Medicaid, mental illness, and violence


The current Washington Monthly reached my mailbox. It includes a cosmically brilliant article on ways to address violence by mentally-ill offenders.


Newtown was an atypical crime, committed by an atypical offender, using a murder weapon that I hope will be outlawed but that remains pretty atypical for gun homicides. Even though we may not be able to stop an event like Newtown from happening again, it seems to be moving public policy more than the routine smaller scale tragedies that we could more easily prevent…. 

It’s naive to believe that we could specifically identify someone such as Adam Lanza before he goes on a rampage, but improved policies could still prevent an unknown, maybe unknowable number of violent deaths. No one policy will dramatically reduce homicides, and the politics and administration of effective mental health policy are both daunting. But making these policies work would provide a fitting memorial to the victims of needless violence across America…. 

(Spoiler alert: Ensuring that low-income young men have access to mental health and substance abuse services, as is done under the Affordable Care Act’s Medicaid expansion, would help.)

Two things struck me as I wrote the piece.

  • First was the dilemma facing correctional officials who face so many mental health issues among the men and women placed into their charge. On any given day, the Cook County jail houses about 2,000 people with significant mental health problems. It is one of the largest de facto inpatient mental health facilities in America. Correctional officials desperately need better ways to address these issues, and better ways to serve offenders upon release from secure settings.  A huge proportion of these offenders are uninsured. Virtually all will be Medicaid-eligible in 2014. I hope we can do better with this very challenging group.
  • Second was the ambivalence among mental health advocates regarding whether Medicaid should finance inpatient care at large mental hospitals–large being defined as more than sixteen beds. For reasons I briefly discuss, Medicaid’s “IMD exclusion” has long-barred such coverage. Good people on both sides deeply disagree about whether repeal of this provision would provide valuable new options, or whether this would merely provide new incentives to warehouse patients under difficult conditions. 

What do our readers think about this latter question?

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