Thursday, January 27, 2011

The Devil Inside: Access to Mental Health Care in the United States

This is third and final posting in a series on the shooting of 13 people in Tucson and its implications for health and social policy in the US. This post is by Robyn R. Liu, MD, who is a family physician in the frontier town of Tribune, KS, in the far western part of the state.

The day Gabrielle Giffords and 19 others were shot is one of those days that most Americans will remember where they were when they heard the news. What I will remember is my husband saying, “A congresswoman was shot in Arizona. She was on Sarah Palin’s crosshairs map.” As our picture of the alleged shooter became more complete, we realized he was not playing John Hinckley, Jr. to Palin’s Jodie Foster. Rather, he is in all likelihood a very disturbed, mentally ill young man.

A CNN/Opinion Research poll demonstrates that most of the public agrees, and thinks that the lack of mental health resources was in part responsible for the horrific act of that day: 41% said a “great deal,” and 29% said a “moderate amount.” When NPR went to a gun show held in Tucson just seven days after the shooting, the man at the front of the line said, “Mentally ill individual, very troubled individual that unfortunately slipped through the cracks somehow. And I think that’s what we need to look at, is how did this fellow get missed.”

As a primary care doctor in a frontier state, I can tell you, those cracks are pretty big.

I wrote a piece last week for another blog about one patient’s experience with the mental health system here in Kansas. This was a patient with insurance and a continuity relationship with a psychiatrist – and even she “fell through the cracks” more than once, although her violence was all self-directed and thus never made headlines. We do not know what Jared Lee Loughner’s health insurance status was, nor whether he had ever sought a therapeutic relationship with a mental health professional. We do know that although his behavior got him rejected from both college and the military, he was able legally to purchase a handgun and a 30-round magazine. As Dr. Dora Wang noted this week in Psychology Today, “It’s easier to get a gun than mental health care.”

I decided to do some looking into mental health services in Arizona. I went to the home page of the Arizona Medicaid program, forthrightly if a bit unfeelingly called the “Arizona Health Care Cost Containment System,” or AHCCCS. I already knew that AHCCCS was looking at cuts in Governor Jan Brewer’s new budget, since by her direction 98 people had had their transplants rescinded under this program. The Division of Behavioral Health Services website describes how the governor’s proposed 2011 budget would alter Medicaid eligibility criteria for “childless adults” like Loughner, possibly removing coverage for 5,200 Arizona citizens with “serious mental illnesses.” The writer hopes, however, that a loophole in the policy will allow “more than 80% of these folks” to maintain coverage under a different Medicaid category. Oh, thank goodness! Now only 1,040 seriously mentally ill people will suddenly find themselves high and dry in Arizona.

The longer we as a society refuse to provide universal health care, with complete parity for mental health, the wider these cracks are going to get. It wasn’t an illegal immigrant who shot down a federal judge, a pastor, two homemakers, a social worker, and a little girl in cold blood. A retired Marine is not lying in the hospital with bullet wounds he suffered trying to protect his now-dead wife because of a drug-smuggling Mexican. Arizona is worried about protecting its borders, but its greatest threat may already be inside. Imagine over 1,000 Loughners walking the streets with no means to get help: it’s absolutely chilling.


Postscript from Josh:

In the January 27, 2011 NY Times, columnist Gail Collins quotes Senator Tom Coburn of Oklahoma from an appearance on "Meet the Press":
“The people that are going to commit a crime or are going to do something crazy aren’t going to pay attention to the laws in the first place. Let’s fix the real problem. Here’s a mentally deranged person who had access to a gun that should not have had access to a gun.”
As Senator Coburn is a physician, he should know. And, hopefully, he will sponsor legislation to create some rational limits on gun access, as well as increasing access to mental health services. But I wouldn't hold my breath.

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