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Outbursts of gun violence always get Republicans talking about mental health. It would be a lot easier to take that talk seriously if so many of them didn’t have lengthy, well-publicized records of opposing government initiatives to improve mental health care.
Texas Gov. Greg Abbott is a perfect example. Last week’s massacre at Robb Elementary School in Uvalde was the state’s sixth mass shooting during his tenure as governor, according to the Texas Tribune. After each one, he has said the tragedy called for government action to bolster mental health care.
But in between the killings, Abbott hasn’t been crusading to bolster state services. On the contrary: Just this past April, he approved a $211 million reduction in funding for the agency that oversees mental health programs.
And Texas, of all states, is in a poor position to weather such cuts. When the nonprofit group Mental Health America put together a nationwide scorecard for access to mental health care, it gave Texas the lowest rating.
Now, it’s not hard to figure out what’s probably going on here.
The talk about mental health care sounds a lot like a dodge — a way for Republicans and their allies to distract public attention from the wide availability of guns, which the evidence suggests is a much more likely cause of this country’s unique gun violence problem.
That would certainly explain what Media Matters discovered when it tallied references to mental health care on Fox News: Mentions reliably spiked with each mass shooting and just as reliably dissipated once the shock of the killings wore off.
“Spare me the bullshit about mental illness,” a frustrated Sen. Chris Murphy (D-Ct.) told his Republican colleagues last week — and, really, it’s hard to blame him.
All that said, the U.S. really does have some big problems with mental health care, with way too many people in need of screenings and treatment they aren’t getting. And there are actually some pretty good solutions out there.
This briefing paper from the Commonwealth Fund has a list of options. This report from the Bipartisan Policy Center has more. This page at the National Alliance Mental Health website is full of links, each one to a different approach.
The sheer multitude of possibilities can make it hard to focus the attention of either politicians or the public. But it’s possible to simplify by dividing the potential solutions into two general categories:
1. Make it a lot easier to pay for mental health care.
The most familiar problem with accessing mental health care is its cost. That’s a problem for people with and without insurance, given that many plans have large out-of-pocket costs — which, inevitably, affect mental health care as surely as they affect other forms of care.
In 2018, 38% of Americans said they didn’t get mental health care because of cost, according to survey data from the Substance Abuse and Mental Health Services Administration. That was actually an improvement from 2008, when the figure was 45% ― perhaps because the Affordable Care Act reduced the number of people without coverage. But, obviously, it’s still a staggeringly high percentage.
And it has some serious real-world effects. If going to the doctor or getting a test or filling a prescription costs a lot of money, more people are going to skip that treatment or exam ― and, sometimes, end up worse off because of it. A 2020 paper, for example, shows that people with schizophrenia were less likely to take prescribed medication when it cost them more.
Fixing this is a matter of making sure everybody has insurance and then making sure everybody’s insurance covers the care and medications they need ― in other words, moving closer to the kind of truly universal coverage schemes they have in most developed countries.
Of course, in states like Texas, the most obvious and straightforward way to do that would be to expand Medicaid through the Affordable Care Act ― a move that could provide more than 1 million residents with insurance, including coverage of mental health care.
But Texas Republicans have repeatedly refused to take that step, and Abbott has stood with them.
2. Make it a lot easier to find and get mental health care.
It’s why so many people can’t find therapists in their insurance networks. It’s why patients with acute mental health needs end up waiting for hours, even days, in the emergency room for inpatient psychiatric beds. It’s why many people with severe mental illness end up in prisons — which have effectively become warehouses for people who needed treatment but didn’t get it.
A big issue here is funding. The money from both private and public insurers isn’t enough to attract more mental health professionals into the field. The low pay also makes it harder to keep professionals on the job in what becomes a grim, self-fulfilling cycle: They have to shoulder bigger workloads, increasing their stress and burnout, causing more of them to leave for other lines of work.
One way to address these shortages is to increase provider salaries, which the government can do directly when it’s paying for them through Medicare, Medicaid or other public programs. Other options include new subsidies for training on the front end (by offering tuition assistance) and on the back end (by offering generous loan forgiveness, especially for those working in underserved areas).
Loosening license restrictions so that qualified professionals can take on more duties can also make a difference.
But improving access to mental health providers doesn’t just mean getting more professionals into the field. It also means putting more professionals in the right places ― specifically, places where the people who need mental health care can get it easily.
An example would be working to make sure more primary care providers have mental health professionals physically in their offices — so that, for example, a pediatrician could call in a consult at the office rather than referring somebody to a professional who might be on the other side of town and have a long wait for appointments.
“We know that most people don’t follow up on referrals, for one reason or another, and as a result, people don’t get the care that they need,” Ben Miller, president of the Well Being Trust, told HuffPost. “If you bring care to them and you make it seamless, integrated, they’re more likely to have those needs addressed that immediate moment, which is oftentimes much more effective for both the patient and their family.”
Miller, a veteran psychologist and scholar, is among the advocates who see such changes as part of a much bigger transformation of mental health care ― one that focuses on prevention and detection, as well as treatment, and that reaches people not just in clinical settings but also through schools, libraries and other community organizations.
None of these steps could happen quickly. All would require sustained political effort to raise funds — or to move funds around and change regulations — because, inevitably, there are interest groups, businesses and institutions that benefit from the status quo and want to keep it in place.
It’s the kind of effort that Republicans eager to improve mental health care could certainly provide, although it would require paying attention to the issue even after the memories of the latest shooting fade.
That hasn’t happened in the past. But maybe this time it will.