President Trump on Monday suggested the United States needs more mental institutions to help keep individuals who are viewed as a potential harm to others off the streets and get them needed treatment—but states and mental health advocates say a Medicaid policy change might be more effective.
Trump made the comments during a meeting with governors focused on curbing gun violence in the country. Trump held the meeting in response to a recent mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida. Law enforcement authorities believe 19-year-old Nikolas Cruz—a former student who allegedly had been expelled from the school for disciplinary reasons—entered the school and open fired, killing 17 people and wounding at least 15 others.
Cruz had been known for displaying odd behavior, such as killing animals and selling knives. Cruz previously had received treatment at a mental health clinic, though he had not received such treatment in over a year. The FBI said it had received a tip as recently as Jan. 5 from an individual close to Cruz who reported concerns over Cruz's "gun ownership, desire to kill people, erratic behavior, and disturbing social media posts, as well as the potential of him conducting a school shooting." The FBI said, "Under established protocols, the information provided by the caller should have been assessed as a potential threat to life," but the agency confirmed that the information had not been forwarded for investigation.
Last week, Trump said Cruz "should have been nabbed a number of times" based on what had been reported about Cruz's mental health, but Trump said if authorities "catch somebody" who has a mental health condition, there is "no mental institution to bring them" to for treatment.
During his meeting with governors on Monday, Trump said, "You know, in the old days we had mental institutions. We had a lot of them. And you could nab somebody like this, because they … knew something was off." He added, "We're going to have to start talking about mental institutions," because "we have no halfway. We have nothing between a prison and leaving him at his house, which we can't do anymore."
Expert says more mental institutions won't reduce gun violence
Some experts say opening more mental health institutions in the United States would not significantly curb gun violence, because individuals who commit such crimes do not often have mental health conditions that require institutionalized treatment.
Michael Stone, a forensic psychiatrist at Columbia University who has studied mass killers, said the notion that expanded access to mental institutions would help stop such violence "is ridiculous, because you can't put half the people in the country with a mental disturbance in mental hospitals." He added, "Most of these shooters are angry, antisocial individuals you cannot spot in advance, and even if you could, you don't have the right to institutionalize them."
States, advocates call for Medicaid policy changes regarding inpatient mental health care
Instead, groups representing state officials and individuals with mental health conditions say the federal government should reverse a decades-old regulation known as the "IMD exclusion," or "institution for mental diseases" exclusion, which prohibits Medicaid from covering treatment in mental health facilities that have more than 16 beds.
Matt Salo, executive director of the National Association of Medicaid Directors, said, "Thirty years ago, when you were talking about a mental institution, a state-run mental institution, you were generally talking about a place to warehouse people who we didn't know what to do with or people we didn't want to deal with." He continued, "That's not what anyone's talking about. We're not looking at a return to warehouses to just stick people with mental illness."
Salo added, "There is a need for a spectrum of services for people suffering from mental illness and substance abuse." He said, "That spectrum should include everything from community-based resources as well as more structured institutional care."
John Snook, executive director of the Treatment Advocacy Center, said, "There is no argument that stepping forward and addressing the IMD exclusion would have a huge benefit to mental health systems in states across the country," adding, "We have a situation where the most severely ill are cycling in and out of emergency rooms and jails."
Trump administration officials similarly have acknowledged a need to revise the policy. For instance, Elinore McCance-Katz, who leads HHS' Substance Abuse and Mental Health Services Administration, said, "The IMD exclusion makes it very difficult for people with serious mental illness to get a bed when they need that care, and the 24-7 safety, security, and treatment that an inpatient facility provides." She continued, "That contributes to jails and prisons becoming de facto mental institutions in this country."
According to the AP, CMS spokesperson Johnathan Monroe on Monday said states have pressed the administration to allow them to seek waivers that would allow Medicaid to cover mental health treatment in facilities with fewer than 16 beds, and officials are weighing how to handle the requests. "We've continued to receive ... proposals and strong interest from states to allow similar demonstrations for individuals with serious mental illness," he said, adding, "We are actively exploring how best to provide states with new opportunities to improve their mental health delivery systems" (Morin, Politico, 2/26; Alonso-Zaldivar, AP/Sacramento Bee, 2/26; Owens/Baker, Axios, 2/27; Carey, New York Times, 2/22).
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