In the wake of the shooting deaths of 17 people at a high school in Parkland, FL, the question of what can or should be done to reduce the risk of spree killings in the United States has come into sharp focus. Following years of ineffective responses to similar events throughout the country, victims of the Parkland shooting, their family members, and their friends have pressed for stiffer action to be taken.
One proposal that is frequently made is to beef up America’s mental health system so that professionals can identify potentially troubled individuals before they act. President Donald Trump has been a strong proponent of this type of solution. Reactions to the idea, however, have not been without controversy. Foremost on many critics’ minds is the question of whether mental health screenings would even be effective at identifying potential shooters in the making. Beyond this concern is the problem of whether the U.S. health system is currently equipped to handle the task.
The fact is that the U.S. is facing a looming shortage of doctors. According to a report by the Association of American Medical Colleges, experts expect that the country will lose more than 100,000 doctors by 2025 due to a combination of retirement and death. Similarly, enrollment in medical programs simply has not kept up with increasing demand in a nation with an aging population. The report stated that given the fact that physician training takes up to a decade, any attempt to solve the problem should have been initiated no later than 2015.
The problem is compounded by the fact that large swathes of the country are considered “primary-care deserts.” The process of identifying who may or may not need mental health support tends to begin at the lowest levels of the healthcare field, and even there, resources simply aren’t available. In many rural areas and underserved communities in urban regions, there just isn’t a doctor of any kind, let alone a specialist such as a psychiatrist, available to treat patients. If people in certain areas of the country can’t expect to even come into contact with a primary-care provider, the odds that they’ll have a chance to sit down with a psychiatrist are not good.
The country’s lack of qualified health professionals raises a glaring question for those who advocate for using mental health screenings to identify potential mass shooters. If a person’s mental health fails and there isn’t a physician there to see it happen, how can an individual crisis possibly be averted? That’s before even thinking about dealing with late-stage issues that may manifest in large-scale acts of violence directed toward other members of the community.
The economic structure of the industry leads many primary care physicians, who are already a scarce resource, to specialties that are more profitable. For example, specialized surgeons often earn twice the annual salary of the average family practitioner. The potential for more money is, understandably, hard to pass up. With doctors and other health professionals leaving practices focused on early interventions, however, those in need of help with psychiatric issues are often left without the proper support.
The Insurance Industry
It’s hard to talk about any aspect of healthcare in the U.S. without eventually discussing insurance, especially what it will or won’t pay for. This has become very pronounced with regard to psychiatric treatment. There’s a high level of variability between what sorts of care one insurance carrier might pay for versus another.
Insurance companies often refuse to cover the costs of care that they consider voluntary. Because of this, an individual who isn’t displaying signs that they need immediate treatment might not seek help out of fear that their insurance provider won’t cover the cost. Simply studying the list of what a carrier might cover rarely helps, as it’s hard to discern what is covered or not until a bill comes back rejected or accepted.
It’s important to note that the quality of insurance coverage and mental health support isn’t the same across the country. For example, the northeastern U.S. has more practicing psychiatrists than other areas due to the presence of educational institutions and research centers. However, successfully pairing a patient with a psychologist or psychiatrist only occurs in areas where the availability of insurance carriers and mental health services providers overlaps. Otherwise, there’s a good chance that an individual won’t come into contact with the mental health system prior to a serious incident involving law enforcement.
An Imbalance in Supply and Demand
To get a sense of the scale of the psychiatrist shortage, one can look at the supply versus the demand for them. According to recent estimates, there are 28,000 psychiatrists currently practicing in the U.S. For reference, there are more than 100,000 doctors in family practice, a field that’s also considered woefully understaffed.
Exasperating the shortage of qualified psychiatrists and psychologists is a high demand for mental health treatment. Americans stand out in the developed world for their willingness to seek psychiatric care. While this is a good thing, that willingness to visit a mental health professional has triggered a demand-side surge. According to a report from Merritt Hawkins, an organization that tracks physician search data, online searches for psychological help have gone from the ninth most common to the second most common in the last decade. The passage of the Affordable Care Act has also encouraged more people into the system, placing greater strains on it.
What Can Be Done?
Given the broad breakdown of the system and inherent conflicts between declining supply and increasing demand for mental health services, it’s hard to see one immediate solution for gun violence that amounts to anything like the proposals to increase provision of care. Foremost, demand simply outstrips supply. Beyond that, seeing that an individual is actually put in contact with a qualified professional before issues in their life have degraded to the point of directing violence outward is challenging at best. The American healthcare system, in its current form, simply isn’t equipped to handle the task.
Regardless of whether you feel that improvements in mental health screenings would better identify and possibly treat potential spree killers, there’s little dispute that America needs to focus on supplying services in a more effective manner. Unfortunately, making the proper improvements will require significant shifts in institutional and cultural commitments. These shifts would most likely take years to implement, and that’s only after society comes around to treating the structural issues as real problems. To get the mental health system on the right track, the country needs:
Before the system can be effective, the number of individuals involved in psychology and psychiatry has to increase significantly. This will require a fundamental realignment of economic incentives for those entering the medical professions. Pay should be increased, where possible, but other approaches are also worth considering.
For example, removing financial and administrative barriers that make it hard to get into the profession should be considered. Modern business intelligence systems could also be used to help pair individuals who profile as potential psychiatrists with the mental health arena. This is all with the understanding that it may take years for individuals to show up in the field as practitioners and even longer for them to develop experience within their chosen specialty.
Incentives will also need to be put in place to direct practitioners toward underserved communities. The Parkland shooter was an individual who came into contact with the foster family system, but resources did not appear to be directed toward him. This is despite the fact that young men from disrupted family settings are more likely to engage in acts of violence. Incentive options to help put more psychiatrists in contact with such potential patients include tuition forgiveness and subsidies.
Some suggestions have limited capacity to improve the situation. Telemedicine may give people in remote areas greater access to care, but it still suffers from specific biases. For example, telemedicine users are more likely to be self-selecting. Similarly, some degree of immediate human contact in mental health services is important.
Another option worth considering is to expand the number of psychiatric nurses who are available to provide treatment. This suggestion, however, faces headwinds in light of the fact that job postings for psychiatric nurses are already outpacing the available supply. Regardless of what solutions are used to improve access to care, it’s critical to get more practitioners into the mental health field across all geographic areas.
While the ACA tried to address challenges associated with lack of access to mental health services, there remains much to be done. Coverage still needs to be expanded to more than 20 million Americans who don’t have it. The rate of uninsured individuals is expected to increase even further over the coming years. Efforts need to be made to ensure that individuals who have access to mental health services are confident that they’re covered. By maximizing what will be covered by carriers, patients’ fears of being stuck with the bill can be minimized.
One of the biggest problems is figuring out how to get government more involved. In some instances, the government’s involvement has actually served to diminish the number of practitioners entering the field. This happened in 1997 when caps were placed on Medicare payments for doctors’ residency programs. The move was made at the time because there was a greater fear of a glut of doctors in the system than a lack of them. No effort, however, has been made since to reverse the policy and start putting new professionals into training immediately.
In the U.S., there is also still a strong conflict over what role government should play in Americans’ lives. While one political party generally advocates for government involvement, the other tends to oppose pro-interventionist programs. Short of a significant political and cultural shift on a bedrock question like this, any attempt to expand coverage will face a range of financial and legal challenges.
One suggestion that the anti-interventionist side proposes is tort reform. One of the biggest fears people face when entering the medical professions is the risk of being sued. By placing caps on potential settlements, these fears might be abated, encouraging more people to enter the field.
The greatest difficulty involved with addressing events like the Parkland shooting through mental health screenings is related to the fact that the mental health field really needs decades to fully scale up in order to be effective. Even a large-scale commitment to address the psychiatrist shortage today isn’t going to yield immediate results. Improvements in healthcare nationwide need to take place, which brings up questions about whether the United States is even close to being prepared for the changes.