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 long-anticipated 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 background-check system for all gun purchases, banning military-style assault weapons and high-capacity 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 government 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
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.”