With many state legislatures adjourning in early spring, we have a lot of updates packed into this issue, covering legislative news from Jan. 1 through April 4. This quarter, Treatment Advocacy Center helped advance 17 bills in 13 states. 

We are celebrating big victories in Alabama, Georgia, Kentucky, Virginia and Washington, where bills making substantial improvements to civil commitment laws have passed legislatures and will make treatment more accessible for those with severe mental illness (SMI). We also have updates on civil commitment laws to share in Idaho, South Dakota, Utah and West Virginia. Additional civil commitment bills Treatment Advocacy staff are involved with are moving through the legislative process in Louisiana, Maine, Maryland, New York, Oklahoma and Ohio.

As lawmakers in California and New York pursue sweeping changes to their civil commitment laws and consider new policies to tackle age-old problems, Treatment Advocacy Center has been there to share our expertise each step of the way. 

Increasingly acknowledging the shortage of psychiatric beds as a result of deinstitutionalization, state lawmakers are connecting the dots between SMI, homelessness and other systemic problems the pandemic has exacerbated. As they propose legislation to address psychiatric bed shortages and the discriminatory IMD exclusion, legislators are increasingly turning to Treatment Advocacy Center publications and consulting our staff for solutions. 

Maryland became the eighth state to obtain a federal waiver of the institutions for mental diseases (IMD) exclusion, finally allowing Medicaid funds to cover inpatient psychiatric care in IMDs in the state. Legislation directing agencies to apply for the federal IMD waiver are under consideration in New York and Missouri. Bills were introduced in at least five states to increase capacity of civil psychiatric beds, and other states introduced bills taking different approaches to address the bed shortage. 

The Kentucky legislature passed a bill exempting those with serious mental illness from the death penalty, and similar bills were introduced in six additional states. 

As the July deadline for states to launch the federally-mandated 988 crisis hotline for mental health emergencies approaches, Treatment Advocacy Center is making sure that the needs of the SMI community are not ignored. 

This quarter, we ran legislative campaigns in six states, asking you, our partners on the ground, to urge your lawmakers to support bills that would expand access to treatment. We also joined our founder Dr. E. Fuller Torrey in a renewed #RightToResearch campaign, calling on the National Institute of Mental Health (NIMH) to restore the balance between clinical and basic research at NIMH. We are sincerely grateful to each person who participated. Sharing your experiences as constituents interacting with the broken mental health system makes all the difference. Visit our Action Center to find our active campaigns and write your lawmakers today!

We hope you find our second issue of SMI Advocate, your quarterly update on legislative efforts related to SMI, informative. If you missed our first issue, find the Winter 2021 issue here. If you have feedback on this publication or would like to share information about a bill in your area, we'd love to hear from you! Contact Legislative Advocacy Manager Clara Keane at keanec@treatmentadvocacycenter.org. 

Thank you for partnering with us as we work to eliminate treatment barriers for people with SMI across the country. 

State Updates 

Key Civil Commitment Bills that Passed the Legislature 

We are so thrilled to share the news that bills making critical improvements to civil commitment laws have already passed legislatures in five states! In each case, Treatment Advocacy Center has been working with our local partners over several years to advance these changes to make treatment accessible sooner for those with SMI. 

• Alabama - HB 70 improves continuity of care in Alabama. This bill finally provides a definition for what "real and present threat of substantial harm to self or others" means, taking Alabama off the short list of states with no definition in law. The bill will make step-down assisted outpatient treatment (AOT) more accessible to ensure robust support for those being discharged from inpatient treatment back to the community. The bill also includes several recommended changes to both the emergency and inpatient criteria so that timely care is easier to achieve. Thank you to NAMI Alabama for collaborating with us on this effort! The bill passed the Alabama State Legislature on March 17 and is awaiting Governor Kay Ivey's signature to become law.
• Georgia - HB 1013 is a sweeping mental health reform bill introduced by the House Speaker David Ralston and supported by Gov. Brian Kemp. The bill includes a substantial section on civil commitment that will establish a three-year AOT grant program for five sites; improve the AOT criteria by replacing the requirement that a person be determined to imminently need inpatient treatment without AOT to instead determining if outpatient treatment is needed to prevent deterioration; provide a pathway for law enforcement to detain an individual for evaluation without witnessing a crime; and require important data collection. A version of this bill that would have removed the harmful imminence criteria for inpatient commitment passed the House but was removed in the Senate. The bill follows many of the recommendations of the Georgia Behavioral Health Reform and Innovation Commission, which Treatment Advocacy Center Staff engaged with last year. The bill passed the Georgia General Assembly on March 30 and is awaiting Governor Brian Kemp's signature to become law.
• Kentucky - HB 127 improves Tim's Law (AOT) by broadening how a person's history of nonadherence with mental health treatment is considered, removing the requirement that a person be determined to have anosognosia, and correcting language ambiguities regarding clinical evaluations and timeframes. Because anosognosia, a symptom that impairs a person's ability to recognize their illness, is not commonly used in medical settings, requiring a finding of anosognosia in AOT criteria is inconsistent with clinical practice and has proven a barrier for AOT candidates in Kentucky to qualify. We would like to thank Judge Stephanie Burke of Louisville for her leadership in crafting and advancing this bill that responds to specific barriers identified in AOT implementation. Governor Andy Beshear signed the bill into law on March 25.
• Virginia - HB 633reorganizes the mandatory outpatient treatment (MOT) statute which has proven difficult for programs to implement. Treatment Advocacy Center staff has participated in an MOT stakeholder group over several years that resulted in significant substantive changes in 2021. HB 633 clarifies those changes in the statute and makes it easier to follow. Both HB 633 and the changes enacted in 2021 take effect October 1, 2022. The MOT stakeholder group is now focused on implementation, and an initial budget request has been submitted to fund training on the new law. HB 633 passed the Virginia General Assembly on March 7 and is awaiting Governor Glenn Youngkin's signature to become law.
• Washington - HB 1773 simplifies and improves Washington's AOT law. The bill extends the maximum duration of an AOT court order from 90 days to 18 months, opens up petitioning to a broader range of professionals, counts voluntary admissions (currently excluded) as qualifying prior hospitalizations for eligibility, and clarifies procedures and uses for both AOT and "less restrictive alternative" (LRA), another form of outpatient civil commitment. We want to thank our local partners, NAMI Washington and Jerri Clark with Mothers of the Mentally Ill (MOMI). Governor Jay Inslee signed the bill into law on March 30.

Key Civil Commitment Bills Moving through the Legislative Process

Treatment Advocacy Center has been actively involved in drafting the following bills and helping them advance through the legislative process. These bills take a range of approaches to improving civil commitment laws, from removing harmful standards requiring an "imminent" risk of danger to receive treatment, to starting a pilot AOT program, and entirely re-envisioning a state's mental health system. 

• California: Governor Gavin Newsom launched CARE Court, a proposal to establish a new form or court-ordered outpatient treatment, on March 3. This initiative is part of Governor Newsom's ongoing efforts to address untreated mental illness and homelessness across California. Legislators in both chambers have introduced bills (SB 1338 and AB 2830) that would establish the state-mandated CARE Court program. Treatment Advocacy Center is also tracking a number of other bills that have been introduced as a result of the California State Legislature's efforts to reform the Lanterman-Petris-Short (LPS) Act, California's statute governing civil commitment and conservatorship for grave disability. Many of the bills relate to issues that came up during a Dec. 2021 hearing on ways to improve LPS. The legislature adjourns on August 31.
• Louisiana - HB 335 would add the risk of psychiatric deterioration as grounds for emergency evaluation and civil commitment. The bill defines "psychiatric deterioration" as a "decline in mental functioning, which diminishes the person's capacity to reason, exercise judgment, or control his behavior" and adds "significant risk of psychiatric deterioration" to the definition of "gravely disabled." We would like to thank Janet Hays and Healing Minds NOLA for their tireless advocacy to make this bill possible. Introduced on March 2, the bill is under consideration in the House Committee on Health and Welfare. The legislature adjourns on June 6.
• Maine (2) - Private hospitals, intensive case managers, ACT teams, or county sheriffs must currently pay the legal fees to initiate an AOT petition, known as progressive treatment program (PTP) in Maine, for people with SMI who are being discharged from private facilities. LD 1994 would remove this barrier to care by covering the legal costs of initiating the PTP process for those individuals. LD 1993 would create a liaison position for the PTP to help hospitals, courts, families and the state understand and properly utilize PTP. LD 1994 passed the Maine Legislature on March 31 and is awaiting funding in the state budget and Governor Janet Mills's signature to become law. LD 1993 was reported out of committee in March and is expected to be scheduled for a floor vote soon. The legislature adjourns on April 20.
• Maryland - HB 1017/SB 807 would establish an AOT pilot program in Frederick County. Maryland remains one of only three holdout states (along with Connecticut and Massachusetts) without statutory authority for AOT. Treatment Advocacy Center staff and board member Evelyn Burton worked closely with the sponsors in the drafting of this legislation. Both bills were introduced in early February and had their first hearings in early March. The legislature adjourns on April 11.
• New York (2): The tragic subway killing of Michelle Go spurred a renewed effort to address dysfunction in New York's mental health system. In a New York Daily News op-ed, Policy Director Brian Stettin recalled how a similar tragedy led to Kendra's Law, which Stettin was instrumental in drafting back in 1999. In the article, he proposed several policy actions for New York to prevent future tragedies. Stettin advised in the drafting of S 8508 to reduce barriers to inpatient treatment for those who need it most. Introduced on March 8, the bill would expand the definitions of "care and treatment of a person in a hospital" and "likelihood that the person's actions may commit serious harm." Additionally, provisions to extend Kendra's Law and to add a substantial increase in symptoms following the expiration of an AOT order as an indicator of a history of lack of compliance with treatment are included in the state health and mental hygiene budget proposal for the 2022 - 2023 state fiscal year (A 09007/S 08007). The legislature adjourns on June 2.
• Ohio - HB 439 would establish a psychiatric deterioration standard. Nearly half of all states include psychiatric deterioration in their criteria for inpatient commitment. The bill would enable law enforcement and other designated professionals to intervene in instances in which a person has a history of untreated mental illness, is too ill to appreciate their need for treatment, and without treatment is likely to suffer mental deterioration and, as a result, become a danger to self or others. Treatment Advocacy Center is part of a coalition mobilizing support for this important bill. Our partners include our board member Judge Elinor Stormer, NAMI Ohio, the Ohio Judicial Conference, the Ohio Psychiatric Physicians Association and the Ohio Psychological Association. The Civil Justice Committee has held four hearings on the bill and is expected to vote this spring. The legislature meets year-round.
• Oklahoma - HB 3877 would eliminate the imminence requirement from the state's inpatient commitment criteria. Introduced on Jan. 20, the bill has been referred to the Judiciary - Civil Committee. The legislature adjourns on May 27.

Other Changes to Civil Commitment Laws

The following four bills also passed this spring. Here's how they change civil commitment laws. 

• Idaho - SB 1327 makes changes to the civil commitment statute recommended by a team of stakeholders organized by the Idaho Behavioral Health Council. The bill changes the definition of "gravely disabled" in civil commitment criteria to include a person's "demonstrated inability" to meet any of four circumstances: to attend to one's basic physical needs, such as medical care, food, clothing, shelter, or safety; to protect oneself from harm or victimization by others; to exercise sufficient behavioral control to avoid serious criminal justice involvement; or to recognize one's illness, whereby absence of treatment may result in deterioration to the point where one of the previous three circumstances may be satisfied in the near future. Notably, a person no longer has to be "in danger of serious physical harm" presently or in the reasonably near future. The bill also assigns financial responsibility for pre-commitment holds and post-commitment cost, assigns responsibilities for organizing examinations and transportation, and expands requirements for qualifications of designated examiners. Governor Brad Little signed the bill into law on March 21.
• South Dakota - HB 1105 allows for a good cause exception to the time for an involuntary commitment hearing. Within five days after the person is taken into custody (with adjustments for weekends and holidays), the person must be provided an involuntary commitment hearing. The hearing may be continued for good cause prior to the running of the applicable time period. The referring county shall pay any expenses incurred by the board holding the hearing. Governor Kristi Noem signed the bill into law on February 10.
• Utah - HB 363 makes several changes to the civil commitment statute. The bill expands the definition of "substantial danger" for purposes of civil commitment to include the risk of deterioration if the individual remains untreated; extends the maximum period for adult temporary civil commitment from 24 to 48 hours; and provides that at a hearing for civil commitment, the court may order assisted outpatient treatment if the individual does not meet the conditions for inpatient civil commitment. The bill also describes certain rights of an adult who is temporarily civilly committed, requires a court to order an applicant to consult with the appropriate local mental health authority before the court issues an order of civil commitment, and allows a designated examiner to conduct an evaluation of an individual for civil commitment through telehealth. Governor Spencer Cox signed the bill into law on March 24.
• West Virginia - HB 4377 makes a number of changes to civil commitment law. These include: directing a study of the feasibility of developing alternatives to law enforcement transportation of patients, requiring an audit process for mental hygiene services, clarifying conditions for which involuntary commitment is inappropriate (a diagnosis of dementia, epilepsy, or intellectual or developmental disability alone), authorizing video conferencing for hearings and evaluations, establishing time limits for completion tasks necessary to the commitment process (increasing the time limitation for institution of final commitment proceedings from 10 to 20 days and the time limitation for conclusion of all proceedings from 20 to 35 days), and clarifying the distinction between hospitalization for evaluation versus treatment. Governor Jim Justice signed the bill into law on March 30.

Treatment Beds & IMD Repeal Bills 

Treatment Advocacy Center partnered with our board member Evelyn Burton and Schizophrenia & Psychosis Action Alliance to see Maryland become the eighth state to be granted Medicaid waiver of the discriminatory IMD exclusion in January. While applying for these waivers is a regulatory process, legislators can introduce bills to require agencies or administrators to apply for the waiver. This has been the case in New York (S 8422) and Missouri (HB 2013 and HB 1978) in 2022. 

The shortage of psychiatric beds as a result of deinstitutionalization has only been exacerbated during the COVID-19 pandemic, which brought numerous challenges, including a staffing crisis resulting in hospitals operating below capacity. Research organizations, the media, and legislators frequently turn to Treatment Advocacy Center's research publications on psychiatric treatment capacity in the United States and the recommended bed supply per capita (which we estimate to be 40-60 beds per 100,000 individuals). 

Legislators introduced bills to increase capacity of civil psychiatric beds in at least five states and also pursued other approaches to address the shortage. Treatment Advocacy Center is particularly impressed by a bill recently introduced in Colorado (HB22-1303) that would authorize funds to initially create 16 additional civil beds and to create, develop or contract to add at least 125 additional psychiatric beds across the state. Bills were introduced in Iowa and Wisconsin to fund a specified number of psychiatric beds, and bills in Hawaii and Massachusetts would increase capacity by an undesignated number. Iowa HSB 531 would fund 32 additional adult beds. Wisconsin AB 92 would have funded 22 additional beds but did not pass. Bills in Hawaii (SB 2737)and Massachusetts (H 4532) would authorize funds to open an unspecified number of new beds. Additionally, bills in Nebraska and Iowa take different approaches to the bed capacity problem. Iowa HF 2125 would implement a tiered reimbursement rate based on the level of patient acuity for Medicaid psychiatric intensive inpatient care, and Nebraska LB 1223 would set a minimum number of beds state hospitals must provide for each of the five designated priority populations for admission to state hospitals.

Death Penalty Updates

The Kentucky General Assembly passed a bill (HB 269) prohibiting the use of the death penalty for individuals with serious mental illness. At least six additional states have considered similar legislation in 2022. Bills in California (AB 2657), North Carolina (H 912), Tennessee (SB 2310/HB 2809), and Oklahoma (SB 1738) are under consideration. While bills in South Dakota (SB 159) and Florida (SB 770) did not pass this year, they created important momentum for future efforts. SB 159, in particular, made impressive progress, passing the Senate before the House ultimately voted against it.

Federal Updates 

As we enter the third year of the COVID-19 pandemic, mental health continues to be top-of-mind at the federal level. President Biden identified mental health as a priority during his first State of the Union address. The accompanying White House fact sheet to address the national mental health crisis includes evidence-based community mental health services, which encompass life-saving assisted outpatient treatment. 

Treatment Advocacy Center stays apprised of federal efforts to address mental health issues and crisis response to ensure the needs of people with severe mental illness and their families are not left out. 

988 Crisis Line Implementation 

Many state legislatures are struggling to meet the July 16 deadline by which states must have a call system in place for people experiencing mental health and substance use crises. The National Suicide Hotline Designation Act of 2020 established the 988 crisis line to complement 911 and imposed the July 2022 deadline on states. Now federal efforts are underway to assist states that are having varying degrees of success implementing the crisis line on their own. 

Executive Director Lisa Dailey has been a leader in the CEO Alliance for Mental Health's efforts regarding the rollout of 988 to ensure a full continuum of mental health and substance use care is established that successfully serves those with the most severe illnesses. Dailey and Ben Miller of Well Being Trust led a briefing to staff of the Congressional Mental Health Caucus on the CEO Alliance for Mental Health's roadmap for 988 implementation in February. 

Treatment Advocacy Center supports Rep. Tony Cardenas' (D-Calif.) 988 implementation package, the 988 National Suicide Prevention Lifeline Implementation Act (HR 7116). The bill includes provisions that would fund the launch, infrastructure, and modernization of the new hotline and amend and develop Medicaid. It would also exclude crisis centers from the IMD payment prohibition. The Behavioral Health Crisis Services Expansion Act (HR 5611/S 1902), which included critical elements to the success of 988 (expanding the availability of behavioral health crisis services, including robust mobile crisis and 24/7 crisis stabilization services, and providing coverage of these services in the majority of health insurance plans) is included in this larger bill.  

President Biden's fiscal year 2023 budget proposal includes $696.9 million for 988 implementation. Under the proposal, funds would go towards strengthening Lifeline network operations, enhancing local capacity to provide a behavioral health crisis response, establishing and maintaining a 988 and Behavioral Health Crisis Coordination Office and supporting public awareness with targeted 988 national messaging.

Additional Federal Bills 

The three bills below address discriminatory policies affecting people with SMI and research we need to study the psychiatric illnesses associated with COVID-19.

• Increasing Behavioral Health Treatment Act  (HR 2611): Introduced by Rep. Grace Napolitano (D-Calif.) in April 2021, this act would repeal the discriminatory IMD exclusion.
• Brycen Gray and Ben Price COVID-19 Neurological Impact Act  (HR 5180): Introduced by Rep. Anthony Gonzalez (R-Ohio) in Oct. 2021, this bill would authorize the Director of the National Science Foundation to award grants to support research on neurological and psychiatric illnesses associated with COVID-19 infection. Given the unique link between schizophrenia and COVID mortality, such research may lead to new research advances for those affected by SMI.
• Medicare Mental Health Inpatient Equity Act of 2021  (HR 5674/S 3061): Introduced by Sens. Susan Collins (R-ME) and Tina Smith (D-Minn.) and by Reps. Paul D. Tonko (D-N.Y.) and Bill Huizenga (R-Mich.) in Oct. 2021, this act would repeal Medicare's discriminatory 190-day lifetime coverage limit for psychiatric inpatient care.