On December 14, 2012, 20-year-old Adam Lanza shot and killed his mother in their home near Newtown, Conn. He then armed himself with guns taken from his mother’s collection, drove to the Sandy Hook Elementary School, forced his way in and opened fire. There, he killed another six adult staff members and 20 children before he fatally shot himself as the police closed in.

On July 20, 2012, 25-year-old James Eagan Holmes bought a ticket to a premiere of The Dark Knight Rises at the Century 16 multiplex theatre. Approximately half an hour into the film, he left the theatre through an emergency exit and returned minutes later wearing protective gear and armed with multiple weapons. He opened fire on the crowd, killing 12 and wounding 58 before surrendering to the police.

On January 8, 2011, 22-year-old Jared Lee Loughner shot U.S. Representative Gabrielle Giffords in the head at point blank range during a public constituent meeting held at a Safeway grocery store parking lot. Immediately after shooting Giffords, Loughner fired on the crowd in attendance, killing six and injuring 13 others. Giffords survived the attack.

There were more than a dozen mass shootings in the United States last year, raising the death toll from these events to nearly 90, plus another 60+ wounded. Looking further back, there have been more than 60 mass shootings in the U.S. since the early 1980s.

A history of violence

Mass violence of this kind is not new. The deadliest school attack in the U.S. occurred not within the last few years, but in 1927, when farmer Andrew Kehoe, facing foreclosure and outraged over the taxes raised to pay for the Bath Consolidated School in Bath Township, MI, rigged the school building to explode with more than a ton of dynamite and pyrotol. After the initial blast, Kehoe murdered his wife at their farm, drove to the school where a crowd had gathered to respond, and detonated his explosives-laden truck. Kehoe ultimately killed 58 people including himself. Thirty-eight of his victims were children.

Mass violence of this kind is not even exclusive to the United States. On the same day of the Sandy Hook massacre, a knife-wielding man in China attacked a class of young schoolchildren, wounding 22. An especially notable event took place near Oslo, Norway in 2011 when ultranationalist Anders Behring Breivik detonated a car bomb near the Prime Minister’s office building in Oslo, killing eight people. Breivik then traveled to nearby Utoya island, where he assaulted a Labour Party youth camp. For more than an hour, Breivik hunted down camp attendees and staff, and by the time he was apprehended, he had  killed 69 people and injured 110 more (55 of them, seriously). It was the single worst act of mass violence in Norway since World War II.

And yet, against such a bloody context, the Sandy Hook massacre stands out. Perhaps because the victims were so young, or perhaps because the event occurred at the end of a year when there had been so many other shootings, the shooting began a national discussion over why such events repeat themselves and what can be done to prevent them. Sandy Hook also became a comparative event for subsequent acts of violence that have captured the public’s attention: a six-day hostage standoff in Alabama that ended with the death of 65-year-old survivalist Jimmy Lee Dykes; the Texas shooting range murder of retired Navy SEAL sniper Chris Kyle; the serial murder of police officers by Christopher Jordan Dorner in California, which ended with Dorner’s death after he was cornered in a mountain cabin.

The number of people killed at Sandy Hook — and in all U.S. mass violence events combined for 2012 — is miniscule compared to the nearly 14,000 homicides and nonnegligent manslaughters that the FBI reports as having occurred in the U.S. in 2011 alone. The United States lives with almost constant murder and manslaughter, and yet, it is the incidents of mass violence that shock the public into calls for action. Predictably, gun control has dominated the discussion on how to address mass violence — it has been at the forefront of the White House task force convened in response to the Sandy Hook shooting — but, for many, restricting weapons access overlooks a far more important issue: mental health.

A history of illness

Of the numerous mass shooters in 2012, many of them exhibited clear signs of mental illness. Adam Lanza had a well-documented history of mental instability, which his mother tried — tragically and ironically — to address by training him how to shoot firearms. James Eagan Holmes, the Aurora shooter, was reported to have exhibited signs of mental disturbance significant enough for him to fail a membership application to a local gun range shortly before the cinema shooting. Jared Lee Loughner, though found sane enough to stand trial for the Tucson shooting, was diagnosed with paranoid schizophrenia by two different medical evaluations.

In January 2013, less than a month after Sandy Hook, the National Alliance on Mental Illness (NAMI), a grassroots organization dedicated to improving mental health, met with Vice President Joe Biden’s task force and urged action to strengthen and expand the nation’s mental health care services.

NAMI stressed four key points during the meeting. First: that the current system of obtaining adequate mental health care is, for most, impossible to navigate, especially when it comes to getting access to early identification and intervention, treatment and support of those showing signs of mental illness. Second: that school personnel, law enforcement, families and community leaders receive training so they might better identify and respond to those experiencing mental health issues. Third: that school-based mental health services receive better support, so that children and young adults with mental health issues can receive treatment and continue their education. Fourth: that key provisions in the Patient Protection and Affordable Care Act (PPACA), including mental health parity provisions, receive full implementation.

NAMI executive director Michael J. Fitzpatrick said that the Task Force’s recommendations, whatever they are, must include mental health care. “Treatment works — if a person can get it,” Fitzpatrick said. “We must have a national dialogue that builds systems of care that provide treatment and support to people who need it, when they need it.”

Fitzpatrick’s call for better mental health services echoed what had already been said by others in the days that followed Sandy Hook, but few matched the viral intensity of one blogger named Liza Long, Chair of General Education at Brown Mackie College-Boise in Boise, Idaho. Long responded to Sandy Hook with a detailed essay entitled “I am Adam Lanza’s mother,” in which she identified with the Lanza family, and the difficulties of raising a child with mental illness leading to violent tendencies. According to Long, getting her son the mental health care he needs is a significant challenge, and would be unaffordable if she did not have employer-provided health coverage. Without that, her son’s best hope for getting care would be if he entered the penal system, which would likely happen only after he committed the kind of act his treatment is meant to prevent. “I love my son,” Long wrote. “But he terrifies me.”

Long’s post quickly drew huge numbers of comments. Some responded viscerally to Long’s call for a national dialogue on the subject, criticizing Long personally. Still others criticized the connection being made between acts of violence and mental illness.

But there was a huge amount of supportive feedback as well, especially from those who echoed Long’s observation that actually getting adequate mental health care, especially for someone who might need it but not necessarily want it, can be nearly impossible. One response published by an unidentified psychiatrist laid the gauntlet at the feet of the health insurance industry. “My main complaint is with you,” the author wrote. “You make it so hard to keep people in the hospital when they need to be there, and it’s even harder to keep them in intensive outpatient services. Please create protocols for difficult cases and loosen the purse strings for extremely troubled individuals — before it’s too late.”

Meanwhile, the health insurance industry — arguably the one private group with more to gain or lose from a national conversation about mental health care than any other — has remained noticeably silent.

Since the Sandy Hook massacre, of the 25 largest U.S. health insurers, only two — Cigna and Aetna Group — issued any kind of public statement in response to the event, and in both cases, it was to announce that they had set up telephone support lines for those affected by the tragedy. In the case of Cigna, it offered two weeks of telephonic crisis support services. Two other health insurers operating in Connecticut also recognized the tragedy: Anthem Blue Cross Blue Shield of Connecticut publicly announced that those affected by Sandy Hook could make use of Anthem’s own Employee Assistance Program, which provided telephonic crisis support, much like the services Cigna offered. ConnectiCare also offered the use of a crisis hotline as well as access to other crisis care resources.

Other than that, there was no response from the health insurance industry on Sandy Hook, nor on any of the other mass violence events of the year, and certainly nothing to echo NAMI’s call for better mental health services across the board. In contrast, since Sandy Hook, most major health insurance companies have issued public announcements regarding the effects of health care reform. One made a public notice about how much weight its staff members had collectively lost. But this indifference hardly seems surprising, as the health insurance industry never had a particularly strong record when it came to mental health care in the first place.

The issue of parity

Like acts of mass violence, mental illness in the U.S. is nothing new. According to the Substance Abuse and Mental Health Services Administration, 45.6 million Americans — almost 20 percent of the population—suffered from some kind of mental illness in 2011. Of these, some 11.5 million — almost five percent of the population — suffered from a serious mental illness. Despite this, however, most private health plans traditionally either did not cover mental health services of any kind or they imposed a large deductible for services — $2,000 or more in some cases, putting necessary care out of financial reach even for those who were insured.

In recent years, to address a lack of mental health care coverage, various states enacted their own laws requiring health insurers to at least offer some form of mental health care as part of their insurance offerings. These ranged from simple therapy services to addiction counseling to treatments for more serious mental disease. As of 2010, however, only 22 states plus the District of Columbia had any laws requiring insurers to offer mental health care. Of those, 18 require insurers to cover mental health; the other four only require insurers to offer such coverage. Nine of those states limit their requirements to “biologically based mental illness” and/or “severe mental illness,” which typically include conditions such as major depressive disorder, schizophrenia and bipolar disorder. In 10 states plus the District of Columbia, minimum levels of coverage are specified. All other states have no laws mandating mental health coverage and are not required to enact any.

But what is perhaps more important is that the states that require coverage are the ones that require parity — that insurers must provide at least as much coverage for mental health care as for physical health care. In this regard, 14 states — Arkansas, California, Connecticut, Delaware, Hawaii, Maine, Massachusetts, Montana, New Jersey, Ohio, Rhode Island, South Dakota, Vermont and Washington — require parity.

In addition, there is a series of federal parity laws going back to the Clinton Administration. The Mental Health Parity Act of 1996 requires parity in annual and aggregate lifetime limits. The Mental Health Parity and Addiction Equity Act of 2008 expands parity requirements to treatment limitations, financial requirements (such as co-payments) and in- and out-of-network covered benefits. Despite these laws, however, some health insurers have used tactics such as “partial denial” to essentially find a workaround to parity laws; a policyholder who needs four days of therapy a week only gets covered for two, for example, in the mental health equivalent of giving somebody half of a chemotherapy treatment. More importantly, the federal parity laws themselves are not even fully implemented, robbing them of any real sticking power.

PPACA sought to address this with provisions that expand the reach of applicability of extant federal parity standards and mandated the coverage of certain mental health and substance abuse services that have yet to be formally identified. Overall, PPACA is a porous law when it comes to strengthening mental health care coverage, essentially allowing the states themselves to continue applying and enforcing their own parity standards rather than hew to a federal one.

Such enforcement seems to carry little weight. New York recently fined insurers a total of $2.7 million for failure to abide by Timothy’s Law, which requires insurers to notify small businesses that they were eligible to buy special insurance coverage for mental illnesses and children with serious emotional disturbances. Oxford was fined $1.3 million. Empire nearly $500,000. MVP and HealthNet more than $200,000 each. But critics point out that such fines amount to a slap on the wrist. In the case of HealthNet alone, its CEO was paid $4.4 million in 2008, and presumably could have funded his company’s fine personally out of pocket. This, in an industry where, healthcare reform advocates point out, UnitedHealth, WellPoint, Aetna, Cigna and Humana collectively made some $14 billion in profit in the first half of 2011 alone. At that scale, New York’s enforcement efforts are very nearly a hollow effort to spur an industry that, had it already proven its intent to improve its mental health care offerings to the public, would not have been mandated by so many states to bring such offerings to market.

Moreover, since the passage of PPACA, a report from the Government Accountability Office notes that there are many more types of mental health and substance abuse treatment exclusions in employers’ 2010 and 2011 plan documents than there were in 2008. Put another way: the passage of health care reform has resulted in employers offering less mental health care coverage, not more.

The cost catalyst

It is easy to see why the industry has kept such distance from providing better mental health care services to its clients. According to a 2012 survey on health care costs by the Health Care Cost Institute, the average inpatient cost for mental health and substance abuse services ran $7,114. While this comes in fourth out of five inpatient categories (medical: $12,036, surgical: $27,100, deliveries and newborns: $7,371 and skilled nursing facility: $5,205), it was the category that changed the most from 2009-2010, by 8.6 percent.

The average length of stay for mental health and substance abuse was 7.3 days, nearly twice as long as surgical visits (4.1 days) but almost half the duration of skilled nursing (16.3 days). Once again, the average length of stay for mental health/substance abuse was the biggest gainer from 2009-2010, at 5.1 percent, while all other categories decreased.

The average change in price per mental health/substance abuse service went up nine percent from 2009-2010, while the actual usage of such services remained flat, showing an increase in how these services are priced rather than how much they actually cost. Failure to rein in health care costs has long been a central criticism of PPACA by health insurers. However, there appears to be little evidence whatsoever that the same insurers who are ultimately passing along the cost of health care in the form of insurance premiums have made any attempt to encourage the health care providers with which they do business to scale back what they charge.

At the time of this writing, the country is between mass shootings. There is no telling when the next one will occur, or how many lives it will claim. But one thing is certain: as long as there remains an open discussion not just on gun control, but on addressing the violent outbursts of the mentally ill, then it is only a matter of time before the American public and its legislators turn their attention from forcing the small arms industry to restrict its business to forcing the health insurance industry to expand its own. If PPACA is any measure, waiting for the federal government to legislate solutions where the market fails to act tends to deliver results that the market quickly regrets. Whether the same will be said regarding health insurance and mental health care remains to be seen. But there will be another mass shooting in the United States, and one after that, and one after that. And with each bloody incident, the industry is forced one step closer to taking some kind of preventive action on behalf of the mentally ill, whether it wants to or not. The question, then, is: Will the industry plot its own course of action, or will it let its legislators do it for them? Time to find out.

This is the first in a series of articles addressing the state of mental health care insurance and its role in helping to prevent acts of violence. Read the second part of this series here.


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