WMH Season 2 Ep 15: Mental Health Policy: What to Expect in 2025

This is a transcript of Watching Mental Health Season 2, Episode 15 which you can watch and listen to here:

Katie Waechter: Hi everyone, and welcome to another episode of Watching Mental Health, and I'm so excited because this is our last episode of season two and I think a great way to end season two because we will be talking all about mental health policy legislation, what the recent election means, what the upcoming legislative session it has in store for us. And I'm just really pumped because we're going to have an expert here. We've had him before. Trey Delap, he's the director of group six partners and advocates for accessible healthcare, particularly in addiction recovery and mental health.

So his track record for success and his ability to analyze complex issues and develop effective solutions is what makes him a valuable asset in achieving policy and political objectives in healthcare because he is solution oriented. So, which is perfect timing because on this episode, like I mentioned, we're going to be talking about that fallout from the recent election and then really diving into the upcoming 83rd Nevada legislative session and just some recent things that have been happening with the state in mental health. So a lot of really exciting things I think happening. A lot of things making people nervous. So I think it's going to be really a great timing to have him on board. And so we're going to really talk about what to expect when it comes to Nevada healthcare and mental health policy. And so with that in mind, let's bring Trey on so we can dive right in.

Trey Delap: Hello Katie. Happy holidays.

Katie: Happy New Year.

Trey: Thank you, Happy New Year!

Katie: Thank you again for joining me today. I know that there's been a lot of activity in Nevada and there's a lot of activity coming up in our state as well, and so it's exciting times. I remember the last time you were on, we talked very specifically about having you come back during this time, and so I'm really glad that you're here. And so with that, just jump in. You can speak a little bit more about what's going on with you, about your organization and then what's going on here in Nevada that you've been seeing since the fallout of the election.

Trey: Well, sure. I really appreciate it, Katie, and I'm glad that you invited me back. So what I'm working on is the same stuff I always do, which is just monitor the legislature, look at the politics. A little different view that I take is a political view, so it's more about elections and the power structure and campaigns and stuff. And a lot of nonprofit advocacy organizations don't do that because they, one, they're extremely nervous about violating 5 0 1 C3 if they're a nonprofit. And a lot of the work I do is try to educate organizations on their most valuable asset, which is information and connecting with their local person because the problem isn't going to get any better unless there's the right information. And what every organization that's working on the ground has is on the ground information. And legislators don't get that information. They get a very high level view and are often surprised about what's going on.

So withholding that information is kind of a bummer that happens because the frustration of no change is you got to do something different if you want to change. So a lot of that, what that means is politics is the acquisition distribution and maintenance of power, and the people expressed their voice through elections, and we had a general election and the result was single party dominance of all three branches, well of Congress and the presidency. And that is a fun fact piece of trivia, the longest time in the United States history where a single party dominated the Congress and the presidency was during the New Deal era, and that was 20 years that Democrats had control of all three notes. So just or two. So it's not unprecedented. Anyway, the general election occurred. Now we're looking at the federal government, which is being, the things that are coming out are what's the cabinet going to look like?

Who are the leader's going to look like? And there's been lots of energy expressed about that process. So that's the status there. But one thing to keep in mind is in two years we're going to have another election and a third of the US Senate will be up for reelection. And so they are the most active and engaged in approving nominees at the federal level. But in Nevada, the federal block Grant and things like funding that comes to Nevada should not see any interruption, at least in near future because primarily the major funding source is a block grant, which is a formula block grant. So the money is distributed by formula, and the other part is fmap, which is Medicaid. And that shouldn't change until something changes. So we'll have a couple years of still happening. That doesn't mean that our state isn't immune from new and exciting politics. And basically the result of the general election at the state level was the Republicans took one seat from the Democrats in the Nevada Senate, and then they took one seat in the assembly. So what that did is it denied the Democrats a super duper majority where they could singularly override any veto. So the mantra that the Republicans were using for this election were protect the governor's veto, protect the governor's veto, and by peeling off those two seats or flipping those two seats, they have protected the governor's veto.

That makes, and the Senate was kind of written off, but Dallas Harris losing her race, put the Republicans back in play in the Senate prior to that. They didn't need to go there if they really wanted to. But what we'll see during the session is a great deal of pressure put onto these Republicans who are the minority. So it should be good times.

Katie: Yeah, definitely. And so do you think that the two seats that have been flipped will be better for healthcare or worse, or do we have no idea? And I say that because I was born and raised here and I found that Sandoval who was a Republican governor did very well for healthcare in the state of Nevada. I think Lombardo is trying, he says that he wants to do these things. I'm not sure what's happening. And if the election of these Republicans is going to assist him, what are your thoughts just on that?

Trey: Well, on a basic power dynamic, he has a much more power now that he has a veto that could be sustained. And that means a lot because with, if the Democrats had a super majority in both houses of the state legislature, he could veto all day long and theoretically those vetoes could be overturned by a simple vote. However, now that veto matters and there has to be effort done. The challenge here, and one of the reasons I bring up the pressure of the universe will be on these Republicans heads if there's a veto, and it's a controversial issue, is it could be good for healthcare because healthcare is business. But it's silly complicated. For example, a lot of people believe that the health and human services committee is where all things healthcare go. That's not true. The Health and Human Services Committee primarily oversees the Department of Health and Human Services, licensing, insurance, all those things happen in the Commerce and Labor Committee. So you can see that there's a distinction there where it's less about the healthcare and it's more about the business operations of things. And so I think on one level, the healthcare is a problem. Global is true. How much can the state do on that? I'm not sure. But Governor Lombardo is more of, Sandoval is a Republican conservative, but he understood the burden of governing. And I think Governor Lombardo has the same appreciation for it.

Katie: And then we had another interesting election this year or just this year, and a big changeover of power here locally in Las Vegas with our mayor. And so our new mayor coming in, Shelly Berkeley also has the healthcare background. Do you think that that will help, or do you think that it's all show essentially?

Trey: Well, I have to disclose that my first job in politics was working for Shelly Berkeley in 1998, so that was her first congressional race and OG Shelly. But I, life has changed. So her husband's a doctor and she's been connected to healthcare forever. Family members are doctors and then seeing churro, she was very candid on the campaign trail that she didn't know anything about running medical school, but did it anyway. And so I think her heart is in the right place now. When I worked with her doing constituent outwork with healthcare issues, she was an enthusiastic energetic advocate and she still got that. The challenge is what can the brand ambassador, AKA, the Las Vegas mayor really do to change healthcare? They can build a medical district, they can build this stuff, but there is no way to make the children's hospital appear faster. So beyond that, there's not a whole lot that can be done at the local level, really just licensing and zoning and stuff like that. But there's a lot of social programs that they can do with regard. But that would, I guess, is homelessness a healthcare issue? It all kind of goes together and there's some stuff like that. And also the power of the pulpit, just being the head or the face of Las Vegas, you can do a lot, but how much is who knows what. Yeah,

Katie: Yeah, yeah, absolutely. And you did mention a children's hospital, so I was going to jump into the legislature next, but let's just talk about a couple of items first. So first, a brand new children's hospital has been announced is coming to Las Vegas, and for the most part, people are excited for it. I think for the most part, people are happy that it's happening because they believe that we need it. There are other people who are more hesitant simply because they don't think that bringing a new hospital is actually going to solve the problems, the systemic problems that we have in healthcare on the youth side. Now on the youth side, our mental health is part particularly bad. So what are your thoughts on the new hospital? Is there any talk about will there be a behavioral health aspect to this hospital? Is it too early in the game? Do you think that this is a good gamble on us? Just tell me more about that.

Trey: Sure. I got to tell you, this is a benefit of being old. In 2000, Aaron Kenny County commissioner was talking about extending attacks to open a children's hospital. So this has been something that's an issue. The question is more about facing the reality of being a metropolitan area with near 3 million and growing people. So when we look at our facilities, we start becoming the largest community or city or metropolitan area that doesn't have these critical infrastructure pieces.

So part one is if we want to be a big city, we're going to have to have big city stuff. And there you go. Also to note, we're way behind and the primary motivation for expanding, and this is terrible, that this was the motivation, but the Department of Justice found the state of Nevada in civil violation of the A DA because of their lack of children's services. Now, this resulted in the levy of a tax that's a services tax. The hospitals will be paying that money is supposed to be used to build up children's behavioral health. And so in progress kind of thing, in talking about these issues, it's hard to have a complete conversation about all the pieces. There is no single solution, a hospital, a children's hospital is part of the puzzle and we can't be held up on what's that going to do for us? We need to make the investment because we're already behind and it's just going to get worse. So it's kind of, it always challenges Nevadans to realize the expense of government and is it worth it because it just sounds better to have low taxes and very weak government, but then the result of that is constant chronic tragedy and

That's the cost.

Katie: Yeah, for sure. And we'll touch more on that I think when we talk about the legislature. But first, another big item that's been happening in Nevada is this potential overhaul of mental health licensing. So that also has, I think a few people scratching their heads wondering what's going to happen. So can you speak more to that?

Trey: Well, you mentioned Governor Sandoval and Governor Sandoval in 2005 and seven. There was a critical failure of the licensing boards to issue licenses fast enough. And the professions, the way Nevada works is there's little tiny semi autonomous groups of government. So the Board of Marriage and Family Therapists, the board of examiners for drug alcohol and gambling counselors. And there are autonomous little pieces of government that there's no oversight on. The governor appoints the members and that's it. They have their own employees that the money that they charge for fees never hits the general fund. So there's really no oversight of the boards and their operations. And their mandate is to protect the public by licensing people. And this is done very differently in different states. A lot of states have a central bureaucracy, the department of everything, like Colorado's Department of Taxation seems to handle everything. But in Nevada, we've just had these little tiny pieces of government in 2005 and seven, the problem was they just couldn't turn licenses fast enough and there was a threat to basically go in and force, but it was a hard issue. But the governor was basically expanded emergency power to go in there and force licenses on people.

So this has been a long time coming. What I think is happening is right now the proposal only addresses behavioral health practitioners, so marriage and family therapists, licensed clinical counselors, and they all have their different boards. So basically the idea is to take the authority to issue those licenses, run it through a central bureaucracy, a department of the state, and then have what one version has a super board where it'll be comprised of 13 members that represent all the regulated professionals. Now, this is making everyone nervous and hand wringing, and the driver of this issue is the department of business and industry. So on one level, and from my experience working with occupational licensing, there's two parts to it. One, there is your professional competence, do you know what you're doing? The other one is professional conduct, which is not lying on forms, filling out papers, not having dual relationships.

And that part, professional conduct can be assessed by anybody. I mean, you don't need to have special expertise in the field to identify if someone's conducting themselves professionally. Competence is completely different. That's where you need what is reasonable for a marriage and family therapist, what's reasonable for psychologists, and that's where you need the specialized knowledge. So the challenge here is the professions, the MFT profession has complete power over their practice and they will lose that under any sort of consolidation proposal. So that's the detail there, but it will grant more power to the state vis-a-vis the governor and the legislature because they'll have more direct oversight over the bureaucratic functions of licensing and stuff like that. So what I think is the bigger note to take is that they're going to start with these smaller boards. They have a two year rollout plan, but if maybe a slippery slope or maybe a hint to the future, this could happen to medical nursing and whatever, and you could wind up all those boards losing their independent unchecked authority.

Katie: So I find that really interesting because I wrote an article about why Nevada can't hang on to its doctors last year. And one of the points of that article was problems with licensing was the fact that many doctors, because each board is so independent in its own way, depending on the specialty, they may be waiting 6, 8, 10 months or longer to get licensed. And I have heard that there are some boards that operate on a mob like mentality where it's like, well, if you're not in our states, if you weren't homegrown, we're going to make this more challenging. So I've heard this be an issue. So that's interesting that the state has also apparently heard this and is now stepping in essentially after what seems like decades because this back in 2005, this conversation was being had, right?

Trey: Yeah. I mean theoretically it was happening way before that. In an interesting twist, it is not like oh five and oh seven where there was a clear focusing event of a failure to function.

Katie: But

Trey: One way to look at it is the threat of some sort of consolidation or overhaul got lit a fire under the boards and they streamlined their licensing processes because these horror stories of these delayed licenses is horrible project aware funded social worker in every school, and they couldn't fill them because they couldn't get licensed fast enough. And there was no good explanation as to why that happened.

Katie: So

Trey: When I talk about the centralized bureaucratic process, the problem is let's say that you are mistreated or you're a mob like mentality, and there could be epic stories from the dental board and the dental school and stories. But one challenge though is that if you're a social worker and you had a horrible licensing experience, are you really going to challenge the structure of that agency when you're livelihood? Depends on it. And unfortunately, that's kind of the posture they take. If it's in a more centralized bureaucracy that's not a little bit immune from, I think individual practicing will have more voice in how the process works rather than having to resort to lawsuits. Only doctors and rich people with bigger paychecks can handle all that legal stuff, but it's a real threat. I mean, you take someone's license away and there you go. And it can have a ripple effect nationally as well.

Katie: Right, right. Are other states, do they operate this way where they've taken licensing into the state? Essentially

Trey: Many of them, and I'm going to use medical as one I'm most familiar with, most states have boards that are connected to some sort of central bureaucracy.

Katie: And

Trey: One example is Texas. So Texas Medical Board is a revenue generator. So they charge fees and let's say they raise $10 million that goes to the general fund and the legislature then grants 'em a budget of four. So they're actually making money. But the legislature has control of that in Nevada's scheme where the boards own their money and there's no way to get in there. There's no way to influence the boards. Now they need a lot to operate off of. But so a money grab is if a board had to come every two years and fight for their budget, they're going to be much more open to problems and challenges. The other thing is when you look at these little tiny boards, if there's a problem with MFT or a gambling counselor, and the biggest issue in those professions is dual relationships and appropriate relationships, do they have the ability to protect the public? Can they properly investigate if they have a reserve of 10, $15,000 that could easily be eaten up by one case easily. So the other thing I think is can they adequately protect the public?

Katie: So that's interesting and that's actually a great segue I think into the Nevada legislature. So as you know, but just to remind our audience, Nevada legislature only meets once every other year. We're a small but mighty government, and you've mentioned this before, we don't like to be taxed. We want small government, Nevadans in general, I think across the state, don't want that extra tax. We enjoy that kind of independent life, but that comes with these consequences. That comes with frankly kind of a shabby healthcare system that there's just a lot of issues that I don't know if they're necessarily and they aren't because they haven't been solved in one legislative session. So with that in mind, we have the 83rd legislative session coming up. There's been a shakeup of power. I have heard healthcare is going to be important in the legislative session. I know it's a little early, but can you speak a little bit to what you might be expecting to see? Is this issue around board licensing, is this going to be brought into the legislative session or is this separate until it's done and then the legislature takes over? Can you just speak more on some of these topics?

Trey: Sure. So one thing to keep in mind is yes, our legislature only meets for 120 days every other year. And at this point we see what topics are being proposed. So what will happen is it's like a funnel. We'll start out with 1300 bills and a big old chunk will fail a deadline and another chunk, and we'll deal with whatever's at the left at the end. This proposal with the consolidation is being brought by the Department of Business and Industry so that you have an whole agency of state government bringing this issue. Healthcare is on everyone's mind all of the time, but what exactly to do now, the most powerful influence influences from health insurance plans and hospitals that pay money to have lots of lobbyists and lots of influence.

So, Any organization that's not one of those is operating in a different world finding. Absolutely. And the other part here is Medicaid will go to a total MCO model. So that issue is already in play. One thing I always like to encourage people not to accept information that the deal is done. We haven't even started the session yet. There is no deal until midnight on sign die the last day. That literally, it is remarkable what can get done at the Nevada legislature once they suspend the rules. Magic happens all over the place. Zombies live. I have resurrected zombies and gotten them over the finish line. So people will say nothing to see here, nothing to see here, nothing. And there was an issue last session that really, really affected the doctors. They weren't at the table and there was this magical decision. And what's interesting about that decision is there was a, don't talk about this anymore for 10 years, we've printed this for 10 years, which means no one and some about our legislatures, 20% of them are brand new, first time office holders and term limits is real. You've got a handful of them that this is their last session. So where are they going after this? 10 years is halfway between the next governor's term, whoever that is. So punting that long is easy for the politicians in office now they won't be there in 10 years. So it's up to the people and longtime advocates to do stuff.

Katie: That's very true. And on the mental health side specifically, I think that the same issues have been brought up many times. Housing in particular is an issue we tried to put forward. I think attacks on the hotels before, I don't think that worked. So I think that they are creative with mental health. Have you seen anything on the mental health side that we kind of want to be aware of that we know is going to be brought up? I feel like maybe youth mental health will be something that'll be brought up, but not sure in what respect. So any thoughts there?

Trey: I think what a lot of mental health advocates are going to be looking at is there isn't. Last session there was ARPA and there was tons of money. Has that money been spent? There is some consternation about that because it's one thing to get free one shot funding, but that creates a liability. So yay, great to build the opioid treatment center, but now we've got to pay for it forever with the tax system that's all over the place.

That's a problem. And will that get fixed? I think what a lot of advocates are doing is they're, they want to make sure they're protecting what they already have. And with the chaos and just this division in the country, I think people are still wondering what exactly the impact's going to be. This one thing to note is whatever changes happen at the federal level, let's remember, we are states and the federalism is real. So the federal government does this stuff, but then states can do their own thing. And so we're going to have a lot of people, we have a lot of people moving in from a state that does a lot into a state that does very little and how much will that sway things? And really in a political view, what happens in this session is going to be campaign issues in 2026 when our governor Ag, all the constitutional officers are up and then they'll be halfway through the next president's term and we'll see what happens there. But I think one thing to watch for is 2026 since we're watching mental health with Katie.

Katie: Yeah, yeah, absolutely. And you're right, 2026 is coming up. So I mean this is America, right? It's a constant elections. There's always an election on the horizon. So if you're not happy with it now, just hang on. So I find that interesting that you say that people are just kind of trying to hang onto what they have. Let's talk a little bit about the money. I know we're almost at time, but the money is a challenge here in Nevada. Frankly, we've gotten money from the federal government that we don't know how it's been spent. We don't know where it's been spent on the mental health, on the behavioral health side. The opioid money I've heard was just a catastrophe and how that fell out. And then you mentioned earlier this idea of bringing licensing into the state. That's a potential way for the state to make some money, which really the state needs some money. We don't want to increase taxes, but we need money in order to change some of these problems. So can you just talk a little bit more on that ways we can potentially maybe watchdog that in the future or just what are your thoughts around it?

Trey: Well, one very simple thing is when you look at the numbers and the source of funds that the majority of mental health services in Nevada are paid for by the federal government through pass through grants and through Medicaid and whatever. So the block grants are their formula block grants, and the issue always is with the single state agency and how that money is distributed, you talk to a lot of organizations, it's just there's a cashflow issue where a lot of organizations are held up by delayed reimbursement. So on one level we have a cash management issue that really does frustrate things. There's an illusion of excessive fraud. But one thing about having such a crappy payer system is that we can't even get fraudulent actors to engage. So I think one part, one is the money. The state only puts up the minimum amount to match to get the federal dollars. That's it. So when the state whines about paying money, I think they need to be mindful that most of the money that's being paid is federal money. So it's kind of not your money kind of thing. It's like just passing.

Katie: How is the money being managed once it gets into the state? Why is it not being, and part of this stems from our issue on youth mental health. We've had more beds shut down. To me, it just feels like if money is coming in from the federal government, where is that money going? And I suppose I'm not the only one asking that question.

Trey: Well, it's inadequate. It's inadequate. It's never intended to be the system. Every state,

Katie: The system, okay,

Trey: And every state gets the formula block grant, but they pay for it with the tax revenue and we just don't do that. But Katie, it pushes the issue. You hear some of these issues when I heard during an IFC meeting that Medicaid was returning $300 million or 4% of their budget because they weren't able to spend it, where's the outrage? It's like if the legislature appropriated increased reimbursements for providers and Medicaid can't figure out how to pay them,

That's shocking. So part of it is how do we make this message relevant to the general public? How do we tell people that we're going to take money away from our horribly funded schools and put them into a horribly funded behavioral health system? Then you start really seeing advocacy points where people are like, these are choices and they can do fine, get out of the state. It's a horrible situation. So part of it is if people aren't engaged or paying attention, then it's not going to change in any way. And for advocates who do want to see change, how do you make your message relevant to the general public is the key detail. And that's something we definitely cover in NAMI Smarts, don't we?

Katie: Yeah, absolutely. Well, I think that's a great way to end it. I want to end this on a positive note. So what good things do you see coming from in the near future? We do have a shakeup in leadership. We do have a legislative session coming. We do have advocates at the helm that are ready to go. NAMI Smarts is ready to train more advocates as they come. And it feels like there's always hope, right? So tell me more about that.

Trey: There's always hope, and I've been aware of civic participation since I was a we lad, Dante's first level of hell is for the people who do nothing. We live in a dynamic Republican form of government where you elect people and you have power. And if it wasn't clear to you before this 50 50 near miss thing, I mean looking at some of the returns, small numbers of people have a lot of power. So the biggest concern is people checking out and they're like, I can't change it anyway. It's like, yeah, but we can do some stuff. We can work together and improve things and if we have better this and we have better, that everything improves. So there's always an opportunity to do that. And there's so many people that are doing good work and you don't have to look hard to find someone who's really doing some great work and how do we expand that, support it, not duplicate it, but optimize it and we have the ability to do that.

Katie:

Yeah, absolutely. And I think part of that is breaking down those silos that a lot of mental health and healthcare operates in. And I think that we do have some of our nonprofits working really hard to break down those silos. And so I think that it's always interesting times. I know myself, I've really checked out on a federal level of engagement. Of course I voted but for the last couple of years. And it's because I realized that on a state level and on a city and a county level, I have a lot more power than people realize and people do in other states. So Nevada I think is an exciting state to live in. I think you're right, we're a purple state, and so really anybody who votes their vote really does count. I think it's a big deal to stay engaged, even if you're not happy with who's at the leadership right now, there are so many ways that you can make an impact.

And so it's exciting. With the legislative session coming up, there's going to be a couple behavioral health days I think. So if you are an advocate who's listening, please keep an eye out on that. I believe that NAMI Nevada is going to be doing something in May. They have a walk at Carson Cities, so that'll be really exciting. I think there's another behavioral health organization that is also doing something, so really cool stuff that we're getting some good representation on a mental health front, but I'm hoping that we can make good asks and actually see some good changes come from this. So I'm excited and I will keep following you, Trey, and be there to advocate along with you.

Trey: That's great. Well, and also want to shout out to our new legislative buildings down in Southern Nevada. So Grant Sawyer is gone and now there's much more space to get directly involved for every committee room in Carson City. There's an equivalent committee room down here. So advocates don't necessarily have to go to Carson City to advocate during committees and stuff like that. So our legislature is much more accessible. The already most accessible legislature in the country is even more accessible by driving down near the airport. And so these excuses for you not participating are getting thinner.

Katie: Yeah, absolutely. Absolutely. Yeah, you are so right, and that's so exciting. So we're really growing as a city and it's time that we implement some of these structural changes, and I know they can be growing pains, but that's part of it. It's part of Las Vegas, and I'm just excited to see what happens with healthcare and mental health. I know we have some new leadership and I know some people are a little bit scared, but you know what? Leadership changes all the time and we'll see what happens with these guys in the lead for now and we'll go from there. But in the meantime, thank you everyone for tuning in. This was the final episode of season two. We are going to have an episode next in two weeks from now on the third Wednesday, but it will be a repeat. So this will be the final episode of season two, and then we're starting off fresh with season three on January 1st. I'll be participating in the PR Connections marathon, so make sure you tune into that. That'll be my first episode there for season three, and I'm already stoked. We got a great lineup of guests. It's going to be so good. And the show is just going to keep on growing. So keep on growing with us and we will see you in the new year. Happy New Year!