This blog post was written by graduate assistant Heather Woycheshin, a master’s student at the Baylor School of Social Work.
As one of the graduate archival assistants here at the W. R. Poage Library, I have had the unique experience of exploring the intersection between archival material and my passion for social work and mental health services. This post highlights materials from the Chet Edwards State Legislative papers on MHMR from the 69th and 71st sessions of the Texas Legislature to examine the historical context of the Texas Department of Mental Health and Mental Retardation (TDMHMR) during the 1980s under the Reagan Administration.
As a disclaimer, ‘TDMHMR’ will be used throughout this post, but inclusive, person-first language, in accordance with the American Psychological Association (APA) guidelines on bias-free language, will be used regarding persons’ identities. House Bill 2292 (2004) abolished TDMHMR and consolidated the agency into the Department of State Health Services (DSHS) and the Department of Aging and Disability Services (DADS).
Chet Edwards receives an award from Mary Gibson of Waco, TX, from the National Alliance on Mental Illness (NAMI).
Ronald Reagan became President in 1981 amid ongoing deterioration of the American welfare state that began under Richard Nixon. Under Reagan, this dismantling accelerated through policies emphasizing devolution, the act of reducing federal interference and returning authority to state and local governments. Localizing social welfare policy can have significant implications on beneficiaries as resource distribution is often inconsistent due to state-mandated requirements for public assistance programs like SNAP and Medicaid. These programs are widely controversial because of the assumption that it incentivizes individuals to rely on governmental assistance. Simultaneously, supply-side economics or “Reaganomics” gained prominence during this time. This approach was characterized by large tax cuts and reduced government spending to boost economic growth to “trickle-down” to economically disadvantaged individuals to become more self-sufficient.
Funding for public assistance programs and government-funded mental health agencies like TDMHMR were largely targeted and impacted. As a result, mental health services shifted towards community-based efforts known as “deinstitutionalization,” or the act of discharging patients from psychiatric state hospitals to smaller residential facilities. While the intended purpose of deinstitutionalization was to foster client autonomy and individualized care, the Reagan administration failed to render the necessary tools for successful reintegration, ultimately leading to increased housing instability and poverty, heightened incarceration rates for non-violent offenses, and discontinuity of care for vulnerable populations. Concurrently, the judiciary adopted a stricter approach known as judicial restraint, or the narrow interpretation of laws and reduction of judicial involvement in policymaking; this is contrasted with judicial activism, a broader view of law that addresses systematic inequality and unjust policies to adapt to contemporary societal standards, such as in Brown v. Board of Education. Understanding the political and economic trends during this time is critical to contextualizing the reevaluation and restructuring of TDMHMR and other mental health agencies during the 1980s, while also serving as a possible explanation for the controversies surrounding the agency.
Management Study Group title page
In March 1986, the Management Study Group started its assessment and evaluation of TDMHMR, specifically reviewing human resources management, financial and contract management, service delivery management, and structures and practices of the agency. The purpose of the study was to conduct a needs assessment on staff concerns, evaluate the program’s effectiveness, and improve service delivery. The findings of the study parallel today’s concerns. For instance, increased demands for workers with limited resources and inadequate pay, the need to clearly define roles, responsibilities and interdepartmental relationships within a bureaucratic system, and formalized plans that are worker-informed that counteract the autocratic approach that often overlook client and worker needs. Lastly, the study recommended the use of a legislative liaison, a role that would serve as a bridge to improve public perception and relations with stakeholders and government entities, while also serving as an interpreter for evolving legislation and policies and its implications on agency programs.
A few years prior, the Health Care Financing Administration (HCFA), currently known as the Centers for Medicare and Medicaid Services (CMS) implemented the Prospective Payment System (PPS). This system introduced a fixed reimbursement rate system for healthcare providers based on the Diagnosis-Related Group (DRG), a classification system for standardized billing. This system was partially a response to Lelsz v. Kavanagh, a lawsuit surrounding TDMHMR’s allegations of abuse, neglect, and inappropriate institutionalization. This initiated a shift towards least restrictive environments, a concept which considers diagnostic criteria and necessary support for individuals with Intellectual and Developmental Disabilities (IDD), while also prioritizing community integration and self-sufficiency.
Around this time the agency also faced scrutiny over potential supplementation or “double-dipping” regarding community-based Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID). These Medicaid-funded facilities are designed to support clients with intellectual disabilities to maintain independence within the least-restrictive environment. Allegations of “double-dipping” or supplementation within this context is the fraudulent act of receiving reimbursement from both Medicaid and PPS. However, the issue was complicated by vague guidelines from the HCFA because Medicaid stipulations were not specified and thus were open to interpretation and administrative discernment. The letter below details the response of Dr. Miller, commissioner of TDMHMR, to Senator Chet Edwards about the controversy and the agency’s plan to address the allegations.
Letter to Chet Edwards from Dr. Miller, commissioner of TDMHMR, about supplementation.
This ambiguity was further convoluted by the “six beds or less” rule, which encouraged community-based services and least restrictive environments under the guise for personal autonomy and family involvement. However, without the necessary structural reform needed for community-based care, clients were made to reintegrate into a society that was not constructed for them, leaving individuals without adequate resources and increasingly vulnerable. Framed as a progressive shift towards more humane care, community-based care and least restrictive environments ultimately led to significant funding cuts and inadequate training for community-based service providers, further exacerbating existing healthcare disparities. A member of Advocacy, Incorporated, suggested health providers had two difficult options: combine resources to continue adequate care with the risk of allegations of supplementation or discontinue services completely, all while posing the most important question: what happens to the clients? Unfortunately, this situation encapsulates a broader issue still present today. When policies are implemented without clear guidelines and structural reform, and weaponized rhetoric is used against vulnerable populations, clients and providers face significant implications in how healthcare is delivered and received, perpetuating a continuous cycle of systemic barriers and institutional racism.
Dr. Shervert Frazier – a Baylor alum, the first TDMHMR commissioner, and a powerhouse in the mental health field – stated it perfectly during the 1987 Executive Committee meeting of the Texas Board of MHMR: “It has been said that the test of a civilization is how we take care of the people who can not take care of themselves” (Frazier 10). This sentiment resonates with mental health providers, researchers, and advocates to this day. Despite ongoing advocacy for reform, issues with resource allocation, legislative and bureaucratic interference, and ethical dilemmas continue to be a cyclical pattern of today’s challenges. Reflecting on the challenges practitioners and clients experienced in the 1980s, we are reminded of the lasting impact of policy decisions and how it continues to inform how we approach the complexity of equitable healthcare today. Lasting reform is incremental and slow-natured, centered around the narratives of those most affected, and supported by policies and lawmakers that prioritize the dignity and worth of every person.
Works Cited
Advocacy, Incorporated. “Testimony Before the Senate Subcommittee on Health Service”, 14 April 1988. Address. Thomas Chester “Chet” Edwards State Legislative papers, Accession #8, Box #205, Folder #11, Baylor Collections of Political Materials, W. R. Poage Library, Baylor University.
Chet Edwards receives an award from Mary Gibson of Waco, TX, from the National Alliance on Mental Illness NAMI. Baylor Digitial Collections. digitalcollections-baylor.quartexcollections.com/Documents/Detail/nami-award/463061. Accessed 25 April 2025.
Cornell Law School. “Judicial Activism.” Legal Information Institute, www.law.cornell.edu/wex/judicial_activism. Accessed 25 April 2025.
Federal Register. “Health Care Finance Administration”, www.federalregister.gov/agencies/health-care-financeadministration#:~:text=0503%2DAA39%20SORN-,Health%20Care%20Finance%20Administration,and%20related%20quality%20assurance%20activities. Accessed 25 April 2025.
Frazier, Shervert. Executive Committee of the Texas Board of Mental Health and Mental Retardation, 26 February 1987. Address. Thomas Chester “Chet” Edwards State Legislative papers, Accession #8, Box #205, Folder #13, Baylor Collections of Political Materials, W. R. Poage Library, Baylor University.
John Lelsz v. John J. Kavanagh, M.D. 807 f.2d 1243 (5th Cir. 1987). Justia Law, law.justia.com/cases/federal/appellate-courts/F2/807/1243/311787/. Accessed 25 April 2025.
Management Study Group. Final Report. Texas Board of Mental Health and Mental Retardation. Thomas Chester “Chet” Edwards State Legislative papers, Accession #8, Box #116, Folder #9, Baylor Collections of Political Materials, W. R. Poage Library, Baylor University.
Miller, Gary E. Texas Board of Mental Health and Mental Retardation, 11 April 1988. Letter. Thomas Chester “Chet” Edwards State Legislative papers, Accession #8, Box #205, Folder #11, Baylor Collections of Political Materials, W. R. Poage Library, Baylor University.
Overview ICF-MR Issue. Thomas Chester “Chet” Edwards State Legislative papers, Accession #8, Box #205, Folder #11, Baylor Collections of Political Materials, W. R. Poage Library, Baylor University.
“Prospective Payment Systems – General Information.” CMS.gov, www.cms.gov/medicare/payment/prospective-payment-systems. Accessed 25 April 2025.
Texas Department of Mental Health and Mental Retardation Rule Transfer, www.sos.texas.gov/texreg/transfers/mhmr091004.html. Accessed 25 April 2025.
“The Reagan Presidency.” Ronald Reagan Presidental Library & Museum, www.reaganlibrary.gov/reagans/reagan-administration/reagan-presidency. Accessed 25 April 2025.