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A bad combination
Linking gun control, mental health bills questioned

By Jessica Zigmond
Posted: April 27, 2013 - 12:01 am ET

With the Senate's gun-control legislation stalled—and mental health provisions along with it—behavioral healthcare advocates wonder whether tying the issues together is the right approach.

Both topics were raised in the days after the shooting massacre at Sandy Hook Elementary School in Newtown, Conn., that horrified the country last December. A month later, President Barack Obama released a plan to reduce gun violence in America that listed improving mental health services as one of its core components.

The two hot-button issues became further intertwined when mental health amendments were attached to Sen. Harry Reid's Safe Communities, Safe Schools Act.

Reid (D-Nev.) said on the Senate floor April 17 that the legislation “will honor the memory of 20 first-graders and six of their teachers who were killed last year in Newtown, Connecticut—as well as tens of thousands of others who are killed by guns each year—by voting on a number of measures to strengthen the laws that prevent gun violence in this nation.”

The plea was unsuccessful. After an amendment on background checks for gun buyers failed to receive 60 votes, Reid set the bill aside.

Reid's bill included a bipartisan amendment from Sens. Tom Harkin (D-Iowa) and Lamar Alexander (R-Tenn.) that would reauthorize education and health programs related to mental health conditions. Meanwhile, a proposed amendment from Sens. Debbie Stabenow (D-Mich.) and Roy Blunt (R-Mo.)—the Excellence in Mental Health Act—would enhance access to community behavioral health services and make changes to Medicaid payment for those services. The Senate didn't consider that amendment before Reid pulled the full legislation.

With those mental healthcare provisions connected to the gun-control bill, the question now is: Does hitting the pause button on gun-control legislation have the same effect on mental healthcare efforts in Washington?

“The president has said this was Round 1, the majority leader said he'd like to return to it, and the question is when will that return?” said Chuck Ingoglia, vice president of public policy at the National Council for Community Behavioral Healthcare, whose group did not have a formal position on the gun bill. Ingoglia said that he thinks the overall bill will be the basis for continued discussions and that a merger of different amendments will shape that discussion. And as those conversations take place, behavioral healthcare advocates prefer that mental healthcare legislation not be part of the gun-control debate.

“We don't think it's the right way to go because it adds to the stigma of mental health—it would mean that people who have mental health problems are violent by nature,” said Mark Covall, president and CEO of the National Association of Psychiatric Health Systems.

Covall, Ingoglia and others emphasized that the majority of people with mental illness are victims, rather than perpetrators, of violence.   

“The problem is: The ability to predict who will use a gun to hurt themselves or someone else is pretty limited,” said Dr. Marvin Swartz, division head of social and community psychiatry at Duke University. “Two-thirds of gun violence by people with mental illness is by suicide.”

Still, Covall said anything that “moves the ball forward” on access to mental health treatment is a good thing. That message was echoed by Wayne Lindstrom, president and CEO of not-for-profit advocacy group Mental Health America.

“From a pragmatic standpoint, while I don't like the vehicle and prefer it to stand on its own, if it ultimately helps the population we advocate for, I support that,” Lindstrom said.

Lindstrom's group strongly supports the Harkin-Alexander amendment to the gun bill, which the Senate approved 95-2. The near-unanimous support for that measure sends a strong signal to other lawmakers and the behavioral healthcare community that there is still momentum in the Senate to bolster mental healthcare services in America this year. And that amendment, originally drafted as a bill in the Senate Health, Education, Labor and Pensions, or HELP, Committee—where Harkin serves as chairman and Alexander as ranking member—has a clearer path to passage, said Ingoglia of the National Council.

That's primarily because the legislation is a reauthorization bill for mental health services, also because it garnered such solid support from both Democrats and Republicans. Called the Mental Health Awareness and Improvement Act, Harkin and Alexander's amendment would reauthorize the Garrett Lee Smith Memorial Act to provide information and training for suicide prevention; grants to states, Indian tribes and not-for-profit private entities to train teachers and other personnel about the signs and symptoms of mental illness; and a National Child Traumatic Stress Initiative to support a network of child trauma centers that includes university, hospital and community-based centers as members.

Meanwhile, the amendment from Stabenow and Blunt that was tied to the stalled gun legislation would create criteria to establish federally qualified behavioral health centers, which would serve those with mental illnesses and addiction disorders through multidisciplinary, evidence-based screening, assessment, prevention and treatment, according to a summary from the National Council. It would also extend current Medicaid policy for federally qualified health centers and rural health clinics—which are reimbursed through a prospective payment system—to these new federally qualified behavioral health centers.

That payment strategy might prove a thorny issue, as the National Association of Medicaid Directors opposes it. In a letter to the Senate HELP Committee, the association's leaders wrote that Medicaid currently is required to reimburse federally qualified health centers per-visit based on cost. Consequently, the letter noted, states are facing problems incorporating FQHCs in care-improvement initiatives because of the Medicaid prospective payment system.

Matt Salo, executive director of NAMD, said in an interview that Stabenow's bill would create similar entities for behavioral health “and give them the same federally mandated, inflated, bloated payment rate. It is so many flavors of wrong, it doesn't make any sense.”

But Lindstrom of Mental Health America said he thinks the payment structure can be based on a prospective payment system and still be accountable for outcomes. Meanwhile, as his organization waits to see how and if these mental health bills resurface on Capitol Hill, they're also waiting for the Obama administration to launch a series of town hall meetings on mental healthcare.

Obama's gun-control strategy called for a “national dialogue” on the issue with HHS Secretary Kathleen Sebelius and Education Secretary Arne Duncan. Lindstrom said it appears that the White House has gotten 10 major cities to host the meetings throughout the rest of the year and expects an announcement in early May. The idea for those meetings, Lindstrom said, is to keep mental healthcare at the forefront in an effort to “remove the stigma, heighten the conversation, and result in better public policy.”

Follow Jessica Zigmond on Twitter: @MHjzigmond

President Obama hugs Nicole Hockley, the mother of a Newtown shooting victim, last week. Gun control legislation stalled in the Senate, and with it mental health provisions.
Photo credit: GETTY IMAGES

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