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A mental health report card for all 50 states

By Bill Coffin, Danni Santana, Juliahna Green

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Bath County, Virginia does not seem like a typical place for a murder-suicide story to grab national attention, but then again, what place would? Bath County is a sleepy rural expanse on the border of West Virginia, home to not even 5,000 residents whose major industries are a local hydroelectric plant and a variety of hot mineral springs. It is represented in the Virginia state Senate by 55-year-old Creigh Deeds, a Democrat whose long political career has earned him the friendship and respect of his colleagues on either side of the aisle.

Deeds joined the House of Delegates in 1992 and in 2001, he joined the Senate. There, he ran for attorney general in 2005, and for governor in 2009. Both times, he was beaten by the current governor, Bob McDonnell. Deeds’ gubernatorial loss was compounded when in 2010, his marriage collapsed, the result of more than 20 years of the pressures that come with a political career. Deeds’ friends noted that he has going through a rough time. But that would be nothing compared to the early morning hours of Tuesday, November 19, when his son 24-year-old son Austin stabbed him multiple times in the head and upper body, and then killed himself with a single gunshot.

As yet, details on what exactly transpired in the moments leading to the attempted murder-suicide remain sparse.

After his stabbing, Deeds, escaped his home and walked some 75 yards to a nearby road where a cousin picked him up and brought him to a nearby farm. From there, Deeds was flown to the University of Virginia Medical Center in Charlottesville. He was immediately listed in critical condition but soon upgraded to stable. Conscious and lucid upon admission, Deeds was able to relate details of what transpired during the attack, but those details have not yet been made public. They may never be. There, he quickly upgraded from critical to fair condition, and three days later, he went home. Hours after his release from the hospital, he tweeted, “I am alive so must live. Some wounds won’t heal. Your prayers and your friendship are important to me.”

Austin “Gus” Deeds was one of four children, and had been attending the College of William and Mary since 2007, though not continuously. Earlier this semester, he withdrew from school and was not enrolled at the time of his death. He was regarded as a good student with a strong academic record.

Austin was charged with underage possession of alcohol in 2009, though those charges were later dropped. According to the Richmond Times-Dispatch, by Monday, November 18, Austin was evaluated at Bath Community Hospital, under an emergency custody order that allowed Deeds to be held for as long as four hours to determine whether he should be kept longer, up to 48 hours, under a temporary detention order. However, a lack of psychiatric beds meant that none could be found for Gus anywhere in western Virginia, and he was released. Hours later, he stabbed his father and killed himself.

The event shocked Virginia and became a national story, especially because of Gus’s mental health evaluation, and the failure to hold him not because he was deemed well, but because there were insufficient public resources with which to treat him. Governor McDonnell issued a full investigation as to how Gus Deeds could have been allowed to leave Bath Community Hospital, but the Governor’s order has all of the hallmarks of a too-little, too-late order that will only confirm what people already know.

Virginia, like many other states since the start of the Great Recession, has drastically cut public mental health care funding. According to figures released by the National Alliance on Mental Illness, Virginia cut its mental health budget by 8.9% ($37.7 million) from 2009 to 2012, from $424.3 million to $386.6 million. The state’s austerity on this front is the 11th highest in the country. Other states, such as South Carolina, Illinois and California to name a few, have cut their mental health care budgets far deeper than that. All told, 28 states and the District of Columbia have cut their mental health care services since 2009, mostly cutting inpatient hospitalization services. Of those states that have not cut spending, all but six have increased their spending by single digits only. (One of those states, Vermont, closed its only state mental hospital in the wake of Hurricane Irene.)

All of this points to the stark reality that even during times of fatter state and federal budgets, looking to the state for adequate health services was an option fraught with uneven service and public stigma. A private solution through health insurance has been touted by many within the health insurance industry especially, as the way to go. But is it, really? And especially for mental health care?

National Underwriter has been examining this issue for nearly a year, here, here and here, ever since the Sandy Hook school shooting touched off a national dialogue about gun control and mental health care. The gun control issue has a life of its own, and continues every time a subsequent issue of mass violence erupts, which has happened over the course of this article series before the publication of each additional installment. Violence inflicted by the mentally ill upon the public appears to be something that happens with grim regularity, just enough to remain in the public consciousness, not often enough to spur any real action to address it.

In the third part of this series, we examined what the private health insurance markets have to offer policyholders who are seeking to get health insurance mainly for the mental health care benefits they provide. The results were not good, which comes as little surprise,given that the health insurance industry needed to be forced by legislation to provide parity for mental health services in their health care plans in the first place.

As we gathered the data to get a sense of just what the private health insurance market has to offer those seeking to protect themselves from mental illness, a few trends emerged worth noting. We already pointed out that there seem to be three kinds of mental health plans for anyone looking to buy health insurance – plans that offer full coverage but are so expensive as to obviate the need for coverage, plans that offer partial coverage which open the policyholder to crushing costs halfway through treatment, and plans that simply do not cover mental health services at all. With such an array of insufficient options, one does not wonder why there are so many Adam Lanzas and Gus Deeds in the United States. One wonders why there are not more.

Another point worth noting is that, in many states, there is simply not a competitive marketplace worthy of the name. Numerous states are dominated by a single health insurance provider. Those that are not are dominated by two or three in most cases, all offering policies that bear complicated, ill-describing names designed for actuarial reference rather than to interest the consumer. These virtual monopolies were to be addressed by the Patient Protection and Affordable Care Act, in part, with a federal program meant to lend money to start health insurance co-ops in states and provide a not-for-profit alternative to established health insurance providers. The idea was to apply competitive pressure to insurers who were experiencing none, and thereby spur them to produce more compelling products for the marketplace. The funding crisis that resulted from the so-called “fiscal cliff” at the end of 2012 meant that this program was scrapped, and only 24 co-ops received federal start-up loans. The last of these companies, Land of Lincoln, began enrollment in Illinois on Oct. 1. There would have been many more new insurers like Land of Lincoln had the loan funding not dried up.

The generally poor nature of private mental health insurance becomes even more evident when run through a report card grading system. National Underwriter took the sample data it pulled from Healthcare.gov (the much-maligned Obamacare website, which provided a broad sampling of the mental health care plans available in any given state) and ran it through a scoring system to tally the presence of co-payments, co-insurance after deductibles, and failure to cover mental health needs at all.

These criteria were matched against a selection of 15 policies from each state representing the most expensive, least expensive, and average cost coverage available through Healthcare.gov. For every policy in which mental health inpatient or outpatient services carried a copay (regardless of cost), that state was given two points. For every policy that imposed co-insurance after deductible (regardless of percentage), that state was awarded four points. For every policy that did not cover mental health care at all, that state was awarded six points.

These tallies were then applied against a grading system. States with more than 120 points got an F. For every four points less than that, the state’s grade went up a step, all the way to A+. The results are dismal. 20 states so graded received an F. Another 8 got a D-, D or D+. Another five got a C or a C-. Seven got a B- or a B. The remaining nine states – Alabama, Arkansas, Hawaii, Maine, Missouri, Montana, Rhode Island, Vermont and West Virginia – all got either A or A+. The interactive map below shows each state’s results.

This grading system is not perfect. It does not take into account average cost of policies, for example – in many cases, you get what you pay for, and only in a few states, such as Alabama and West Virginia, do there appear to be plans which are both affordable and provide generous mental health care coverage. Nor does this grading system take into consideration onerous deductibles, which are present on most of the mid-range and low-cost plans. These factors do much to qualify the suitability of any of the policies National Underwriter surveyed, and ultimately, virtually all of them were found to be lacking in some way, shape or form.

Despite that, there is a clear difference in the parameters set by services covered or constrained by way of copay, coinsurance and failure to cover. One might be tempted to associate more consumer-friendly states with overall wealth, but that does not bear out – West Virginia is one of the poorest states in the country, yet it scored an A+. One might also be tempted to link consumer-friendly states with more liberal states, but that does not bear out either – New York, a bluest of blue states, scored an F.

All that can be determined by looking at these scores broadly is that the United States offers a deeply uneven and fractured insurance marketplace, with offerings in one state having little or nothing to do with offerings in a neighboring state, all of which seem to reflect a free market when it is dominated by lack of consumer knowledge, provider monopoly and stunted regulatory incentive.

After conducting the research it has conducted over the course of this article series, however, there can be only one conclusion to draw from the data present: that when it comes to helping the American public deal with the medical and financial burdens of mental illness, the private health insurance market is at best a questionable resource, and at worst, a deeply unhelpful one. Realities such as this are what drove the public discontent that resulted in the Patient Protection and Affordable Care Act, a deeply flawed and contradictory set of laws that tried to address the worst of the insurance industry’s multiple failings and poor behaviors without turning to a nuclear option of establishing a federal single-payer system. A close look at the state of private mental health care coverage shows that when it comes to protecting the consumer, the Patient Protection and Affordable Care Act does not go nearly far enough. When it comes to working with the industry it regulates, PPACA simply complicates things unnecessarily.

The law’s many critics point out that the law does little to address the cost of medical care, and it will ultimately restrain consumer choice when it comes to obtaining their own medical care. If the example of what consumers can expect in terms of mental health care, then such criticisms fall apart, for the coverages pass along medical costs to their policyholders and often provide little meaningful choice between insurers and their products. The reality is that health insurers seem to treat providing mental health care coverage as a secondary or tertiary concern, and have structured their policies to reflect it. All the while, the industry is merely continuing the same kind of market behavior that led to PPACA in the first place, even after PPACA has become the law of the land. With a track record such as this, an impartial observer is left to wonder which is the greater spur to a federal, single-payer system: the federal government that seeks to impose it, or the private industry that seems to disregard regulatory cause and effect.

A final word: It is not the policy of National Underwriter to pass judgement on the insurance industries it covers. However, this publication’s founder, E. J. Wohlgemuth, put it best when he defended the duty of an impartial observer to call attention to that which needs it most:

“…where the interests of the insurance business and the public which it serves, after making every possible effort to harmonize those interests, conflict, the National Underwriter believes that the best interests in the insurance business are served by taking the stand of the public. In the final analysis, the insurance business can only be successful if it is conducted on the basis of the truest and best service of which it is capable to its clients and the public. This, I take it, is a fundamental principle and the one which has kept the National Underwriter from being a mere paid organ of special interests. Its policies are based on the broad foundation of good citizen ship and the recognition that insurance,as well as all other business, exists primarily not for the men who are engaged in it, but for the people whom they serve.”

Further Reading:

Part 1: The darkness within

Part 2: America’s mental health care crisis: A story in numbers

Part 3: Skewering the mentally ill upon Morton’s Fork

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