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Mental health care in the U.S.

After the shooting at a Connecticut elementary school on Friday, like so many others, our first thought (well, after this) was “Why?” Why do these kinds of mass shooting keep happening with disturbing regularity? And is there anything we can do to stop them?

One obvious place to begin is by examining our mental health system. These shooters are clearly mentally ill, so why didn’t they get adequate psychiatric treatment? Did lack of access to mental health services play a role?

And so we looked into the state of our mental health system and actually found a bit of good news: the U.S. has made tremendous strides over the past few years in ensuring coverage for mental illness (particularly thanks to Obamacare).

Mental Health Parity

Back in 2008, Congress passed the Mental Health Parity and Addiction Equity Act. Kaiser Family Foundation explains what it did:

Under that law, employers with more than 50 workers that include mental health services in their insurance plans were barred from covering them at a lower level than other medical conditions. That means that the plans could not provide fewer inpatient hospital days or require higher out-of-pocket costs, more cost sharing or separate deductibles for mental health conditions.

There were a couple big loopholes though. For one, the law doesn’t say that these employers have to offer mental health coverage– just that if they do, then they must cover it like they would any other illness (85% of employers do offer some type of mental health benefits though). Also, individual and small business plans were exempt from the act.

The Affordable Care Act and mental health coverage

The Affordable Care Act starts by ensuring that 30 million Americans without insurance can get coverage. It also extends the Mental Health Parity Act to include small business and individual market plans. But it goes a step further– unlike large employers, these plans will be required to provide coverage for mental health and substance abuse.

It’s unclear exactly what services will be covered though– the law says mental health care is an “essential health benefit” that must be covered, but the White House left specific decisions (for example, whether or not group homes would be covered) to the states. It does spell out some preventive care benefits that will be covered without a copay or deductible though– and that list includes depression screening for adults.

Obamacare also expands Medicaid to cover anyone making less than 138% of the federal poverty line, and that too will cover their mental health care. Unfortunately if states opt out of this expansion, and with these same states cutting back on public mental health services (more on that below), there could be a serious gap in mental health treatment for their poorest residents.

Other ways the Affordable Care Act should improve mental health treatment

Training more mental health providers: The law includes $10 million in grants to social work and psychology schools to help recruit students and provide support for clinical training in mental and behavioral health. The goal is to boost the number of number of social workers and psychologists who work with Americans in rural areas, military personnel, veterans, and their families.

Integrating primary care and mental health care: The law sets aside $35 million to provide both mental and physical health care in one place for certain populations. The law also experiments with projects like “medical homes” that would reward providers for teaming up to better coordinate care. American Medical Association president Jeremy Lazarus thinks this is a good idea:

A good example of this is the DIAMOND Initiative organized by the Institute for Clinical Systems Improvement in Minnesota. There, psychiatrists are being paid for consulting with primary care practices on the best way to manage patients with depression, which has resulted in dramatic improvements in patient outcomes.

The traditional fee-for-service system is a barrier to this kind of teamwork, since most specialists are paid for face-to-face visits with patients, but not when they provide advice directly to the primary care physician.

New Funding under the law’s Prevention and Public Health Fund. The list includes:

  • $53 million to improve mental health screening: Specifically by integrating screening, brief intervention, referral, and treatment services within general medical and primary care settings.
  • $18 million for data collection: This should help determine areas of the country where mental health services are lacking.
  • $10  million to support suicide prevention programs

The range of Home and Community Based Services (HCBS) offered to people with disabilities who require long-term care, but do not wish to be institutionalized, will be expanded. States will also be allowed to target these services toward specific groups, such as people with serious mental illnesses.

National Depression Centers of Excellence will be established and funded with 5 year grants. These institutions are intended to promote increased access to the best interdisciplinary, evidence-based care for people with depression, disseminate research and establish treatment guidelines. (These last two come from the website KevinMD, who also did a great post on Obamacare and mental health.)

What else we can do for mental health

In the wake of other mass shootings, some states pursued mental health reform on the state level. For example, Colorado Governor John Hickenlooper has proposed spending $18.5 million to “redesign and strengthen” the state’s mental health support system:

Hickenlooper’s plan would include changes to state law allowing the judicial system to instantly transmit mental health commitment records to the Colorado Bureau of Investigation so the information would be immediately available for firearm background checks. The plan would also establish a statewide mental health crisis hotline and would open five 24/7 walk-in mental health crisis centers. Services for “seriously mentally ill” people would be expanded, including help with housing as patients transition from mental health hospitals back into the community.

Virginia passed a mental health reform bill in the wake of the Virginia Tech shootings that loosened their involuntary commitment law and provided $42 million in additional funds for mental health services.

Unfortunately, Virginia is also a good example of what’s wrong with our mental health system at the state level. Since the mental health reform bill passed, they passed across-the-board budget cutbacks that reduced services by 5%. Meanwhile, the current governor’s proposed budget would leave mental health services with less money than before the shootings. Virginia also has a severe-shortage of crisis care psychiatric beds, meaning that if someone with a dangerous psychiatric crisis is committed there is often nowhere to take them.

Virginia’s not alone in these cutbacks. According to the National Association of State Mental Health Program Directors, states cut $4.35 billion in public mental health spending from 2009  to 2012, even though the system has seen a 10% increase in usage. Increasing (or at least not cutting) state public mental health funding would go a long way in ensuring those suffering from mental illness get care.

Will improving access to mental health care prevent mass shootings?

It should help, but there’s only so much we can do. As Dr. Richard Friedman points out in an important New York Times op-ed, even trained mental health professionals have trouble predicting who might be violent in the future, and as Ezra Klein of the Washington Post has noted:

There’s no evidence, at least not yet, that an inability or unwillingness to get mental health treatment was a problem for the Lanza family. And we need to be very careful that we don’t tip into profiling the mentally ill, who are vastly more likely to be the victims of violent crime than the perpetrators.

What would help though, is reducing the amount of harm people can do if they become violent (whether that’s due to mental illness or not), which means having a conversation about guns. We’ll look into guns as a public health issue in our next post.

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