Obamacare and Mental Health

A version of this article appeared in National Journal Daily on Wednesday, October 15, 2013.

In the last year, the shootings at Aurora, Newtown, and the Navy Yard have fueled a conversation about what the country should do to keep people who suffer from mental illnesses from becoming a danger to society.

But when unarmed Miriam Carey was killed after leading police on a car chase to the U.S. Capitol—which ended with officers firing multiple shots at her vehicle—it highlighted the fact that people battling mental illness are more than just the perpetrators of tragic shootings.

Two U.S. Capitol police officers were put on modified duty following the death of Miriam Carey. Carey -- who struggled with depression -- was shot in her vehicle after leading police on a chase to the Capitol complex.
Two U.S. Capitol police officers were put on modified duty following the death of Miriam Carey. Carey — who struggled with depression — was shot in her vehicle after leading police on a chase to the Capitol complex.

A discussion about limiting access to guns for people with mental illnesses wouldn’t have changed Carey’s fate. But policy action to improve patients’ access to insurance and reduce the cost of treatment options could have filled a void for Carey and the other Americans whose inner struggles ended in moments of national pain.

To be sure, not all mentally ill patients are violent. Dr. Eliot Sorel, a clinical professor of psychiatry and behavioral sciences at the George Washington School of Medicine and Health Sciences, said that while the news stories illustrate a problem in health care, they also create a stigma around mental illness. He said that not all people who commit violent acts are mentally ill, and those of them who are are typically not seeking medical help.

“The severely mentally ill who are not in treatment are the ones who are potentially violent, and we need to attend to this,” Sorel said.

Increased access to mental health services is one component of the Affordable Care Act, and insurance coverage in the health law’s exchanges begins Jan. 1 for those who sign up by Dec. 15. The full implementation of the ACA, according to a February 2013 Health and Human Services report, will provide first-time access to mental health services for 32.1 million Americans.

The new health law requires all insurance plans in the exchange and in the individual and small group markets to treat mental health services equally with other forms of care in terms of copays and deductibles. Traditionally, insurance companies did not cover—or required higher out-of-pocket costs for—mental health services. Sen. Debbie Stabenow, D-Mich., proposed the parity requirement as an amendment, which was passed and added to the ACA, reflecting the existing requirement for mental health care parity in large employer-sponsored plans.

“After each one of these tragedies, everyone talks about improving mental health services in America,” said Stabenow, who is working now on legislation to heighten the quality of care for uninsured patients seeking mental health treatment in community centers. “It’s time to finally take action to do that.”

Lack of insurance and high costs of care are the biggest reasons mental health patients don’t seek treatment, according to a study released in this month’s Health Affairs, a top health policy journal.

“People with mental illnesses are more likely to have lower incomes,” said Kathleen Rowan, a doctoral student at the University of Minnesota and the primary author of the study. “That’s because mental illness might be limiting in terms of the work they are able to do or the hours they are able to work. And so many people face cost barriers in terms of access to care.”

The law will open the doors to affordable care for many of these individuals, Rowan said, through the subsidies on the exchange and the expansion of Medicaid.

Stabenow’s communications director, Cullen Schwarz, said that had the Navy Yard shooter had access to treatment, there could have been a different outcome. People who go without treatment after experiencing their first psychotic episode are 15 times more likely to commit acts of violence than those who do receive treatment, he said, citing a study in Schizophrenia Bulletin, a psychiatric journal.

“It’s not that we’ll always stop these tragedies from happening,” Schwarz said, “but we can certainly strengthen mental health services and reduce the number.”

The next obstacle, Rowan said, will be whether the scope of services and the number of doctors are able to meet the increased demand for mental health care.

For lawmakers, one solution might be adding incentives for physicians, nurses, psychiatrists, and other health care providers to adopt an integrated, team-based approach. Sorel said collaborative care restructures the system in a way that meets the total needs of mental health patients and creates communication between providers who could potentially stop the patients from taking violent action.

“You know what our biggest provider of mental health services is?” Sorel said. “U.S. jails and prisons. That’s the result of us not attending to this need.”

Scapegoating Nancy Lanza

It is not the job of the journalist to point the finger at the dead.

Airing Feb. 19 on PBS’s Frontline is Raising Adam Lanza, a documentary about the mother of the boy who shot and killed 26 children and school administrators at Sandy Hook Elementary in Newtown, Conn. His mother Nancy was his first victim, he was his last.

Is Nancy Lanza the victim or is she to blame?

Reporter Alaine Griffin of the Hartford Courant collaborated on the documentary. She told NPR that question is for the viewers to answer for themselves. But should we answer that question when she isn’t around to defend herself?

Journalists help the public locate who to hold accountable. When the lights went out at Super Bowl XLVII, journalists kindly protected the reputations of Beyonce, Bane and Entergy New Orleans (the Superdome’s power company) by retweeting statements about the source of the problem. They do the same when politicians run for re-election and they tell you how they voted on major policy decisions.

What purpose does it serve to hold the dead accountable?

Griffin tells NPR that in the documentary, the public will learn of Nancy Lanza’s gun hobby. She collected guns and went to shooting ranges because she had developed the passion while growing up on a farm in N.H. Griffin says family members called Nancy a devoted mother who cared that her children were doing the right thing. The family members also said she shouldn’t have exposed Adam to guns or violent video games. But let’s face it – there are so many children who grow up with guns and violent video games and do not turn out to be the next Adam Lanza. How could she have known? Why is what Adam did on Dec. 14, 2012, Nancy Lanza’s fault?

Now watch this:


That’s the preview for Tuesday’s documentary. Griffin says she wants you to decide for yourself, but PBS wants you to think that the Newtown massacre might have been prevented had Nancy Lanza seen the signs and found help for her son.

What about his brother or his father? What about his teachers? What about his doctors? What about the people who worked at the gun range Nancy frequented with him? What about the local grocery store owner who must’ve seen him, the other parents of his peers in school, the neighbors, the babysitter, the pastor, the mayor, the…

The documentary airs Tuesday. I’m interested to see how PBS deals with the blame factor. In response to the tweet from my classmate Christine D’Alessandro (@cmcdel) asking “Invasive? Too soon?” about the documentary, no, I don’t think so. Nancy Lanza’s dead and it’s been more than two months. That’s not the issue I raise when seeing what is already out there about this documentary.

I’m concerned that instead of this movie sparking real discussion about autism and societal awareness of children’s needs – regardless of whether Adam Lanza was autistic or not – that instead of that discussion, this movie will lead people to blame Nancy for being ignorant or for being a bad mother. The movie is, after all, titled Raising Adam Lanza and it’s marketed about being a documentary on Nancy.

A child isn’t raised by a mother. A child is raised by society. Does PBS ask those questions?

Because the point of continuing the news discussion of Newtown should be to move society forward, to keep this from happening again. And maybe the documentary will do that on Tuesday. But the marketing makes me not so sure.

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