Category: Mental Health

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General Healthcare Disparities Mental Health Public Health

Let Me Be Brief: Addressing Health Disparities Among the AAPI Community

A series of briefs by Texas Medical Students

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. 

References

  1. 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/
  2. Asian American and pacific islander. (n.d.). Nami.Org. Retrieved April 8, 2022, from https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/Asian-American-and-Pacific-Islander
  3. The center for Asian health engages communities in research to reduce Asian American health disparities. (n.d.). Nih.Gov. Retrieved April 8, 2022, from https://www.nimhd.nih.gov/news-events/features/training-workforce-dev/center-asian-health.html
  4. Kochhar, R. (2018, July 12). Income inequality in the U.s. is rising most rapidly among Asians. Pew Research Center’s Social & Demographic Trends Project. https://www.pewresearch.org/social-trends/2018/07/12/income-inequality-in-the-u-s-is-rising-most-rapidly-among-asians/
  5. 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
  6. 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
  7. 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
  8. Why Asian Americans don’t seek help for mental illness. Mcleanhospital.org. Accessed December 20, 2021. https://www.mcleanhospital.org/essential/why-asian-americans-dont-seek-help-mental-illness
  9. 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
  10. Products – data briefs – number 314 – July 2018. (2019, June 7). Cdc.Gov. https://www.cdc.gov/nchs/products/databriefs/db314.htm
  11. 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
  12. 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
  13. Products – data briefs – number 361 – march 2020. (2020, June 26). Cdc.Gov. https://www.cdc.gov/nchs/products/databriefs/db361.htm
  14. https://www.congress.gov/bill/117th-congress/house-bill/3573/text#:~:text=Introduced%20in%20House%20(05%2F28%2F2021)&text=To%20amend%20the%20Public%20Health,Hawaiian%2C%20and%20Pacific%20Islander%20 population. 
Categories
General Healthcare Costs Healthcare Disparities Mental Health Public Health Women's Health

Let Me Be Brief: Maternal Mortality

A series of briefs by Texas Medical Students

By: Radhika Patel and Sanika Rane

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

  1. 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
  2. Texas Medicine March 2023. www.qgdigitalpublishing.com. Accessed April 1, 2023.
    https://www.qgdigitalpublishing.com/publication/?m=55178&l=1
  3. 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/
  4. 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/
  5. 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
  6. 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
  7. 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
  8. Texas Medical Association. Senate Finance Committee – Senate Bill 1, Article II Hearing
    Texas Health and Human Services Commission. TMA; 2023
  9. 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.
  10. 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
  11. 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
  12. CDC Newsroom. (2016, January 1). CDC. https://www.cdc.gov/media/releases/2022/p0919-
    pregnancy-related-deaths.html
Categories
General Healthcare Costs Healthcare Disparities Mental Health Public Health

Let Me Be Brief: Addressing The Texas Mental Health Crisis

A series of briefs by Texas Medical Students

By: Jasmine Liu-Zarzuela, Isreal Munoz, Rozena Shirvani

Background

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.¹ 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

  1. 198 (out of 254) Texas counties are considered Health Professional Shortage Areas for mental health.15
  2. An additional 23 Texas counties are considered a mental health Health Professional Shortage Area for low-income populations. 15
  3. 221 of 254 (87%) of Texas counties lack adequate mental health resources. 15
  4. Among adults with serious mental illness, only 64.8% received mental health services in the past year. 16
  5. 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.

Resources

  1. https://www.apa.org/news/press/releases/2022/11/mental-health-care-strains
  2. https://www.texmed.org/uploadedFiles/Current/2016_Advocacy/Texas_Legislatur
    e/TMA-written-testimony-mental-health.pdf

References

  1. 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
  2. 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/
  3. 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
  4. 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/
  5. Kathirvel, N. (2020). Post COVID-19 pandemic mental health challenges. Asian journal of psychiatry, 53, 102430.
  6. 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).
  7. 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.
  8. Ren, F. F., & Guo, R. J. (2020). Public mental health in post-COVID-19 era. Psychiatria danubina, 32(2), 251-255.
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. Mental illness. (n.d.). National Institute of Mental Health (NIMH). Retrieved March17, 2023, from https://www.nimh.nih.gov/health/statistics/mental-illness
  17. 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