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Analysis of the mental health provisions of the Executive Action on Reducing Gun Violence announced by President Obama on Jan 4, 2016.

Prepared by Mental Illness Policy Org. (http://mentalillnesspolicy.org)


Summary


The $500 million proposed investment in mental health services should be narrowly targeted to increasing access to evidence based treatments that reduce violence, homelessness, arrest, incarceration, and suicide in adults known to have serious mental illness. There are many sections of the Executive Order that do not do that. The administration should use the funds to support  proposals put forth by Representatives Tim Murphy (R., PA) and Eddie-Bernice Johnson (D., TX), in the Helping Families in Mental Health Crisis Act (HR2646)


The Executive Order provisions to add persons with serious mental illness who have been deemed by courts too ill to manage their own funds to the NICS database are appropriate as are the provisions to carve out narrow exemptions in HIPAA to allow the reporting.


Data Points used for our analysis:

  • People with serious mental illness who are allowed to go untreated are more violent than others.  
  • People with any mental illness, and the seriously ill who receive treatment, are no more violent than others. This violence occurs to self and others.
  • Because gun violence is so rare, and mass violence by people with guns even rarer, the effect of prohibiting people with mental illness from owning guns is unclear.
  • Providing treatment to people with serious mental illness reduces overall violence (knives, guns, fists, furniture, etc.) and reduces homelessness, hospitalization, suicide and cost to taxpayers
  • Whether or not America adopts gun restrictions people with serious mental illness need better care.

Executive Order’s Introduction (followed by our analysis)


Increase Mental Health Treatment and Reporting to the Background Check System


“The Administration is committed to improving care for Americans experiencing mental health issues. In the last seven years, our country has made extraordinary progress in expanding mental health coverage for millions of Americans. This includes the Affordable Care Act’s end to insurance company discrimination based on pre-existing conditions, required coverage of mental health and substance use disorder services in the individual and small group markets, and an expansion of mental health and substance use disorder parity policies, all of which are estimated to help more than 60 million Americans. About 13.5 million more Americans have gained Medicaid coverage since October 2013, significantly improving access to mental health care. And thanks to more than $100 million in funding from the Affordable Care Act, community health centers have expanded behavioral health services for nearly 900,000 people nationwide over the past two years. We must continue to remove the stigma around mental illness and its treatment—and make sure that these individuals and their families know they are not alone. While individuals with mental illness are more likely to be victims of violence than perpetrators, incidents of violence continue to highlight a crisis in America’s mental health system. In addition to helping people get the treatment they need, we must make sure we keep guns out of the hands of those who are prohibited by law from having them.“


Analysis: The Executive Order focuses on those with “mental health issues.” That is far too broad. The focus should be people known to have serious mental illness as they are the ones most likely to become violent, arrested, incarcerated, homeless, suicidal and an expense to taxpayers.


The Executive Order properly notes that ACA has benefitted people with mental illness by eliminating discrimination based on pre-existing conditions, and offering parity in private insurance. However, Medicaid is still the largest source of discrimination against those with serious mental illness. Medicaid funds hospital services for everyone who is eligible, except one group: adults with serious mental illness. Medicaid’s “IMD Exclusion” causes state psychiatric hospitals to lock the front door and kick the seriously mentally ill out the back because the federal government won’t help provide for their care. This causes needless violence, homelessness, arrest and incarceration. We are also getting increasing reports that people with serious mental illness are being forced to wait months for appointments with doctors.


The Executive Order repeats the mental health industry mantra that stigma’ is an important barrier to care, but research shows, ‘stigma’ is far behind cost, lack of availability, lack of transportation, and anosognosia (lack of awareness of illness) in driving people from care. The Executive Order repeats a misleading platitude that people with mental illness are more likely to be victims than perpetrators. Those studies are not of equivalent populations or limited to the seriously ill. Studies of equivalent populations show people with serious mental illness are more likely to be perpetrators of injury causing violence than victims of it.


Executive Order’s Specifics (followed by our analysis)



“1. Dedicate significant new resources to increase access to mental health care. 

Despite our recent significant gains, less than half of children and adults with diagnosable mental health problems receive the treatment they need. To address this, the Administration is proposing a new $500 million investment to help engage individuals with serious mental illness in care, improve access to care by increasing service capacity and the behavioral health workforce, and ensure that behavioral health care systems work for everyone. This effort would increase access to mental health services to protect the health of children and communities, prevent suicide, and promote mental health as a top priority.”


Analysis: Mental Illness Policy Org welcomes new investments in mental illness treatment, especially those designed to “improve access to care by increasing service capacity.” We are concerned other sections of the order do not focus the investments on delivering evidence-based treatments that reduce violence in adults known to have serious mental illness. Instead they divert funds to programs that “work for everyone”, “protect health of children and communities” and “promote mental health.” The investments appear to be going to those with “diagnosable mental health problems” (18% of adults), rather than those with “serious mental illness” (4% of adults). Past proposals for investments by President Obama have also been to amorphous programs supported by the mental health industry, that have no impact on people with serious mental illness.  We would encourage him to spend all the $500 million on those that “improve access to care by increasing service capacity” for people known to have serious mental illness



“2. Include information from the Social Security Administration in the background check system about beneficiaries who are prohibited from possessing a firearm. 

 

Current law prohibits individuals from buying a gun if, because of a mental health issue, they are either a danger to themselves or others or are unable to manage their own affairs. The Social Security Administration (SSA) has indicated that it will begin the rulemaking process to ensure that appropriate information in its records is reported to NICS. The reporting that SSA, in consultation with the Department of Justice, is expected to require will cover appropriate records of the approximately 75,000 people each year who have a documented mental health issue, receive disability benefits, and are unable to manage those benefits because of their mental impairment, or who have been found by a state or federal court to be legally incompetent. The rulemaking will also provide a mechanism for people to seek relief from the federal prohibition on possessing a firearm for reasons related to mental health.”


Analysis: Mental Illness Policy Org supports this proposal which essentially requires SSA to report to NICS recipients of benefits who are so mentally incapacitated the court has assigned them a representative payee to manage their money. We believe this represents a group of seriously mentally ill individuals who should not own firearms. Some in the mental health industry will oppose this by arguing that preventing people with mental illness who are seriously ill from owning guns is a violation of second amendment rights. We disagree. It is an appropriate use of the states police powers and parens patraie powers, since those weapons can also be used to harm self. Some in the mental health industry argue the provision inappropriately links mental illness and violence, but that denies the association between untreated serious mental illness and violence.


“3. Remove unnecessary legal barriers preventing States from reporting relevant information to the background check system.

 Although States generally report criminal history information to NICS, many continue to report little information about individuals who are prohibited by Federal law from possessing or receiving a gun for specific mental health reasons. Some State officials raised concerns about whether such reporting would be precluded by the Privacy Rule issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Today, the Department of Health and Human Services issued a final rule expressly permitting certain HIPAA covered entities to provide to the NICS limited demographic and other necessary information about these individuals.”


Analysis: Mental Illness Policy Org supports this proposal. Some in the mental health industry will argue that reporting people with mental illness to a gun database will cause them to avoid care so they are not reported to the database. Research does not support that. The overriding concern must be keeping the patient they are currently seeing alive and those around them safe — not some hypothetical future client.  It is an appropriate use of the states police powers and parens patraie powers, since those weapons can also be used to harm self. Some in the mental health industry argue the provision inappropriately links mental illness and violence, but that denies the association between untreated serious mental illness and violence.


Conclusions


The $500 million proposed investment in mental health services should be narrowly targeted to increasing access to evidence based treatments that reduce violence, homelessness, arrest, incarceration, and suicide in adults known to have serious mental illness. There are many sections of The Helping Families in Mental Health Crisis Act that do this and sections of the Executive Order that do not.
The Executive Order provisions to add persons with serious mental illness who have been deemed by courts too ill to manage their own funds to the NICS database are appropriate as are the provisions to carve out narrow exemptions in HIPAA to allow the reporting.

Date: 1/5/2016

 

 


The information on Mental Illness Policy Org. is not legal advice or medical advice. Do not rely on it. Discuss with your lawyer or medical doctor. Mental Illness Policy Org was founded in February 2011 and recently received 501(c)(3) status. In order to maintain independence MIPO does not accept any donations from companies in the health care industry or government. That makes us dependent on the generosity of people who care about these issues. If you can support our work, please send a donation to Mental Illness Policy Org., 50 East 129 St., Suite PH7, New York, NY 10035. Thank you. For more information, http://mentalillnesspolicy.org.