Panel Discusses New Firearm Legislation & Mental Health Provisions

Researchers generally agree that allocating Medicaid dollars to behavioral health clinics, telehealth efforts, and school screenings will do little or nothing to prevent mass shootings. But could it be a game-changer for mental health programs? A panel of experts weigh in.

On June 25, President Biden signed the Bipartisan Safer Communities Act into law—a rare move as the country’s political divide continues to expand.

Among the new firearm legislation’s components are several provisions addressing mental health. All states now have access to enhanced Medicaid funds to pay for care at behavioral health clinics. There is also increased Medicaid funding for telehealth integration into value-based care models and screening programs at schools—all in the name of addressing gun violence and mass shootings in particular. How these measures affect the nation’s increases in gun violence is debatable. Some research shows initiatives will not significantly address mass shootings but might prevent self-harm events.

As Jeffrey W Swanson, a sociologist at Duke University who has studied violence and mental illness for more than 30 years, noted recently in an interview with The New York Times, “If we were to succeed, wildly succeed, in fixing the mental health care system and cure schizophrenia, bipolar disorder, and major depression, our violence rate would go down by 4%.”

While any decrease, however minimal, would be welcome news in a nation that seems to be waiting collectively on tenterhooks for the next heartbreaking act of mass violence to occur, most gun violence researchers agree that a more focused approach is needed. The behavioral health provisions in the new law are akin to a fishing crew casting a very wide net into the ocean and catching a lot of fish, but not the kind of fish the crew intended to catch.

But is that such a bad thing in this case? Some mental health advocates are looking at the silver lining. In a recent article in Roll Call, Hannah Wesolowski, chief advocacy officer of government relations for the National Alliance on Mental Illness, said the potential benefit is a “game-changer for mental health. Having that resource available in communities can go a long way to address mental health access issues.”

We asked a group of managed care experts to give us their take. Will the law have its intended impact on mass shootings/gun violence? Is Ms Wesolowski correct in her assessment that these provisions are a boon to behavioral health programs and patients who need them? What needs to happen to ensure the outcome Ms Wesolowski is hoping for? And, finally, what can and should commercial payers be doing to address the behavioral health challenges the United States faces as it emerges slowly from a waning but still present pandemic and economic downturn?

Will the law’s mental health provisions move the needle on mass shootings and gun violence?

Consensus: No. It may help lower the number of firearm suicides. Thus, at best, it is a small step in the right direction.

Gary Owens, MD, president of Gary Owens Associates in Ocean View, DE, said that while it is tempting to link mental illness and gun violence, he agrees that these provisions will have a negligible impact. “However, if the increased funding helps identify those with depression or other conditions that predispose an individual to suicide and helps decrease those deaths, then there is a significant benefit.” The fact is, more than half of gun deaths are suicides, so the upside is clear. As for the impact on mass shootings, “Until we have the ability to restrict or eliminate access to weapons of mass murder, we will still have mass shootings in this country,” noted Dr Owens.

William Rogers, MD, chief medical officer at Applied Policy in Washington, DC, agreed. “This will not impact mass shootings, at all. It may impact suicides to some extent.” Though the bill is not a panacea, Larry Hsu, MD, medical director at the Hawaii Medical Service Association in Honolulu, HI, said he thinks it is a step in the right direction. “Legislatively, up until now, there has been nothing significant passed that deals with gun violence. Now, with bipartisan support, at least they are trying to address behavioral health issues.”

Whether it helps or not, F Randy Vogenberg, PhD, RPh, principal at the Institute for Integrated Healthcare in Greenville, SC, was mindful of how things move along in Washington, DC. “Funds will not be available immediately—they likely won’t be for another 12 to 24 months. Then it takes time to implement programs.” Once the programs are in place, he thinks the impact on gun violence will be modest at best. The efforts at the national level “are following failed state attempts to address gun-related violence. Without applying objective, effective change, we are continuing to throw good money after bad with efforts that are not addressing the root causes.”

Still, there is great pressure to do something, no matter how little it might be, explained Norm Smith, a principal payer market research consultant in Philadelphia, PA. He likened the gun debate to the abortion controversy. There are absolutists on both sides, but also “a fairly large group in the middle that is willing to find areas of agreement where access can be limited in some ways. The way Japan limits guns sounds to me like a reasonable model to follow.”

Will the mental health provisions prove to be a boon to the behavioral health system and patients?

Consensus: They could—if funds are channeled to programs that directly benefit patients. However, Washington’s record in this regard is spotty.

“Any increase in funding for mental health care will be a positive,” noted Dr Owens. He pointed to the dual issues of lack of access and stigma, the latter of which particularly impacts men and younger individuals. “Any funding that increases access or improves public awareness of the mental health issues should have some positive benefit.” Dr Owens added that proper distribution and use of funds will determine how much benefit is realized.

Dr Hsu agreed. “If the funding goes to behavioral health clinics, this will open access to people who need support. Funding and access have always been an issue, particularly in rural and underserved areas. Now, with more knowledge of the need to deal with behavioral health issues and gun violence, this may open more behavioral clinic doors to address the community needs.”

Channeling funds optimally “requires federal and state alignment to make funds available in a timely, as well as appropriate regulatory manner—not an easy thing to do,” explained Dr Vogenberg. Plus, “Medicaid targeted funding is self-limiting and represents a narrow target that has been underfunded for decades.” Moreover, added Mr Smith, even if funds are properly channeled, training caregivers will take time and maintaining skills and knowledge will take effort. “Long term, staffing appears to be a big issue,” he said.

Dr Rogers has little faith that funds will be channeled optimally. “As someone who has been involved in this for decades, I get cynical when I see Washington trying to address a problem by just shoveling money thoughtlessly into the maw of the health care delivery system. I’m sure that the system will effectively consume the money. But whether that actually translates into effective programs that address the needs of patients with mental illnesses is another question. I’ve never seen evidence that this is an effective strategy, so I’m not at all optimistic.”

What can be done to ensure most of the funding reaches patients?

Consensus: In the real world of the fragmented US health care system, not much. But that did not stop some experts from aspirational thinking.

The answers to this question were largely aspirational in nature. Dr Rogers started his assessment with a chuckle that seemed to imply he had little hope anything meaningful could be done under the current system. But theoretically, “You could direct the [United States Department of Veterans Affairs (VA)] to start providing mental health services to all individuals, not just veterans. That way, there would be a place for people to get care, a medical record system in place, as well as a follow-up system. Other than the VA, there isn’t a national system that could pull this off.” Short of that, Dr Rogers suggested giving the reins to the states, which “tend to be a little bit more thoughtful about where the money goes.”

Perhaps if the states were in charge, Dr Hsu’s vision of increased patient access would be realized. “Direct funds to programs that give more patients access to behavioral health clinics—and allow the clinics to support the needs of their local population. That would be a major positive step.”

Mr Smith said the key will be to set concrete goals that are arrived at by consensus but conflicts across the aisle would imply funds might not go where intended otherwise.

Meanwhile, Drs Vogenberg and Owens basically threw their hands up when asked this question.

“Like it or not, behavioral health remains a stepchild to other pressing issues in health care delivery,” explained Dr Vogenberg. He implied that a gun bill will not do the trick. “Without real societal change and sustained financial backing to address mental health over multiple years, we are likely to see the same status year-over-year through the end of this decade.”

“I really don’t have a good crystal ball on this,” said Dr Owens. “Our fragmented US health care system is not often adept at using new funds efficiently, so only time will tell how much benefit, if any, we will likely see from this legislation.”

Are commercial payers doing enough to address behavioral health issues, especially in light of fallout from the pandemic and a downtrodden economy?

Consensus: Commercial insurers should be doing more, but a myopic view in the name of profit obscures a long-term, outcomes-based approach.

“Commercial payers can always do more to improve mental health care, but funding is needed,” said Dr Owens. “Such funding comes from employers and individuals. However, increasing employer cost for health care or increasing individual premiums is not easily done in an era of economic downturn, increased inflation, and unprecedented rising health care cost.” Dr Vogenberg agreed, and suggested the sour economy is but an excuse for inaction. “The rhetoric is strong and passionate, but little has changed in a significant way over the years. Action is lacking.”

Dr Hsu reiterated that whether a mental health program is funded by the government or under a commercial plan, increased access is key. He suggested commercial sponsors start by addressing social determinants of health that pose barriers to mental health services. Dr Rogers said commercial payers have little or no appetite for that. “Commercial insurers are incentivized to deliver as few services as possible during the enrollment period that the patient is in. That’s the bottom line. To expect them to spend more money than the bare minimum
is unrealistic.”