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Since the Newtown massacre, both supporters and opponents of tougher gun regulation have talked a lot about the parallel issue of inadequate monitoring of and treatment for violence-prone people with mental health problems. In the March-April issue of the Washington Monthly, one of the country’s preeminent health policy wonks, the University of Chicago’s Harold Pollack, addresses this issue comprehensively, and concludes that the single most important thing America can do to prevent violent acts by the mentally ill is pretty simple: fully implement Obamacare.
Why do so many people at risk—many of them young low-income men—fail to receive appropriate mental health services? The most important single reason is this: most are categorically ineligible for Medicaid. These men are not custodial parents. They are not veterans. They have not (yet) been diagnosed with federally recognized disabilities. Many get into trouble because they have serious drug or alcohol disorders. Since 1996, substance use disorders are no longer qualifying conditions for federal disability programs.
People often assume that an unattached adult might qualify for Medicaid if he is sufficiently poor. In fact, only a handful of states provide such coverage, even for individuals with no income at all. The homeless man who is not deemed physically or mentally disabled but who does suffer from chronic alcohol or crack dependence is typically ineligible for Medicaid. He might need substance abuse treatment or mental health care (not to mention care for any number of other health needs). If he’s locked up, the correctional service is required to provide these services. If he’s out in the community, he’s both more vulnerable and more bereft of help. He’s reliant on a patchwork of safety-net services, public hospitals, clinics, and emergency departments that’s financially stressed and disorganized under the best of circumstances, and that often allows vulnerable and occasionally dangerous people to fall through the cracks.
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.
The resistance of some Republican-governed states to implementation of Obamacare’s Medicaid expansion is one threat to this progress. But there are others, notes Pollack:
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.
It’s a challenge involving new and old policies, the complexities of the intergovernmental system, not to mention money, politics, and age-old prejudices. But, says Pollack, it’s time to begin getting this right:
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.
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Equal Opportunity Cynic on March 11, 2013 2:35 PM:
...because we're just pretending that Republicans actually care about doing something for the mentally ill, rather than looking for a fig leaf to prevent them from doing something about gun violence.
c u n d gulag on March 11, 2013 2:42 PM:
Here's the first thought I had after reading that - with about 27% of our population being clinically insane "Authoritarians" (men and women), we'll have to build a hell of a lot more asylums.
Maybe we can free-up some space in our privatized prison system, and make those cells a bit nicer. Some plants, throw-rugs, and pillows, might help. Painting them in soothing colors, would also be beneficial.
Either way, it'll take some money.
We can call it a "Mental Stimulus" package?
Dredd on March 11, 2013 3:03 PM:
Yes indeed.
A little prevention goes a long ways.
Gretchen on March 11, 2013 3:11 PM:
Does this ever resonate with me. I have a son who has had drug and mental health issues. I pay for his health insurance, but it doesn't cover prescriptions or mental health coverage. He had a couple of years where he was too sick to hold down a job, but in our red state, he wasn't sick enough to qualify for medicaid, because he was an able-bodied single young man. He's gotten well enough to hold down a job, but most of his meager pay goes to his psychiatrist and psychiatric medications. I am paying $95 a week out of pocket for his therapist. If he didn't have his parents to fall back on, he would be homeless, and we are very worried that that will be his fate once we are no longer able to take care of him. Our Republican state government has no solutions to this problem, except that he should pull himself together. Lord knows he's tried, but it's not that easy.
boatboy_srq on March 11, 2013 3:15 PM:
"Mental health system" and "United States" haven't really belonged in the same sentence since the 70s, when Saint Ronnie started closing California's public system. To even the old-school GOP (and certainly to the modern GOTea), "mental health" is a misnomer: the "mentally ill" fall into the Other category (along with "welfare queens" and "young bucks") who scam a living from the system by pretending to be ill. There is terrific resistance to mental healthcare among the Reichwing, because there's terrific resistance to the concept that non-debilitating mental illness is a legitimate health issue (and conversely that debilitating mental illness - specifically, mental illness that leads the sufferer to harm him/herself and/or others - is a legitimate health issue rather than a criminal/corrections issue), and substantial support for the idea that if the sufferer had proper family/church support then his/her demons would be properly exorcised and s/he could reenter society without a helping hand from Big Gubmint. So long as the Reichwing continues to dismiss mental health as anything other than: a) a con job to get free food/housing/drugs; b) a personal/family matter best dealt with in some Xtian setting; or c) an excuse to avoid a jail sentence; then there will be little if any movement on this issue, since such movement will require persuading them to accept that mental health is a public health concern and not the Eternal Coddling of Slackers.
Josef K on March 11, 2013 3:23 PM:
Sorry, guys, but I don't think another Newton-level massacre occurring every day for the next year will move Congress to actually act intelligently here. But then, looks who is running the joint these days.
Rugosa on March 11, 2013 3:59 PM:
Don't forget that most of the damage caused by mental illness is not the dramatic event like Aurora or Newtown. Tragic as those are, the toll of mental illness includes all those lives lost to drugs on the streets and families torn apart. I have faced "non-debilitating" mental illness in that I was always able to hold on to my job, but had serious problems doing so because of both the illness and the medication to treat it. I could easily have slipped into addiction (which is often the result of self-medication with illicit drugs or alcohol)and even homelessness if I didn't have insurance that covered treatment including extended therapy.
revchicoucc on March 11, 2013 4:07 PM:
In my work as a pastor, I interact regularly with our failing mental health system. Sometimes, the interaction is with an individual or family the system has failed to help, so they come to me, and, at no charge, I listen to their story. But I can only offer a listening ear, no real treatment.
Just yesterday, a woman told me her son, who has a diagnosed mental illness, has been in jail for 8 months on a misdemeanor charge. He has received some mental health treatment, but it has been inconsistent. When he is not taking meds, his behavior becomes erratic, unpredictable, and potentially dangerous and, therefore, alarming to his jailers. This is not the first story I have heard of a person who is mentally ill being incarcerated. Is the prison system becoming the de facto mental health hospital? Must a person commit a crime to be treated?
The connection to the gun debate cannot be avoided. "We must keep guns out of the hands of the mentally ill!" How, exactly, can we identify the "mentally ill" without either (1) mandatory mental health screening of every person in the country; or (2) a national registry of people with a diagnosis, thus violating privacy rights? You can't really tell just by looking, you know.
Finally, with regard to the gun debate, I was startled to learn recently in a presentation about suicide, given by our county sheriff, that 60-65% of gun deaths in the US are from suicide. A stronger mental health system, coupled with strong gun safety efforts, might reduce gun deaths by suicide.
revchicoucc on March 11, 2013 4:17 PM:
In my work as a pastor, I interact regularly with our failing mental health system. Sometimes, the interaction is with an individual or family the system has failed to help, so they come to me, and, at no charge, I listen to their story. But I can only offer a listening ear, no real treatment.
Just yesterday, a woman told me her son, who has a diagnosed mental illness, has been in jail for 8 months on a misdemeanor charge. He has received some mental health treatment, but it has been inconsistent. When he is not taking meds, his behavior becomes erratic, unpredictable, and potentially dangerous and, therefore, alarming to his jailers. This is not the first story I have heard of a person who is mentally ill being incarcerated. Is the prison system becoming the de facto mental health hospital? Must a person commit a crime to be treated?
The connection to the gun debate cannot be avoided. "We must keep guns out of the hands of the mentally ill!" How, exactly, can we identify the "mentally ill" without either (1) mandatory mental health screening of every person in the country; or (2) a national registry of people with a diagnosis, thus violating privacy rights? You can't really tell just by looking, you know.
Finally, with regard to the gun debate, I was startled to learn recently in a presentation about suicide, given by our county sheriff, that 60-65% of gun deaths in the US are from suicide. A stronger mental health system, coupled with strong gun safety efforts, might reduce gun deaths by suicide.
Christopher Hobe Morrison on March 11, 2013 5:10 PM:
You have a lot of people who are mentally ill, but you think it takes too much money to treat them so you just throw them into jail and throw away the key, but then you realize how much money this costs, so you can always toss them out onto the street and let them rot but then it is easier to have a gun than to not have one, especially if you think the world is a gigantic conspiracy against you.
Well, why do you think right-wingers love the death penalty so much? Not just because they love killing people. They love to have a sacrifice to the stern god of justice. But it costs so much! This problem could be eliminated of we adjust the idea of trials a little bit. A modest little proposal I suppose.
revchicoucc on March 11, 2013 8:42 PM:
I apologize for the double post. Captcha told me I got it wrong, so I tried again, but it turns out it was Captcha that was wrong . . . drives me crazy! Oh, that was probably insensitive, wasn't it?
joanneinDenver on March 12, 2013 10:10 AM:
Sadly, in Colorado, all of our mass killers were involved with the mental health system. The presumptive Aurora theater killer had been a graduate student specializing in neurobiology at the University of Colorado Health Science Center.
He had been a patient of the psychiatrist who had organized a the risk management team on campus to identify potentially dangerous students.
It is not clear to us that expanding mental health services would reduce the incident of public violence in our state. It would be necessary to examine what when wrong with the treatment that the killers and assassins were receiving. We could begin with John Hinkley who attempted the assassination of Reagan thirty years ago. However, the law protects the mental health profession and they are very aggressive in protecting their prerogatives. The response usually is that mental health treatment has prevented mass shooting and assassinations. How can you prove a negative?
Please know that I do believe that there is a role for providing mental health services. My experience has been that the inadequate treatment usually results in real pain for the mentally ill person. When that person becomes violent, the first victim may be the person himself. The second targets are family. Better treatment options for these people does not necessarily address the issue of those who kill strangers.