Texas Medical Association, Oct. 2021, https://www.texmed.org/Template.aspx?id=57888.
Sorrel, Amy Lynn. “Legislative Priority #1: Scope of Practice Encroachments, Graduate Medical Education Funding.” Texmed, Texas Medical Association, https://www.texmed.org/Template.aspx?id=60988.
Robeznieks, A. (2022, March 16). 1,000 new GME slots are coming. CMS must not hamper their use. American Medical Association. Retrieved February 14, 2023, from https://www.ama-assn.org/education/gme-funding/1000-new-gme-slots-are-coming-cms-must-not-hamper-their-use
Michas, F. (2022, June 8). Total Medical School graduates in the U.S.by State. Statista. Retrieved February 14, 2023, from https://www.statista.com/statistics/1270398/total- medical-school-graduates-in-the-us/
Formula advisory committees – Texas Higher Education Coordinating Board. (n.d.). Retrieved February 14, 2023, from https://www.highered.texas.gov/about-us/advisory committees/formula-advisory-committees/
Texmed.org. 205.024 Medicare and Medicaid Graduate Medical Education Funding. https://www.texmed.org/Template.aspx?id=43036. Published 2016. Accessed February 14, 2023.
Addressing the Texas mental health crisis is a multifaceted challenge that requires the coordination of various entities and an approach that addresses the underlying causes. Some of the most important aspects of addressing the national mental health crisis is increasing access to mental health care services, improving mental health literacy among the general public, and promoting a collaborative effort between various sectors of society, including government agencies, healthcare providers, schools, employers, and community organizations.Âą Collaboration can help ensure that mental health resources are accessible, that policies and regulations support mental health, and that individuals receive the care and support they need to maintain appropriate mental health.
In accordance with the mental health of minors, The American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP) and the Children’s Hospital Association (CHA) declared a National State of Emergency in Children’s Mental Health in 2021.² It is estimated that 16.5% of children under 18 have at least one mental health disorder, but about 49% did not receive treatment or counseling from a professional.³ To combat this, the 86th Texas Legislature created the Texas Child Mental Health Care Consortium that funded the Texas Child Health Access Through Telemedicine (TCHATT) initiative, which provides telehealth services at no cost to the school or students, such as mental health evaluations, short term therapy, psychiatric care, and referrals to long term treatment to students of participating districts.4 It is important to support funding for these initiatives as they aim to have resources in every school district in Texas; however, only about a third are estimated to be involved.4
TMA Policy
In June 2022, The TMA submitted written testimony that emphasizes the increasing need for mental health resources in Texas, particularly with the aftermath of the COVID-19 pandemic and incidences of gun violence, such as the Uvalde incident.5-8 In fact, Texas has had more school shootings than any other state since 2012 with 43 incidents.9 In this testimony, TMA strongly encourages the importance of firearm safety promotion, mental health investments, and adolescent, family, and community interventions that foster resilience in the midst of childhood adversity. A key issue for the TMA agenda at the 2023 legislative session is preventing suicide and supporting Texans’ mental health. The TMA also has many policies aimed at increasing funding and coverage for services including:
55.033 Children’s Mental and Behavioral Health- supports improved access to mental health services and payment systems that fully integrate mental health care services in primary care10
145.019 Mental Health Equitable Treatment and Parity- supports lobbying state and federal government to increase scope of limited parity laws to include all mental health disorders and supports state funding for pilots to improve treatment 11
215.019 Public Mental Health Care Funding & 215.020 Improved Funding for Mental Illness and Substance Use Disorder(s) – supports increasing funding from Texas Legislature for the mental health care system 12,13
100.022 Emergency Psychiatric Services- supports funding to sustain and expand state investments to redesign mental health crisis services 14
Fast Facts
198 (out of 254) Texas counties are considered Health Professional Shortage Areas for mental health.15
An additional 23 Texas counties are considered a mental health Health Professional Shortage Area for low-income populations. 15
221 of 254 (87%) of Texas counties lack adequate mental health resources. 15
Among adults with serious mental illness, only 64.8% received mental health services in the past year. 16
The economic burden of mental illness in the United States is estimated to be $193.2 billion in lost earnings per year. 17
Current Bills
Senate Bill 672 is a current bill that advises Texas Medicaid to construct a mental health collaborative care model.
Call to Action
It is imperative that medical professionals and students acknowledge the rising national mental health crisis and further promote awareness and create policy to ultimately improve health outcomes.
Saxena, S., Funk, M., & Chisholm, D. (2020). World Health Assembly adopts resolution on mental health. The Lancet Psychiatry, 7(8), 655-656. https://doi.org/10.1016/S2215-0366(20)30306-5
AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. (n.d.). Aap.org. Retrieved March 17, 2023, from https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/
Spotlight 1: Prevalence of mental health services provided by public schools and limitations in schools’ efforts to provide mental health services. (n.d.). Bing. Retrieved March 17, 2023, from https://nces.ed.gov/programs/crimeindicators/ind_s01.asp
Texas child health access through telemedicine (TCHATT). (2021, July 27). MMHPI – Meadows Mental Health Policy Institute; Meadows Mental Health Policy Institute. https://mmhpi.org/project/texas-child-health-access-through- telemedicine-tchatt/
Kathirvel, N. (2020). Post COVID-19 pandemic mental health challenges. Asian journal of psychiatry, 53, 102430.
Vadivel, R., Shoib, S., El Halabi, S., El Hayek, S., Essam, L., Bytyçi, D. G., … & Kundadak, G. K. (2021). Mental health in the post-COVID-19 era: challenges and the way forward. General psychiatry, 34(1).
Shanbehzadeh, S., Tavahomi, M., Zanjari, N., Ebrahimi-Takamjani, I., & Amiri-Arimi, S. (2021). Physical and mental health complications post-COVID-19: Scoping review. Journal of psychosomatic research, 147, 110525.
Ren, F. F., & Guo, R. J. (2020). Public mental health in post-COVID-19 era. Psychiatria danubina, 32(2), 251-255.
States With the Most School Shootings. (2022, May 27). Usnews.com. Retrieved March 17, 2023, from https://www.usnews.com/news/best-states/articles/2022- 05-27/states-with-the-most-school-shootings
55.033 Childrens Mental and Behavioral Health. TMA Policy . (2022, June 14). Retrieved March 16, 2023, from https://www.texmed.org/Template.aspx?id=42554&terms=children+mental+ health
145.019 Mental Health Equitable Treatment Parity . TMA Policy. (2022, June 14). Retrieved March 16, 2023, from https://www.texmed.org/Template.aspx?id=42846&terms=mental+health+equitable+treatment
215.019 Public Mental Health Care Funding. TMA Policy. (2021, July 21). Retrieved March 16, 2023, from https://www.texmed.org/Template.aspxid=43155&terms=public+mental+health+care+funding
215.020 Improved Funding for Mental Illness and Substance Use Disorders.TMA Policy . (2020, October 29). Retrieved March 16, 2023, fromhttps://www.texmed.org/Template.aspx?id=43156&terms=improved+funding+for+mental+illness
100.022 Emergency Psychiatric Services. TMA Policy. (2018, August 20). Retrieved March 16, 2023, from https://www.texmed.org/Template.aspx?id=42696&terms=psychiatric+services
Special committee to protect all Texans. (2022). Texmed.org. https://www.texmed.org/uploadedFiles/Current/2016_Advocacy/Texas_Legislature/TMA-written-testimony-mental-health.pdf
Mental illness. (n.d.). National Institute of Mental Health (NIMH). Retrieved March17, 2023, from https://www.nimh.nih.gov/health/statistics/mental-illness
Mental disorders cost society billions in unearned income. (2015, September 19).National Institutes of Health (NIH). https://www.nih.gov/news-events/news-releases/mental-disorders-cost-society-billions-unearned-income
