Fierce debate over how to treat the mentally ill is threatening House Republicans’ legislative response to mass shootings.
Opposition from Democrats and some mental health groups to a proposal from Rep. Tim Murphy (R-Pa.) is acute despite more than a year of hearings in the wake of the 2012 Newtown, Conn., massacre.
Former Rep. Patrick Kennedy (D-R.I.), a prominent mental health advocate, is working behind the scenes to bridge the divide.
Kennedy and his allies hope Murphy will soon accept alternative language that makes the bill palatable to healthcare providers and advocates. But it is unclear how far Murphy, a psychologist, will bend.
GOP leaders committed to passing mental health legislation after Adam Lanza, who received psychiatric care as a teen, killed 20 children and six adults at a Newtown elementary school before taking his own life.
The National Rifle Association and conservative groups have argued that a mental health overhaul, not new gun controls, is what’s needed to prevent fresh instances of mass violence, and they are pushing House leaders to pass legislation soon.
“Politically, [Murphy] has many incentives to get as broad a base of support for the bill as possible,” said one participant in the debate who requested anonymity in order to speak freely.
Conflict over the measure has exposed deep fault lines among mental health groups about how to help patients and families coping with serious mental illness.
Organizations that represent families who have dealt with mental illness are often at odds with patients rights’ groups, particularly those who have suffered abuse within the system. Medical providers are usually caught in the middle.
Experts agree that the current system has major flaws.
It has been more than half a century since the last major shift in U.S. mental healthcare occurred in the 1960s, when cases of abuse in mental hospitals and easier access to psychiatric drugs prompted an exodus from institutions.
Hospital-based psychiatric care became a matter of national debate thanks to One Flew Over the Cuckoo’s Nest, a 1962 novel by author Ken Kesey that was later turned into an award-winning film.
President Kennedy’s 1963 Community Mental Health Act furthered the trend away from institutions by providing grants for community-based treatment centers designed to replace large mental hospitals.
Supporters of the approach say that while community-based care is poorly funded, deinstitutionalization has significantly benefited patients by protecting their rights, lowering instances of mistreatment and improving their quality of life.
But critics say the closure of psychiatric hospitals has merely shifted the mentally ill into prisons, homeless shelters and nursing homes that aren’t equipped to care for them.
In an effort to protect patients’ rights and guard against abuse, many states have rigid standards governing who can be treated against their will.
Doris A. Fuller, executive director of the Treatment Advocacy Center, argues that the rules place a heavy burden on families seeking help for a loved one who might inflict harm on others due to their illness.
“The standard is so strict that nobody will treat them until they are dangerous,” Fuller told The Hill. “If they’re not dangerous, you have to wait until there is blood on the ground to get care.”
While the vast majority of mentally ill people are not dangerous, shootings such as the one in Newtown have put a spotlight on the experiences of families and emboldened groups that represent them.
When mentally ill patients do not realize or admit their condition, their families are often left with few options under the current system, Murphy says.
“Without lobbyists or taxpayer funding, these families have been up against a system that shuts them out, denies their loved one acute psychiatric care, and cruelly requires a person to be violent or commit a crime before they can access treatment,” he said in a statement.
Murphy’s bill aims to change that by withdrawing mental health block grant funds from states that do not pass looser standards for involuntary care, which often includes medication.
The legislation would amend the Health Insurance Portability and Accountability Act (HIPAA) to allow family members greater access to the private health information of mentally ill people in their care, while increasing Medicaid funding for psychiatric beds.
It would also defund or restructure federal initiatives on mental illness that Murphy argues are ineffective, such as SAMHSA, the Substance Abuse and Mental Health Services Administration.
The bill has roughly 20 other sections, many of which are not controversial.
This has put prominent mental health organizations such as the National Alliance on Mental Illness in a tough position since they have struggled for years to gain traction on legislation.
Representatives of five groups requested anonymity in order to speak freely about the measure, which was repeatedly described as a mixed bag.
“The question is: How do you create a system that respects family involvement, patient rights and includes a continuum of care that can help the mentally ill at every stage?” one lobbyist said. “We want to strike that balance.”
Several groups are divided over the bill’s commitment to easing standards surrounding involuntary treatment, a policy known as “assisted outpatient treatment,” or AOT.
Some argued the laws are inherently coercive, drive patients away from care and fail to produce better outcomes when compared with well-funded voluntary programs.
Others took issue with Murphy’s desire to defund existing programs within SAMHSA like Protection and Advocacy for Individuals With Mental Illness (PAIMI).
Murphy points to documented instances in which the federal program led seriously ill patients to refuse treatment. At least one reportedly ended in fatal violence.
Talks to resolve the policy conflicts are just now getting underway, facilitated by Kennedy, who collaborated with Murphy in Congress.
It is possible a final bill could use assisted outpatient treatment laws as one of several benchmarks for states to receive block grant funding, for example, or require a study to assess the extent of problems within the PAIMI program rather than immediately cutting its funding.
Murphy has succeeded in building some momentum for his measure. It was recently endorsed by the Washington Post editorial board, and has 73 co-sponsors, including 23 Democrats.
But sources close to the process say it the bill is stuck in neutral for now. While the Energy and Commerce Committee says it supports the effort, no markup has been scheduled.
Kennedy said his attempt to find common ground could move the process forward within weeks.
“Passing a manager’s amendment would be the next opportunity to perfect the underlying bill,” he said, referring to a legislative maneuver in which previously agreed-to changes are made during a markup. “We are starting discussions now.”
Murphy, who sits on the Energy and Commerce panel, stressed that he remains open to changes.
“I will not stop until we have reformed this broken system and remain fully engaged with anyone willing to work on good ideas for helping these neglected and vulnerable families in crisis,” he said.