Be­hav­ioral health and guns

Ad­vo­cates want more from gun con­trol plan

Modern Healthcare - - FRONT PAGE - Jes­sica Zig­mond


That’s the num­ber of peo­ple mur­dered in large-scale shoot­ing sprees na­tion­wide since April 2007, when 23-year-old Se­ung-Hui Cho opened fire on the cam­pus of Vir­ginia Tech Univer­sity. And it’s the lives lost in those mas­sacres in New­town, Conn., Oak Creek, Wis., Aurora, Colo., Tuc­son, Ariz., and Blacks­burg, Va., that led Pres­i­dent Barack Obama last week to un­veil a na­tional gun con­trol plan that in­cludes ex­pand­ing ac­cess to men­tal health ser­vices as one of its core com­po­nents.

Men­tal health ad­vo­cates pushed hard for the pres­i­dent to use the na­tional mood of grief and anger pro­voked by the Dec. 14 mur­ders at Sandy Hook Ele­men­tary School to ad­vance their cause along with gun con­trol. They are en­cour­aged by the steps he pro­posed last week even as they char­ac­ter­ized them as mod­est.

The plan’s men­tal health mea­sures in­clude ex­pand­ing the men­tal health­care work­force, im­ple­ment­ing a pro­gram to help iden­tify men­tal ill­ness early in chil­dren, con­duct­ing fed­eral re­search into gun vi­o­lence, of­fer­ing guid­ance to clin­i­cians about re­port­ing threats of vi­o­lence in pa­tients and clar­i­fy­ing lon­gan­tic­i­pated fed­eral reg­u­la­tions for a men­tal health­care cov­er­age par­ity law that has been on the books for years.

The po­lit­i­cal winds fa­vor beefed-up spend­ing on men­tal health ser­vices be­ing in­cluded in any package that emerges from Congress. Politi­cians from both po­lit­i­cal par­ties who are adamantly op­posed to any form of gun con­trol usu­ally point to the need for more men­tal health ser­vices—their alternative ap­proach to curb­ing the all-too-fre­quent vi­o­lent out­bursts that lead to mul­ti­ple slay­ings.

“There’s broad agree­ment that we’re not do­ing enough on treat­ment,” said James Kessler, se­nior vice pres­i­dent for pol­icy for Third Way, a cen­trist group usu­ally as­so­ci­ated with more con­ser­va­tive Democrats. “The prob­lem is the con­sen­sus breaks down when dol­lars are in­volved.”

How­ever, the core of the pres­i­dent’s pro­gram fo­cuses on gun re­stric­tions that have pro­voked an­gry re­ac­tions from gun en­thu­si­asts and their pow­er­ful lob­by­ing group, the

Na­tional Ri­fle As­so­ci­a­tion. If men­tal health spend­ing gets tied to those pro­vi­sions, the leg­is­la­tion could face tough sled­ding, es­pe­cially in the House where a Repub­li­can ma­jor­ity is al­ready re­luc­tant to leg­is­late more money for so­cial pro­grams.

Dur­ing the past month, Vice Pres­i­dent Joe Bi­den and some Cab­i­net mem­bers, who met with more than 200 stake­holder groups, devel­oped a plan to re­duce gun vi­o­lence in Amer­ica by strength­en­ing the back­ground­check sys­tem for all gun pur­chases, ban­ning mil­i­tary-style as­sault weapons and high­ca­pac­ity mag­a­zines and im­prov­ing school safety. Im­prov­ing men­tal health­care ser­vices was the fourth ma­jor leg of the plan.

Dr. Paul Ap­pel­baum, di­rec­tor of the di­vi­sion of law, ethics and psy­chi­a­try at Columbia Univer­sity, said the pro­posal is sig­nif­i­cant for start­ing a na­tional con­ver­sa­tion on men­tal health. HHS Sec­re­tary Kath­leen Se­be­lius and Ed­u­ca­tion Sec­re­tary Arne Dun­can will be lead­ing that dis­cus­sion.

“I would like to see this ef­fort charged with mak­ing con­crete rec­om­men­da­tions in a de­fined pe­riod of time with a com­mit­ment from the ad­min­is­tra­tion to act on those rec­om­men­da­tions,” Ap­pel­baum said. “One thing I think we have to ac­knowl­edge is that much of the re­spon­si­bil­ity of men­tal health­care re­sides at the state level,” he added. “There­fore, the fed­eral government—while it has a role to play—will not di­rectly be able to im­ple­ment changes. But the fed­eral gov­ern- ment can pro­vide a model and in­cen­tive for change, and that will be a valu­able point.”

Called “Now is the Time,” the Obama ad­min­is­tra­tion’s plan asks for nearly $500 mil­lion in fed­eral fund­ing to im­ple­ment its rec­om­men­da­tions. Charles In­goglia, vice pres­i­dent of pub­lic pol­icy for the Na­tional Coun­cil on Com­mu­nity Be­hav­ioral Health, said the re­quest will likely reap­pear in the pres­i­dent’s fis­cal 2014 bud­get. That will be a par­tic­u­larly tough sell on Capi­tol Hill as law­mak­ers gear up for three ma­jor bud­get bat­tles in the next few months (Jan. 14, p. 27).

Tak­ing a wide view, the strat­egy sug­gests

re­forms that af­fect physi­cians, hos­pi­tals, in­sur­ers, men­tal health pro­fes­sion­als, educators and sci­en­tific re­searchers. For in­stance, the plan in­cludes a pres­i­den­tial mem­o­ran­dum that di­rects the Cen­ters for Disease Con­trol and Preven­tion and other agen­cies to con­duct re­search into the causes and preven­tion of gun vi­o­lence.

Also, it asks Congress to pro­vide $ 10 mil­lion for the CDC to con­duct re­search on the re­la­tion­ship among video games, me­dia im­ages and vi­o­lence. “We don’t ben­e­fit from ig­no­rance,” the pres­i­dent said last week dur­ing a White House news con­fer­ence. “We don’t ben­e­fit from not know­ing the sci­ence of this epi­demic of vi­o­lence.”

The plan also laid out a new men­tal health­care ini­tia­tive called Project AWARE, an acro­nym for Ad­vanc­ing Well­ness and Re­silience in Ed­u­ca­tion, which is sup­posed to reach some 750,000 young peo­ple through pro­grams that iden­tify men­tal ill­ness early and also re­fer those in­di­vid­u­als for treat­ment. Project AWARE in­cludes $15 mil­lion for Men­tal Health First Aid, a train­ing pro­gram that would help teach­ers and oth­ers who in­ter­act with chil­dren to iden­tify and re­spond to men­tal ill­ness in chil­dren and adults and also urge both ado­les­cents and fam­i­lies with th­ese prob­lems to get treat­ment. An­other $40 mil­lion in this project would be used to help school dis­tricts work with men­tal health agen­cies and law en­force­ment of­fi­cials in com­mu­ni­ties to make sure stu­dents with men­tal health is­sues re­ceive ser­vices they need.

In­goglia said the plan could have done more to widen men­tal health­care ser­vices for those who need it. “One of the pro­pos­als that we put for­ward—that Sen. (Deb­bie) Stabenow (D-Mich.) en­cour­aged the vice pres­i­dent to in­clude—is to cre­ate fed­er­ally qual­i­fied be­hav­ioral health cen­ters,” he said.

The plan does ad­dress the short­age of men­tal health pro­fes­sion­als, which was one of sev­eral rec­om­men­da­tions from the Men­tal Health Li­ai­son Group, an or­ga­ni­za­tion of be­hav­ioral health as­so­ci­a­tions in­clud­ing the Amer­i­can Psy­chi­atric As­so­ci­a­tion, the Na­tional Al­liance on Men­tal Ill­ness and the Na­tional As­so­ci­a­tion of Psy­chi­atric Health Sys­tems. The ad­min­is­tra­tion pro­posed $50 mil­lion in fed­eral fund­ing to train more than 5,000 men­tal health pro­fes­sion­als.

Some be­hav­ioral health­care ad­vo­cates praised the ad­min­is­tra­tion’s prom­ise to is­sue fi­nal reg­u­la­tions on the Men­tal Health Par­ity and Ad­dic­tion Eq­uity Act that Congress passed more than four years ago. So far, the de­part­ment has is­sued only an in­terim fi­nal rule. Se­be­lius cited the 2010 health­care re­form law as the rea­son why HHS has not yet re­leased a fi­nal reg­u­la­tion. The Pa­tient Pro­tec­tion and Af­ford­able Care Act re­quires health plans to cover men­tal health and sub­stance abuse ser­vices as one of the es­sen­tial health ben­e­fits the law man­dates.

“What we wanted to do is make sure that as we devel­oped the poli­cies for the Af­ford­able Care Act, that it fit neatly,” Se­be­lius said of the men­tal health par­ity reg­u­la­tion. “So this tim­ing ac­tu­ally works pretty well be­cause we’ll use them to cross-in­form.” How­ever, the ad­min­is­tra­tion did not of­fer a date for the rule’s re­lease.

Oth­ers lamented the con­tin­ued de­lay. “There’s been plenty of time to look at the in­ter-re­la­tion­ship be­tween the par­ity law and the ACA (Af­ford­able Care Act),” said Mark Co­vall, pres­i­dent and CEO of the Na­tional As­so­ci­a­tion of Psy­chi­atric Health Sys­tems. “And with the ACA mov­ing for­ward, it’s really even more im­por­tant be­cause we want to make sure that what­ever the fi­nal rule says is built into the plans sold onto the ex­changes and (in) the Med­i­caid ex­pan­sion.”


Among the me­moran­dums of the gun con­trol package signed by Pres­i­dent Obama on Jan. 16 is one di­rect­ing HHS and the CDC to con­duct re­search into the causes of gun vi­o­lence.

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