Mental Health in Nevada — Policy Analysis

Analysis of Mental and Behavioral Health Services in Nevada

Policy Analysis

Lea Moser

April 13, 2020

Executive Summary

According to the World Health Organization, “there is no health without mental health” with health being a state of complete physical, mental, and social well-being; not only the absence of disease. SAMHSA’s Center for Mental Health Services: “Mental health is defined as “how a person thinks, feels, and acts when faced with life’s situations…. This includes handling stress, relating to other people, and making decisions.”

Nevada is in the midst of a behavioral health crisis. High suicide rates, untreated anxiety and depression, serious mental illness, and high rates of opioid use disorder and other drug-related deaths are all signs of the need for accessible, affordable, and comprehensive behavioral health services. However, many Nevadans do not have access to the care they need. Nevada has mental health provider shortages in every county and has fewer mental health providers per 100,000 people than the national average. Nearly half of Nevada’s adults and youth with mental health needs do not receive appropriate services or treatment.

Funding for public mental health services in Nevada is bifurcated across different delivery systems, making it difficult to consistently deliver coordinated care, and limited commercial health insurance coverage of mental health care is a major barrier to providing and accessing services. Numerous gaps across Nevada’s continuum of mental health services and supports prevent Nevadan’s from accessing the right care at the right time.

A lack of timely, integrated, and coordinated services, coupled with the stigma around help-seeking, can escalate mental health needs to a crisis. This may result in people receiving mental health care in inappropriate and high-cost settings (such as correctional facilities and emergency rooms). Untreated mental health issues may also continue to place upward pressure on Nevada’s already high suicide rate.

Contents

Executive Summary. 2

Background. 4

United States. 4

Nevada. 4

Statement of Policy Problem.. 6

Review of Policy Options. 8

Policy Evaluation Criteria. 9

Telehealth. 10

Workforce Shortage and Interstate Compacts. 10

Seek Full Medicaid Expansion. 13

Mental Health Education in K-12 School 13

Mental Health Literacy. 13

S.B. 204. 15

Funding. 16

Marijuana Excise Tax. 17

Reducing the Prison Population and Corrective Spending. 20

Conclusion. 21

Suggestions for Future Policy Research. 22

References. 23

Background

United States

Mental health issues have become increasingly apparent in communities throughout the United States. New research shows that there has been a sharp spike in cases of major depression in the United States (US) in recent years, particularly among teens and millennials (Bernert, Hom, Iwata & Joiner, 2017). In 2015, it was estimated by the World Health Organization (WHO) that more than 322 million people have depression, which roughly equates to 4 percent of the world’s population — an increase of 18.4 percent between 2005 and 2015 (Ritchie & Rose 2018). The Centers for Disease Control and Prevention define mental disorders among youth as “serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day” (CDC, 2018). According to the National Institute of Mental Health, 18 percent — nearly 1 in 5 — U.S. adults live with a mental illness (2019). This increases to 49 percent in adolescents, with 22 percent experiencing severe impairment as a result of mental illness (National Institute of Mental Health, 2019).

In 2017, the Centers for Disease Control (CDC) reported that the suicide rate in the US had increased 31 percent with “more Americans killing themselves than ever before,” (CDC, 2017). In the extreme case of mental health issues, suicides have steadily risen with more than twice as many suicides (47,173) in the US as there were homicides (19,510) (CDC, 2017). Of great concern, suicide is the tenth leading cause of death overall in the US (CDC, 2017).

Nevada

Nevada encounters some of the highest prevalence rates of mental and behavioral health challenges in the US (Center for Behavioral Health Statistics and Quality, 2015). In 2019, Mental Health America, a non-profit mental health advocacy organization, ranked Nevada’s mental health system as 51st overall for children and youth with mental illness for the fourth year in a row (Mental Health America, 2020). According to the National Institute for Mental Health and the U.S. Bureau of the Census (2017), of the 2.2 million people living in Nevada, 74,667 are severe mental health patients, with 296 beds. According to the Department of Child and Family Services (DCFS), 75%-80% of children and youth in schools in Nevada are in need of mental health services but did not receive them (DCFS, 2017). Of those who did receive assistance, 70%-80% received mental health services in schools (DCFS, 2017). In particular, Las Vegas residents have much higher suicide rates than residents of other metropolitan counties in the US, earning the title of “Suicide Capital” throughout the years (Wray, Miller, Gurvey, Carroll & Kawachi, 2008).

Substance abuse and violence is an additional issue when considering how best to understand Nevada’s mental health needs. In 2016, drug overdoses were responsible for approximately 64,000 deaths in the United States, surpassing motor vehicle deaths by 60 percent (National Institute on Drug Abuse, 2018). Alcohol, methamphetamines and prescription pills are three of the most commonly abused substances. Nevada is the second in the US for non-medical use of hydrocodone and oxycodone (Addiction Statistics by State: Nevada, n.d.). In 2016, 665 Nevadans died from a drug overdose. That number equates to 21.7 deaths per 100,000 residents, above the national average of 19.8 (CDC, 2016; Hedegaard, Minino, & Warnder, 2018). Nevada is one of 18 states that allows commercialized casinos throughout the state, and the state’s economy is heavily supported by the success of this industry. Disordered gambling affects approximately 3% of the population, and is associated with a negative consequences such as relationship and financial problems

Nevada consistently ranks first in the nation for domestic violence fatalities. Of the ten years between 2000 and 2009, Nevada was ranked as one of the top five states in nine of those 10 years, and as first in 2005, 2006, 2008 and 2009, thus potentially contributing to the dissolution of those marital relationships. In Nevada, a woman’s chances of being assaulted by her partner at home are greater than that of a police officer being assaulted on the job (Powell & Smith, 2011). The percentage of ever-divorced adults in Nevada by 2016 is 14.2%, which is the highest Percent Ever Divorced among the United States (Statistic Brain, 2016). As of 2016, Nevada has 12,814 divorced individuals under the age of 30 (Statista, 2017b). Thus, whichever method we choose to determine the prevalence of negative environmental exposures and outcomes in Nevada, the state comes out on top. This is not something to be dismissed lightly.

Statement of Policy Problem

A major issue facing Nevada is the gap between the demand for services and the supply of providers and access to mental healthcare. Experts project that the number of child and adolescent psychiatrists will increase to 8,312 in 2020, but this falls short of the estimated 12,624 that are needed to meet demand in Nevada (Packham, Merchand, Etcheqoyhen & Jorgenson, 2017). The entire state of Nevada has only 312 psychiatrists with 17 (5.4%) that specialize in geriatric psychiatry, leaving 239 patients for every one psychiatrist in Nevada (Hunt, Denby, Herlein, Lefforge & Paul, 2018). The school counselor-to-student ratio is 508-to-1, half of what the American School Counselor Association recommends (Wood, Chen & Lau, 2017), exemplifies the significant shortage of mental health care professionals in the state, with only 1.7 licensed counselors per every 100,000 people in the state (Packham, Merchand, Etcheqoyhen & Jorgenson, 2017; Guinn Center for Policy Priorities, 2014).

Addressing the growing mental health burden in Nevada has been particularly difficult due to a lack of support from financial backing. Nevada has maintained a low tax-burden where residents and businesses are taxed considerably below the national average. Nevada has long advertised itself across America as a state where there is “no income tax, no inheritance tax, no sales tax, no tax on intangibles” (Steven Miller, 2011). Historically, this has equated to Nevada providing relatively low-level of state services (Morin, 1996). ­­­­­­In 2018, the Social Capital Project listed Nevada as the second lowest social capital score following Louisiana and ranked in the bottom three states for five of the seven social capital subindices (SCP Index — Social Capital Project — United States Senator Mike Lee, 2019).

Having access to healthcare begins with affordability of basic preventive services such as immunizations, annual physicals, and screening for chronic diseases. However, the continued growth in population, coupled with the increase in proportion of people with health insurance and an ongoing shortage of healthcare providers across the spectrum, has magnified challenges in accessing healthcare for all residents regardless of insurance status.

Recent behavioral health budget enhancements have been fueled primarily by behavioral health crises. In 2014, more than 400 deaths among 10–14-year-old adolescents and more than 5,079 deaths among 15–24-year-old youth and young adults were attributable to suicide (CDC, 2014). As a result, suicide was the second leading cause of death among youth between the ages of 10–24 in 2014 in the United States; second only to unintentional injuries (CDC, 2014). Of late, the 2019 state legislature introduced AB114 regarding suicide prevention courses for students 5th through 12th grade and teacher training on how to identify the warning signs of suicide, but comprehensive mental health education is still lacking (Ellison, 2019).

In Nevada, multiple public systems share responsibility for ensuring the mental and behavioral health needs of children and youth are met. This includes but is not limited to: Nevada Department of Health and Human Services (DHHS), Division of Child and Family Services (DCFS), Nevada Division of Public and Behavioral Health (DPBH), Nevada Department of Education (NDE), Nevada Division of Health Care Financing and Policy (DHCFP) and Behavioral Health Services (BHS). These agencies, plus the departments within 16 counties implement programs to address aspects of child well-being. However, each agency has different rules guiding what they can pay for, different definitions and measurements for child well-being, and difficulties sharing interagency information, resulting in a lack of accountability to each other, and to the children and families they serve.

Other recent expansions of state funding for behavioral health have included: moonlighting and residency programs through the school of medicine, social workers in schools grant program, statewide psychiatric medical director appointment, Stein Hospital, weighted caseloads in rural and frontier counties, and psychiatric nursing positions.

Without appropriate access to decent services and adequate protection, Nevadans with mental disorders and their families face extreme inequity. The focus of this paper, thusly, is on the state of mental healthcare services in urban and rural and frontier Nevada, with specific aim to set out an analysis on the policy context, strategic needs and identified financing strategies.

Review of Policy Options

Improving Nevada’s behavioral health system requires an organized, comprehensive, and coordinated approach that eliminates existing gaps and enhances current services across the full continuum of mental health care. It also requires taking initial steps to system improvement while continually evaluating the impacts of these steps in the context of an evolving behavioral health system.

Policy Evaluation Criteria

Criteria of the policy options were concluded after analyzing the most important aspects of implementation success in Nevada. In order to qualify if the policy option would reduce the health impact, it was assessed on a gradient of low, medium-high in which is assess the overall increase in working knowledge of the importance of evidence-based practices and supporting systems of coordinated multi-tiered approaches for promoting positive behavioral and mental health for all children, including children and youth with disabilities.

Additional criteria included feasibility, which was qualified by asking how likely the program would be implemented in schools, questioning whether it improves on systems for implementation fidelity, durability, and scaling of multi-tiered approaches for promoting positive behavioral and mental health for all children. The cost and budgetary impact is evaluated by whether it increases capacity-expanding strategies and systems that promote positive behavioral and mental health development in schools and education programs. Lastly, it asks whether it increases equity in the promotion of positive behavioral and mental health development among children.

Recommendations that were characterized as “low impact and high resources” were excluded from further consideration. The following recommendations were identified based on analysis of other state's recent behavioral health policies that showed sustainability, buy-in, and potential impact. The policy recommendations assessed include: 1) Support greater use of existing telehealth technology; 2) Address workforce shortages and interstate compact; 3) Seek full Medicaid expansion; 4) Standard Mental Health Education in K-12 Public Schools.

Telehealth

Telehealth involves the use of various technologies to remotely deliver health care services, public health, and health-related education for patients and health professionals. Studies show that telehealth can increase the availability of and access to quality medical care, improve population health, and lower the cost of health care. Telehealth offers an innovative approach for youth to receive differentiated and specific mental health care. Changes in regulations due to COVID-19 are also making it easier for people to access mental health care online. The US Department of Health and Human Services relaxed constraints that had previously made it nearly impossible to meet digitally with a doctor because of privacy concerns under the Health Insurance Portability and Accountability Act (HIPAA). Considering the mental health workforce shortage, telehealth can improve care to youth that otherwise would not be seen by a provider.

Workforce Shortage and Interstate Compacts

There are currently seven licensing boards for mental health professions in the state of Nevada, (Brune & Carreon, 2014) including the Board of Examiners for Marriage and Family Therapists and Clinical Professional Counselors that oversee licensure of clinical mental health counselors. The for licensed clinical mental health counselors is increasing at five times the demand for marriage and family therapists (Brune & Carreon, 2014; Griswold, Packham, Etchegoyhen, & Marchand, 2015) and moreover, there are nearly six times as many annual job openings for counselors in Nevada. Yet, the rate of licensure for clinical mental health counselors is far below that of marriage and family therapists.

In Nevada, the Legislative Committee on Health Care is proposing legislation to consolidate the 20 plus health care licensing boards, including the behavioral health licensing boards such as the Board of Examiners for Marriage and Family Therapists and Clinical Professional Counselors under the State Board of Health. One concern is if such an infrastructure could adequately monitor and maintain high standards in the mental health areas currently under seven different licensing boards (and another 13 health professions). A greater concern, given the tremendous deficit of certain mental health professionals, is if proportional representation (or if some professions are not represented at all) on the board would contribute to further inequities in licensed professionals. For example, there are currently 7.1 psychiatrists and 1.7 clinical mental health counselors per every 100,000 people in Nevada (Brune & Carreon, 2014). Licensed Clinical Social Workers and Marriage & Family Therapists are three times that ratio, at 21.7 and 24.3 respectively. So, given the disparity between certain mental health professions — proportionate representation on a licensing board or worse, a lack of representation — could perpetuate gatekeeping to protect professional ‘turf’ as opposed to ensuring high quality training and professional competency for respective professions.

The Guinn Center recommends making licensure in mental health professions easier for professionals coming from out of state. The counseling profession has a national accreditation group (CACREP: Council for the Accreditation of Counseling and Related Educational Programs) that monitors academic standards for counselor training as well as a national exam (NCMHCE: National Certified Mental Health Counseling Examination). Specific activities might include: Reviewing health professional scopes of practice, health professional licensing boar licensure application and renewal processes, and options for recognizing national accreditations and expanding reciprocal licensing or endorsement opportunities, while maintaining quality standards and patient safety;

Utilizing Interstate Compacts or Model Laws that are crafted by national interest groups is one way to ensure individuals across many states are held to the same standards of practice for their profession. In 2017, Nevada adopted the Association of State and Provincial Psychology Boards Psychology Interjurisdictional Compact (PSYPACT) but will not become operational until seven states have adopted the model 12 legislative language. The American Counseling Association in October of 2018 contracted with the National Center on Interstate Compacts to start the development of model legislative language. Until that happens, Nevada cannot make effective, systematic changes.

Short-term solutions in Nevada’s legislature should include revising the membership of the various licensing boards. Including more representatives of the public, ensuring that minority representation is prescriptive, and including members from various levels of practice is effective for ensuring diverse opinions. Nevada should review the post-graduate supervision requirements to ensure that there is not a burden of an individual to work as an intern at an agency for an extended period. Lastly, until interstate compacts are crafted, Nevada can ensure that licensure portability, licensure by endorsement, or reciprocity are mandated public policies that boards must comply with actively, rather than the passive possibility modifier of pay.

Mental Health Education in K-12 School

Classroom-based mental health education stands to be the overall best option. Considering the research, students are substantially more likely to seek behavioral health support when school-based services are available. Implementing best practices will include integrated regular classroom instruction on brain science and mental health as a pattern of disease. It will target specific curriculum or special interventions tailored to problems faced specifically by Nevada students and will incorporate life-long curriculum for positive development and prevention of mental illness or drivers such as substance abuse disorders. When students have otherwise limited access to support, self-efficacy and knowledge stand as a protective barrier against the onset of negative mental health outcomes and the impact it has over a lifetime.

Nevada’s mental health education and literacy plan should emphasize both short- and long- term approaches to fulfill the goal of mental illness prevention. The policy option to provide mental health education for K-12 public schools should be based on recently passed legislation in New York and Virginia to require mental health education in schools.

The Virginia legislation mandates that mental health education only be added to the health curriculum for the first two years of high school (§ 22.1–207). It shall incorporate health instruction standards that recognize the multiple dimensions of health by including mental health and the relationship of physical and mental health so as to enhance student understanding, attitudes, and behavior that promote health, well-being, and human dignity.” The student-led legislation mandates the use of brain science in order to understand and promote the educational basics of mental health.

Similarly, New York amended their health education laws to include mental health and incorporate how the inclusion of physical health impacts mental health. Their legislation suggests the creation of the New York Mental Health Education Advisory Council, which will act to develop resources and recommendations supporting mental health education specifically for the state.

As policy toward mental health changes, so too does the approach to treatment and education on mental health within society. Although mental health was previously thought to be solely a health service problem, the education system has taken up a key supporting role. School personnel plays a vital role in helping detect and monitor mental health in students, yet it is only one aspect of mental health support. The question that must be asked, is why are schools so important in mental health support, specifically with providing mental health literacy?

Educational programs play a key role in not only informing students, parents, and teachers of the challenges of mental health, but they also provide strategies and skills to help reduce mental illnesses and disorders in students who may or may not have mental health challenges (Capella et al., 2011). With educational programs having a wide variety of support through current literature, what needs to be addressed is how to create an effective educational program in the first place. Specifically, what are the traditional approaches to mental health in schools? What training is available for school personnel? How can student curricula play a role in developing mental health literacy for students and families?

S.B. 204

In the 2021 legislative session, I am proposing two strategies to help schools and districts continue to progress in creating safe and supportive school climates.

1. Encouraging and enabling districts to create positive, supportive school climates by implementing a multi-tiered system of support framework to identify and meet student needs. This includes the mental health education framework that will coincide with the Suicide Prevention framework.

a. Propose to build upon the good work already underway in our state by increasing capacity in schools and districts to successfully implement strategies like Suicide Prevention benchmarks through the buildout of multi-tiered systems of supports (MTSS). Providing tools such as an MTSS practice profile to assist districts in implementing positive school climate strategies will help support districts in providing coordinated services and create additional leadership buy-in.

2. Providing reliable and consistent access to mental health services for students through either staff or partner providers in every school building.

a. Propose to increase student access to mental health services, through additional staff within the school building or through a community partner, such as an educational service district, county health department, or community-based organization. Ensuring that students have access within their school environment to mental health services and necessary referrals is a key support to improving school climate and improving outcomes for students with mental health needs.

Nevada has embarked on some critical work to create positive school climates. Considering that the State Legislature is currently hearing legislation regarding the implementation of a Suicide Prevention Program at every school, which would provide suicide prevention courses for students and teachers to identify warning signs of suicide, it would be apropos to include the incorporation of mental health education as part of the trainer curriculum to guard against suicide and bolster general positive development for youth. In using the already established Suicide Prevention Trainer framework, mental health education could be easily incorporated to expand the scope of Suicide Prevention. The state convened a workgroup on children’s mental health as well, which provided recommendations on how to increase access to mental health services across our state systems, including in schools. We can enhance these and other efforts to deliver services to students and enable districts and schools to create welcoming and supportive environments for every student.

Funding

As of recent, Nevada has attracted many companies due to incentives such as tax abatements that allow businesses to make the transition to Nevada (Ryan Frank, 2014). In addition to an increase in companies moving to Nevada, citizen interstate migration has increased. More than 50,000 Californians moved to Nevada from July 2017 to July 2018, the Las Vegas Review-Journal reported, or nearly 40%of the total number of people who moved from another U.S. state during that time (U.S. Census Bureau, 2019). Many are moving from comparatively high-tax states such as California to come to Nevada since Nevada has low-level of property taxes and constitutional prohibition of creating state income tax.

Unfortunately, local governments in Nevada are primarily financed through a depreciating property tax, which per state law is capped on how much it can be raised. Central to this problem is the need to find revenue channels that can increase Nevada’s ranking among other states when it comes to the health and well-being of Nevadans. In 2017, the Annie E. Casey Foundation ranked Nevada 47th overall among states when it comes to a child’s well-being (Annie Casey Foundation, 2017). Education Week’s Quality Counts report card ranked the Silver State 50th among the 50 states and the District of Columbia (Map, 2018). Additionally, a study done by the Commonwealth Fund ranked Nevada close to last for health care in many categories compared to the rest of the country (2019 Scorecard on State Health System Performance, 2019).

Although the state has seen a boom in population growth, taxes have not. Because of the historical strength of the state’s tourism and gaming industry, Nevada has been able to depend heavily on gaming-related taxes and taxes that are easily exported to non-residents (such as lodging taxes, sales and excise taxes on tourist purchases, and entertainment taxes). However, this model is not sustainable in the long run as international gaming locations become more developed and Nevada’s tax rates become too high.

Viable tax policy options in the state are limited, and entail increasing tax burdens on business, increasing sales tax rates which disproportionately affect disadvantaged individuals, or increasing property taxes (Advisory Commission on Intergovernmental Relations, 1994). For this reason, I contend that Nevada needs to reform its behavioral health revenue structure in order to better stabilize budgetary volatility and promote a more equitable system for those with the least ability to pay taxes.

Marijuana Excise Tax

In recent years, several states have decriminalized the use of medical marijuana, and a handful of states have legalized the use and sale of recreational marijuana. Since Colorado passed its law legalizing recreational marijuana in 2014, the state has brought in $506 million in tax revenue, about half of which has gone to K-12 education (Newman, 2017). Other states that have followed suit, such as Oregon and Washington, have also been able to capitalize on the additional tax revenue (Newman, 2017).

Property Tax

Local governments recently have argued that partial abatements have undercut their ability to conduct business. Budgets are becoming more stressed, with the long-term shift over time from the more stable property tax to the more volatile sales tax as the primary revenue source for local governments. Property tax relief for companies includes up to a 75% reduction of the real property tax for a period of up to 20 years for companies that provide renewable energy sources which meet specific criteria, up to a 50% reduction for new or expanding companies that meet the state’s diversification criteria, pay 125% of the state average wage and provide health insurance to employees, and a personal property tax credit for computer equipment donated to a non-profit educational foundation (Guinn Center, 2017). For a number of companies coming to Nevada, such as Tesla’s Gigafactory, abatements include 100% of sales and property taxes for an extended period of time, allowing Tesla to abate $332 million worth of real and personal property tax abatements over 10 years, on top of additional abatements proposed in the benefit package (Guinn Center, 2014)

If property taxes and local state sales taxes do not increase sufficiently, considering the influx in population in cities in the state, the state General Fund will be required to make up any difference in funding required by the Nevada Plan.

A shift to market value alongside the elimination of the depreciation factor would bring Nevada in line with other states. Although this change would require amending Article 10, Section 1 of the state constitution, if adopted, the repeal of the depreciation factor could be phased in or eliminated outright. However, even if improvements to real property cease to depreciate, they should not be restored to their undepreciated assessed value for reliance reasons.

A study conducted by Applied Analysis suggests that an outright elimination of further depreciation would increase property tax collections by approximately 0.84 %, which would have amounted to $21.6 million in the 2014 fiscal year (Applied Analysis, 2013). An average homeowner would pay less than $30 a year in higher taxes over the first ten years due to the elimination of depreciation. Current benefits from using depreciation are likely outweighed by the complicated nature of calculating it, while its repeal will substantially improve the efficiency and equity of the state’s property tax system and the funds could be shuffled to behavioral health.

Reducing the Prison Population and Corrective Spending

A 2016 report released by the Department of Education revealed that in all but two states, spending on prisons is growing much faster than spending on public education, having quadrupled between 1979 and 2013 (U.S. Department of Education, 2016). The United States imprisons people at higher rates than any other country in the world and has a prison population of more than 2 million — the largest in the world (U.S. Department of Education, 2016). The more than $80 billion in U.S. tax dollars spent annually on the corrections system would be better invested in public schools.

In order to redirect funding from prisons to schools, state policymakers must find ways to reduce their prison populations. A good place to start would be the 1 in 5 incarcerated people that are locked up for a nonviolent drug offense (Wagner & Rabuy, 2017). The Brennan Center for Justice estimates that about 4 in 10 people in state and federal prison today present little or no public safety risk and could be released or have their sentences reduced for a total savings of $20 billion each year (Austin & Eisen, 2016).

In 2009, the Justice Policy Institute noted that some states have begun to decrease the size of the prison population — thereby reducing spending — by providing community-based substance-abuse treatment programs, increasing rehabilitation efforts, improving parole mechanisms and services, and decriminalizing nonviolent offenses (Justice Policy Institute, 2009). States that intentionally decreased their prison populations saw crime decrease even faster than national averages (Mauer & Ghandnoosh, 2015). Other states should consider such reforms. Investing in school systems rather than prison systems would benefit the U.S. student population in more ways than one. Presently, incarceration disproportionately impacts people of color, and students of color disproportionately attend schools with fewer resources and less experienced teachers. Redirecting funding currently spent on corrections to the public education system would not only improve the educational experiences of students of color but could also positively impact their families, communities, and potentially life outcomes — ending, or at least disrupting, the vicious “school-to-prison pipeline” (Elias, 2013).

Conclusion

The issues, examples, and options described in this study serve as catalysts for discussion among diverse policymakers and stakeholders to inform deliberations related to decentralizing mental health care governance and services in Nevada. Numerous factors that may influence such deliberations must be considered, including access to behavioral health care across the State; the status of private and public health care insurance coverage; the effect of the ACA on health insurance coverage and health care providers; the vast geographic expanse that encompasses sparsely populated rural and frontier counties of the State; collaboration among stakeholders within the State; and the costs associated with transitioning to and maintaining a more regional behavioral health system. Considering these issues collectively will help inform future efforts to improve the quality, accessibility, effectiveness, and efficiency of the mental health care system in Nevada.

Nevada’s occupational licensing boards are a structural partner in addressing shortages in the medical provider community. The shortage of behavioral health care professionals, from social workers to marriage and family therapists from psychiatrists to behavioral interventionists, is one element to Nevada’s consistently low ranking in the quality of life for children living with or at risk for mental and behavioral health care needs. The existing 20th-century occupational licensing boards can be improved by removing regulatory burdens, by fast-tracking applicants into the professional workforce, by trusting the licensing boards of other states, and by including diverse voices in the licensing board community. Ecological systems theory reminds us that there is a multitude of influences on a social problem and that the interventions necessary for affecting that social problem must be as varied. Occupational licensure reform is one such measure that can affect the number of qualified professionals helping those with needs in a community. Utilizing a policy surveillance approach to review, this paper set to demonstrate the benefits of searching out evidence-based best practices that exist in at least 50 different statutory and regulatory labs. While universities, community-based organizations, and health departments investigate and implement evidence-based best practice interventions in communities around the nation, state governments need only look to others for promising framework that allow success to happen.

Suggestions for Future Policy Research

In the future, additional research needs to be carried out on existing laws regarding gun control and their impact on violence in schools. Additionally, it would be beneficial to have further research conducted on which specific counseling interventions are most effective in reducing the likelihood of violence within the school setting. Moreover, research needs to be conducted on the most effective procedures for partnerships with mental health agencies in order to offer a more comprehensive approach to assisting mentally ill students. Further, it would be advantageous to determine whether or not a strong correlation exists between school counselors’ practices and a decline in gun violence. If a strong correlation is found, the findings may reinforce the necessity of employing additional counselors in each school. It would also be helpful to conduct further research on the benefits of mental health screenings in schools in assisting students in receiving and accepting the treatment that they need.

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31. Patrick Ibarra, “This Government Brought to You by…,” Governing, April 10, 2013, available at http://www.governing.com/columns/mgmt-insights/col-government-revenue-assets-naming-rights-advertising-sponsorships.html.