President Donald Trump again brought up the issue of mental hospitals in a meeting with governors on Monday, invoking a time when states maintained facilities for mentally ill and developmentally disabled people.
"In the old days, you would put him into a mental institution," Trump said, apparently referring to alleged shooter Nikolas Cruz, whose troubling behavior prompted people close to him to plead for help from authorities, without success. "We're going to have to start talking about mental institutions …we have nothing between a prison and leaving him at his house, which we can't do anymore."
Organizations representing state officials and people with mental illness say no one wants to go back to warehousing patients. But they also say that federal action is needed to reverse a decades-old law known as the "IMD exclusion," which bars Medicaid from paying for treatment in mental health facilities with more than 16 beds. IMD stands for "institution for mental diseases."
Last year, the Trump administration opened the way for states to seek waivers from the policy in cases involving treatment for substance abuse. On Monday a spokesman said states are pressing the administration for similar waivers for mental health care, and officials are looking for ways to address those requests.
"We've continued to receive … proposals and strong interest from states to allow similar demonstrations for individuals with serious mental illness," Johnathan Monroe, a spokesman for the Centers for Medicare and Medicaid Services, said in a statement. "We are actively exploring how best to provide states with new opportunities to improve their mental health delivery systems."
There's no telling if a more robust mental health care system would have saved the 17 lives lost in Parkland, Florida, as well as other victims of mass shootings that have become tragically commonplace. Democrats say it's no substitute for stronger gun control laws.
But state officials would welcome a change to Medicaid's exclusionary rule, said Matt Salo, head of the nonpartisan National Association of Medicaid Directors, which supports full repeal of the policy and, short of that, expanded waivers.
"There is a need for a spectrum of services for people suffering from mental illness and substance abuse," Salo said. "That spectrum should include everything from community-based resources as well as more structured institutional care."
Medicaid is the federal-state health program for low-income people, a major source of coverage for mental health treatment. Experts say the program's longstanding restriction on inpatient treatment is at odds with changes in federal law over the last 20 years to create parity between coverage for mental and physical diseases.
The government's top mental health official said the president is acknowledging that more needs to be done to make Americans safe in their communities.
"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," said Elinore McCance-Katz, assistant secretary of Health and Human Services for Mental Health and Substance Use. "That contributes to jails and prisons becoming de facto mental institutions in this country."
McCance-Katz also said expansion of community-based and outpatient treatment is needed.
Last year a government advisory panel recommended repealing Medicaid's IMD exclusion, and the idea has bipartisan support in both chambers of Congress. But the cost of full repeal has been estimated at $40 billion to $60 billion over 10 years, daunting for lawmakers. State waivers may provide a more manageable path.
Advocates question the cost estimates, saying that savings from keeping mentally ill people out of jail should be factored in as well.
Whether mental illness contributes to violence is a debate rife with misconceptions. On the whole, medical experts say people with mental illness are no more likely to be violent than others.
But McCance-Katz and others say research shows that untreated serious mental illness is a risk factor for violent behavior. The term "serious mental illness" connotes a degree of severity that impairs a person's ability to carry out usual functions of daily life. Treatment effectively reduces risks, said McCance-Katz.
Advocates are making the same point.
"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," said John Snook, executive director of the Treatment Advocacy Center, a nonprofit trying to broaden access to mental health treatment. "We have a situation where the most severely ill are cycling in and out of emergency rooms and jails."