“Far-Reaching Consequences”: Obamacare, Mental Illness, And Guns
After years of delays, the Obama administration has released final regs aimed at implementing 2008 legislation requiring “parity” in insurance coverage of mental illness, as Jackie Calmes and Robert Pear of the New York Times report today:
The rules, which will apply to almost all forms of insurance, will have far-reaching consequences for many Americans. In the White House, the regulations are also seen as critical to President Obama’s program for curbing gun violence by addressing an issue on which there is bipartisan agreement: Making treatment more available to those with mental illness could reduce killings, including mass murders.
Remember gun violence?
In issuing the regulations, senior officials said, the administration will have acted on all 23 executive actions that the president and Vice President Joseph R. Biden Jr. announced early this year to reduce gun crimes after the Newtown, Conn., school massacre. In planning those actions, the administration anticipated that gun control legislation would fail in Congress as pressure from the gun lobby proved longer-lasting than the national trauma over the killings of first graders and their caretakers last Dec. 14.
But there’s another big piece of the puzzle that is necessary to make sure mental health benefits are available to the people most at risk of committing acts of violence: the Affordable Care Act. As Harold Pollack explained in a major article in the March/April 2013 issue of the Washington Monthly, the ACA’s Medicaid expansion alone is a really big deal for people with mental illness and/or addictions who are prone to violence:
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….
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.
So if you want some very good news about the impact of Obamacare, and some very bad consequences if it fails to be fully implemented, there you are.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, November 8, 2013
“The GOP Mental-Health Hypocrisy”: Obstructing The Law That Does More To Advance The Cause Since ‘You-Know-Who’ Became President
So now we’re being treated to the charming spectacle of Republicans, or a few of them anyway, purporting to care about mental-health treatment in the wake of the Washington Navy Yard shooting. How touching. This doesn’t mean, of course, that they care about mental health. They’re just coming up with something to say in the wake of the tragedy that sounds to the willfully credulous like action and that won’t offend the National Rifle Association. Meanwhile, they have devastated mental-health funding since you-know-who became president. And more important than that, they voted against, and are now preparing to vote en bloc to defund or delay, the law that will do more to address mental health and give society at least a chance that future Aaron Alexises will get treatment that could prevent them going on shooting sprees since … well, pretty much since ever.
Alexis bought his weapon in Virginia, a state where anyone this side of Charles Manson can buy virtually any kind of gun he lusts after as long as he’s a resident. Current federal guidelines bar gun sales only to people who have been institutionalized or “adjudicated as a mental defective.” Neither of these narrow criteria applied in Alexis’s case. Not that it would even matter if one had, as The Atlantic noted; the Virginia Tech shooter had been so adjudicated and still was able to purchase his firepower in the commonwealth. (Alexis, being a nonresident, was blocked from purchasing an AR-15).
Alexis was fairly typical of the type of person who stands precious little chance of getting any mental-health treatment in this country. For starters, he was male, young, and black. That’s an unlucky combination of things to be in the United States for millions of people. But hitting that trifecta and being mentally ill on top of it constitutes the holding of a very unfortunate ovarian-lottery ticket. Single mothers, children, and the elderly all qualify for more forms of assistance than men do. Increasingly, there is a place where men like this wind up where they finally might get a little bit of treatment. It’s called jail. Our prisons are full of mentally ill substance abusers who committed crimes.
There are two things society can do about future Aaron Alexises. One, it can do nothing to improve mental-health approaches and let people fester, but even then it can at least take tougher steps to prevent the mentally ill from buying guns. Two, it can try to be a little more proactive about this whole category of illness, which affects nearly 60 million Americans (yep, one in five). On both counts, there is one party in Washington that’s eager to act, and one that is perfectly happy to let crazy people buy guns and perfectly content that we have more and more mentally ill people walking around with no treatment. Any guesses?
You may think I have phrased the above unfairly, but this is what the GOP position amounts to. On tougher background checks for the mentally ill, there were provisions in the Manchin-Toomey background-check bill, the one that nearly every Senate Republican voted against. This week New Hampshire Republican Sen. Kelly Ayotte is talking up new legislation. You perhaps have read that “even the NRA” supports toughening mental-illness regulations. That’s nice in theory, but in fact, the Senate is not going to do anything on guns and mental illness right, and the reason it’s not going to do anything is that Harry Reid knows he doesn’t have 60 votes to pass anything, especially with huge votes on a possible government shutdown and the debt limit looming. Republican Sen. Tom Coburn, a physician who isn’t hostile to tighter regulation in this case, acknowledged to The New York Times that “it’s all politics”—which in this case means that no one has the stomach or stones to take another gun-related vote.
They did, however, have the stomach and stones to cast votes over the past few years that have sliced away at funding for mental-health services. Decreased federal grants have forced states to make massive cuts to mental-health services. The National Alliance on Mental Illness referred in 2011 to the “crisis” that has resulted from states’ slashing of mental-health programs. It’s of course mainly Republicans in Congress who pushed for those block-grant cuts. The sequester made things worse. While the sequester doesn’t affect Medicaid, which funds most mental-health services, the non-Medicaid mental-health services have taken a serious hit, including 103,000 fewer treatment admissions in 2013.
And the Republicans will have the stomach and stones to vote very soon here to defund the Affordable Care Act, which, says University of Chicago health-care expert Harold Pollack, “is the most important change to mental-health and substance-abuse policy in decades,” for two reasons. First, the expansion of Medicaid to all citizens with incomes up to 138 percent of the poverty line will mean that millions of people will be able to afford mental-health care who simply couldn’t before. And second, the ACA requires that coverage of mental illness and substance abuse be offered by insurers “at parity” to more traditional medical treatments. Up to now, these treatments have been more expensive, less likely to be covered, and so on.
Republicans on the Senate Finance Committee actually supported those particular provisions of the ACA on unanimous voice vote. So by that measure Republicans are “reasonable” on this issue. But final votes on legislation is where the rubber meets the road, and that’s where Republicans have voted and voted and voted—and will clearly continue to vote—to make sure that we have more potential mass murderers walking among us, listening to those voices until they can’t take it anymore and go out and slaughter innocents. It’s a party of nihilism that has no desire to solve any social problem, holding the rest of us hostage to its craziness as the bodies mount.
By: Michael Tomasky, The Daily Beast, September 20, 2013
“Cruel Sanctimony”: Bugnut So-Called Reporter Makes Mental Health A Political Issue
I cannot write this the way I want. Doing so would invade the privacy of too many people. But I can’t be silent, either.
Last week, you see, President Obama spoke before a conference of mental-health advocates at the White House. It is necessary, he said, to remove the stigma of mental illness and make sure “people aren’t suffering in silence,” that they know they are not alone, but are supported by the rest of us as they face this challenge.
It would seem a plain vanilla thing to say. But in this endless era of smash-mouth politics, nothing is plain vanilla anymore.
So one Neil Munro, a “reporter” for the right-wing Daily Caller website, duly took exception. Under the headline, “Obama urges public to use government mental-health programs,” Munro in essence accused mental health professionals of making up illnesses. “In recent decades,” he wrote, “the professionals have broadened the definition from severe, distinct and rare ailments, such as schizophrenia and compulsive behavior, to include a much wider set of personal troubles. Those broader problems include stress and sadness, which are medically dubbed ‘anxiety’ and ‘depression’ by professionals.”
Munro was having none of that. “Americans,” he wrote, “have typically responded to stress and sadness by urging stoicism, hard work, marriage, prayer and personal initiative. …”
In other words, we were self-reliant. We toughed it out. And if I could write this the way I want, I would tell you in detail about a friend who was self-reliant. She toughed it out. Right up until she shot herself.
If I could write this the way I want, I would gather people I know who suffer from the types of diseases Munro finds “real” — dissociative identity disorder, bipolar disorder, schizophrenia — and I’d let them describe for you the stigma that attaches even to those sicknesses. The notion that mental illness — any mental illness — should be toughed out is asinine. Would you tough out diabetes? Would you tough out cancer?
It is a statistical matter of fact (one in five of us suffers mental illness in any given year, said the president) that this touches many of us. So I suspect I am not the only one who has stories he cannot tell and names he cannot call. On behalf of those unnamed people, our family members and friends who daily struggle with crippling disorders they did not cause and do not deserve, let us call Munro’s writing what it is: cruel sanctimony.
If his name sounds familiar, it is because last year, he made news for heckling the president during a Rose Garden address. Though ostensibly a “reporter,” Munro was shown in photographs with his hands in his pockets and neither notepad nor tape recorder in evidence.
Which made it hard to see how he was “reporting,” and suggested he was less a member of the Fourth Estate than another ideologue playing dress-up, a fresh emblem of political divisions so broad they can no longer be bridged. So broad that even things we once all agreed upon — for example: reporters don’t heckle presidents during speeches — can no longer be taken for granted.
But what the ideologue play-acting at journalism either does not know, or does not care, is that this is not a game. There is a real-life consequence to spreading ignorance about matters of health. As the military deals with record suicide rates, one shudders to think of the soldier, afflicted with post-traumatic stress disorder, who will read Munro’s scribblings and feel affirmed in his belief that seeking help is somehow unmanly. As our parks fill with the homeless mentally ill, one sighs at the thought of some daughter reading this and believing her dad chose to be that way.
These are our people, said the president, and we should support them. Self-evident truth. Plain vanilla.
And Lord have mercy. Even that’s controversial now.
By: Leonard Pitts Jr., The National Memo, June 10, 2013
“The Problem, Folks, Is The Guns”: Wayne LaPierre Is A Perfect Example
In the aftermath of the massacre of first-graders at Sandy Hook elementary school, right-wing defenders of unregulated guns have gravitated to a common alibi: The problem isn’t guns; it’s mental illness. If only society kept better track of crazy people and kept weapons out of their hands, we could prevent more episodes of armed mayhem.
Senator elect Marco Rubio has spoken of the need to “keep guns out of the hands of the mentally ill” and dozens of Tea Party Republicans have echoed the same talking point. The always predictable Charles Krauthammer wrote: “While law deters the rational, it has far less effect on the psychotic. The best we can do is to try to detain them, disarm them…. there’s no free lunch. Increasing public safety almost always means restricting liberties.” And the NRA’s Wayne LaPierre, in additional to calling for an armed guard in every school, urged an “active national database of the mentally ill.”
Oh my, where to begin? Mental illness is just now starting to become less stigmatized. If we create an even more Orwellian society in which anyone who has ever sought treatment for emotional problems ended up in some national database, you can just imagine what that would do to people’s willingness to seek help. Surely it is better to end the easy purchase of combat weapons than it is to keep a record of everyone in America who might hypothetically go on a rampage.
Surveillance as a substitute for gun control is no idle threat. In the age of anti-terrorism, courts have already permitted the National Security Agency to troll among otherwise confidential records—everything from cell phone and computer-information trails to bank and insurance company records. The Fourth Amendment, which usually requires a warrant for invasion of privacy, has been simply waived. If the justification is preventing “terrorism”—and surely shooting up a classroom is a kind of terrorism—the NSA could create a database in which half of Americans are classified as potential mass killers.
Isn’t it better to just get rid of the guns?
For now, privacy protections such as The Health Insurance Portability and Accountability Act of 1996 (HIPPA) make it illegal to disclose medical records, and mental-health treatment has an even higher standard of privacy protection. But it would be child’s play for the NSA to ignore these privacy protections, as it has others.
A second irony: The very right-wingers shedding crocodile tears over the need to focus on mental illness rather than gun control are the same people who have shredded public budgets that support treatment of the mentally ill. No area of public spending has been cut more deeply.
In Portland, Maine, a pioneering psychiatrist named William McFarlane has devised a strategy and outreach protocol for dramatically reducing the incidence of psychosis. The research of Dr. McFarlane and his colleagues demonstrated that it wasn’t the condition of schizophrenia per se so much as it was the devastating experience of a mental breakdown that disabled young adults and put them into the permanent status of the emotionally impaired.
Dr. McFarlane and his team devised an early outreach and prevention system called the Portland Identification and Early Referral program (PIER) that made use of community education. Teachers, counselors, clergy, youth workers and young people themselves were encouraged to be alert to patterns that might indicate future risks of psychosis. Dr. McFarlane’s main intervention was family education and early counseling, supplemented where necessary by medication.
Many teenagers who were loners or were haunted by delusional thoughts, seeing the educational materials “self-referred.” They would come into the PIER office saying, “that sounds like me.” In Portland, the predicted incidence of hospital admissions for psychotic breaks was reduced by between a third and a half.
McFarlane’s breakthrough was hailed as the most important insight about how to reduce the devastating effects of severe mental illness in decades. With support from the Robert Wood Johnson Foundation, the approach was expanded to several other cities and states. But in Portland, it has been shut down for lack of funding, thanks to that state’s right-wing governor. Reopening PIER in Portland would cost under $100,000 a year and would save many millions on hospital admissions and ruined lives spared.
What’s the connection to gun violence? “These kids who go on gun rampages,” says McFarlane, “tend to be pre-psychotic. Most people with mental illnesses are not dangerous, but these are. They still have enough functioning to methodically plot out their attacks. They have lost capacity for judgment but not for planning.”
“At our very first family meetings,” McFarlane adds, “one of the things we emphasize is safety. Families get it. If they own guns, they either get rid of them, or lock them up.”
It may be a coincidence, but there have been no gun massacres in the communities that have programs modeled on PIER. However, referrals to Dr. McFarlane’s program and others like them are voluntary. Nobody is put into a database.
At the very least, the right-wingers who hope to shift the focus from gun control to mental illness might have the decency to support more funding to treat the latter. According to Michael Fitzpatrick, executive director of the National Alliance on Mental Illness (NAMI), some 60 percent of people with some form of mental illness receive no treatment whatsoever. More than half the counties in America, he adds, have no practicing psychologist, psychiatrist, or clinical social worker.
When press coverage of Adam Lanza first surfaced, there was conjecture that the 20-year-old shooter may have had Asberger’s Syndrome, a loose diagnostic category that is being dropped from the newest edition of the official Diagnostic and Statistical Manual of mental disorders (DSM-V) in favor of the broader category of Autism.
All over America, parents of quirky kids are agonizing over whether their children might be “on the spectrum” or whether they simply hear “a different drummer,” as Thoreau so beautifully put it. Federal and state law gives parents the right to seek a full evaluation, and if a child is identified as having some version of even mild autism, the family can qualify for additional services. But there is the dreaded trade- off of services for stigma.
What if the risk of getting your child listed on some database as potential doers of violence were added to that equation? What parent would ever seek help? In fact, Asberger’s and Autism are seldom associated with violence.
The problem, folks, is the guns.
Absent the guns, the loners who have shot up schools and shopping malls might have gotten out of control, but they would not have been able to go on shooting sprees.
To the extent that the issue is mental illness, the problem is the gross underfunding of known treatments that work. Adding stigma and surveillance while not adding funds would only make an injustice that much worse. Can’t we at least keep that straight?
By: Robert Kuttner, The American Prospect, December 21, 2012
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