March/ April 2013 Reality-Based Mental Health Reform

Preventing mass killings like the one in Newtown may be impossible. But there’s plenty we can do to reduce violence by the mentally ill in general. And the tools are right there in Obamacare.

By Harold Pollack

This will begin to change in 2014. That’s when the ACA will start providing subsidies that will eventually reach thirty-three million Americans without health insurance. An estimated sixteen million will eventually be covered by expanded Medicaid to low-income Americans with incomes below 138 percent of the federal poverty line. That number will include the hundreds of thousands of mentally ill men cycling in and out of places like Chicago’s Cook County Jail and sleeping on grates in cities from Washington, D.C., to Seattle. For the first time, nearly all of these individuals (undocumented immigrants are the big exception) will gain access to regular health care. Moreover, if the law is properly implemented, these same individuals will gain access to mental health services that can reduce their propensity to commit violent acts.

But that’s a big “if.” In theory, both within Medicaid and outside it, the ACA expands the range of mental health and substance abuse services. Insurance plans within the new state insurance exchanges must cover mental health and substance abuse services—and do so under conditions of “parity” so that copayments and other details match plans’ coverage of physical health conditions. In the fine print, evidence-based approaches including screening, brief intervention, and referral to treatment for alcohol disorders are supported in emergency departments and other medical settings.

The devil is in the details. Right now there are major fights under way over how precisely the law will be implemented, and which specific services Medicaid will cover. One fight that’s gotten a fair amount of attention is in states such as Texas and Georgia, where recalcitrant Republican governors so far have refused to allow their Medicaid rolls to expand, even though the federal government will pick up nearly 100 percent of the cost. Almost every health policy expert believes that these governors will eventually relent to pressure from their constituents and from local medical facilities of all kinds who stand to lose billions from the governors’ intransigence. The longer they wait, however, the longer poor and possibly violent mentally ill people walking the streets will be denied treatments that could help them and that might protect surrounding communities from preventable crimes.

Still, health reform represents a genuine sea change in this world of services. Here in Cook County, Sheriff Tom Dart notes that most inmates will be eligible for Medicaid after 2014: “The Medicaid waiver and the ACA have the potential to be game changers, ending the [federal, state, and city] cuts that have made the Cook County Jail the provider of first resort in the city of Chicago and Cook County.”
Other battles must still be fought. States don’t always cover specific promising services such as FACT. It’s especially important for Medicaid to cover evidence-based interventions for young men with cooccurring mental health and substance abuse disorders who pose the greatest public safety concern.

We must also reverse recent punishing cuts to our mental health system. Between 2009 and 2011, states experienced a cumulative shortfall of $432 billion. Mental health agencies in almost every state have cut expenditures, even as recession increases demand for community mental health services, crisis services, and emergency department services.

The ACA helps to address some of this problem, since outpatient mental health services for “non-Medicaid low income consumers” have faced particularly deep cuts. Yet the problems go deeper, including the continued decline in the number of state psychiatric beds. As state hospitals continue to contract in the face of fiscal difficulties, psychiatric emergency rooms, nursing homes, and acute care facilities face growing burdens, seeking to serve the sickest segments of the mentally ill population, who would once have received institutional care.

Finally, one encounters an obscure but important rule that few people have even heard of. Since Medicaid’s beginning, the program has maintained something called the “institution for mental diseases” exclusion, or IMD. Roughly speaking, Medicaid does not cover inpatient care for working-age adults at psychiatric facilities with more than sixteen beds.

This policy may once have made sense. Federal policymakers didn’t want to assume the full costs of extensive state and local mental hospital systems. Advocates for the mentally ill did not want to create further incentives to warehouse people. Today, though, the IMD exclusion hinders low-income patients’ access to inpatient psychiatric care, including specialized residential care for individuals with substance use disorders. Ron Honberg, the national director for policy and legal affairs for the National Alliance on the Mentally Ill, notes that some people require the help, monitoring, and supervision of long-term inpatient care. Family caregiver-activists such as Ilene Flannery Wells emphasize that when the mental health system steps back from providing this care, this leaves vulnerable, potentially dangerous people out on the street until (in all too many cases) a tragedy occurs, or until the correctional system steps in to fill the gap.

It’s a strange thing. Newtown was an atypical crime, committed by an atypical offender, using a murder weapon that I hope will be outlawed but that remains pretty atypical for gun homicides. Even though we may not be able to stop an event like Newtown from happening again, it seems to be moving public policy more than the routine smaller scale tragedies that we could more easily prevent. Newtown has provided a genuine occasion for Americans to think seriously about gun policy, and to consider the very real challenges to our mental health system. We should make the most of this moment.

It’s naive to believe that we could specifically identify someone such as Adam Lanza before he goes on a rampage, but improved policies could still prevent an unknown, maybe unknowable number of violent deaths. No one policy will dramatically reduce homicides, and the politics and administration of effective mental health policy are both daunting. But making these policies work would provide a fitting memorial to the victims of needless violence across America. While we may not be able to entirely solve the tragedies that occur at the intersection of mental illness and gun violence, surely we can do better than we’re doing now.

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.


  • Jonathan Sanchez on March 04, 2013 12:40 PM:

    There's something wrong with the link to the third page of this article--it's looping back to the first page.

  • bigtuna on March 04, 2013 5:04 PM:

    Two thoughts

    1. Perhaps ACA will help with some aspects of mental health and violence. However, you omit another source of death and debilitation regarding weapons and the mental health system - suicides and attempts to prevent suicides. Here, the access to guns is a very big issue, as is the fact that many people who attempt suicide are likely battling depression or other mental health issues.

    2. In this regard, AND in regard the mental health and violence towards others, I wonder about how well ACA will help. Yes, more people will be insured. However, I think many elements of ACA that will govern reimbursements to health care provides will rely on evidence-based care - that is, covreing more people, and we hope at lower costs, will mean a tight control on the nature of care given, the amount of drugs, tests., etc. So if a heart med is 85% likely to reduce hearth attacks in patients, it will be paid for. Bone marrow transplants for various cancers? Various radiological scans for certain conditions that have a 30% rate of showing something? Probably not so much. There is nothing wrong with this sort of system - it injects a level of evidence based medicine to our system, and has to be done if we are going to offer basic care to people w/o insurance.

    However, When it comes to mental health, I bet the stats are much harder to come by; while some treatments will be pretty verifible, others are not. THis is going to be pretty tricky territory for the system as it is reformed.

  • Rich on March 11, 2013 11:49 AM:

    What about services funded by CSAT and CMHS? What is Illinois doing with this money? What about locally raised funds? In many places, much of teh funding is raised locally.

    ACA-related insurance, including Medicaid expansion will require the same things that make it difficult to maintain entitlements. Marginal mentally ill people may lack a permanaent address or ways to remain in touch with whatever system manages these benefits.

  • Dana on March 16, 2013 10:21 PM:

    However accessible or effective we make mental health care, it is useless against violence as long as the mental health system refuses to define violence as pathological. For all the controversy surrounding DSM-V, there was not one peep suggesting that - just as one example - domestic abusers should have a diagnostic code. Half of the mass killings in the United States are honor killings. But as defined by our mental health system, most of the perpetrators are perfectly sane.

  • Ron Wagner RN, MA on April 03, 2013 12:37 PM:

    An interesting article. It really doesn't offer anything valuable in the way of solutions however. It seems to be a plea to support Obamacare. Dual diagnosis of substance abuse and mental illness does offer some indication of mental illness, but just substance abuse alone is the primary indicator. Behavior period, is the key indicator. Diagnosis is over rated. Past behavior is the best indicator of future behavior. Past behavior may not be violence itself, but preparations for it. That is not illegal, unless it involves illegal weapons.

    The best solution is actually for individuals to learn to avoid, and defend against dangerous people. For schools, that means being able to keep them out. Mass murderers are attracted to places where people are known to be defenseless.
    Police must keep records on those who are dangerous, for whatever reason. They should request mental evaluations, and treatment should be considered. Anyone can be committed if a trained medical provider can be convinced that a person is a danger to himself or others. There is a danger to civil liberties inherent in the abuse of the ability to commit, and it is difficult to keep someone for more than a few days. Society cannot afford to, and should not commit many people. Once committed guns can be taken from the patient, but they can always obtain them on the black market, along with other weapons.

  • Cary on July 15, 2013 11:09 PM:

    The comment that the reason the mentally ill don't get help is they don't have access to Medicaid is ridiculous. Definitely plugging obamacare. I have a brother who is bipolar, ptsd and alcoholic. He is a vet so has been in and out of va many, many times. They can't legally hold him long enough to stabilize him. I've been told so many times that he has the right to be crazy--in other words, unless he's pointing a gun at himself or someone else, that's just fine. Very frustrating that its impossible to get a mentally ill person help with or without insurance. Obamacare won't change that. Sickening to even suggest it.