Voices and Silence

It was no secret that Jason Molacek heard voices telling him to murder. Cops, counselors, his parents--they all knew. So why didn't anyone stop him before he shot his mom to death?

Sometimes people with severe mental illnesses can't be reached. Sometimes families, acting in concert with talented and dedicated professionals, cannot prevent situations from spiraling out of control and ending in addiction, homelessness, violence. And maybe that's what happened to Jason Molacek and his parents. It seems unlikely, however. It's hard not to think that a much larger problem is money. Specifically, residential mental health services for children can cost upward of $250,000 a year. Families, schools, insurance companies, and local governments frequently spar over who should foot the bills. Because it's so hard to get the care paid for, there aren't nearly enough good treatment facilities.

Because it was created while he was a minor, and because it involves his health care, the majority of Jason Molacek's official paper trail is secret. The privacy laws that make this so are designed to protect Molacek, but they also make it impossible to do more than raise questions about some crucial junctures in his case. Did the Molaceks' health insurer work hard to get appropriate care for Jason, or did it insist on the cheapest treatments? Was his family steered toward the child welfare and juvenile justice system as a back-door means of getting those services? There's a long history of both practices in Minnesota.

According to the General Accounting Office, 1,071 Minnesota children were placed in the child welfare system in 2001 solely to secure appropriate mental health services for them. The majority were teenaged boys. "Many of these children were violent and had tried to hurt themselves, their parents, or their siblings and often prevented their parents from meeting the needs of the other children in the family," the congressional agency reported. Although the families came from all walks of life, the agency found, "children from middle class families are more likely to be placed because they are not eligible for Medicaid and their families do not have the funds to pay for treatments not covered by insurance."

Photo image courtesy of Hennepin County Sheriff's Office

The agency surveyed child welfare authorities nationwide and visited six states, including Minnesota. "Almost all state child welfare directors and county juvenile justice officials who responded to our surveys reported that private health insurance limitations were increasing the number of child welfare and juvenile justice placements to obtain mental health services," the GAO reported. "For example, according to parents and state and local officials in all six states that we visited, many private insurance plans...offered limited coverage for traditional or clinical treatments, such as psychotherapy or psychiatric consultations, and did not cover residential treatment placements."

Minnesota's numbers are much higher than those of the other states surveyed. For example, Mississippi and Kentucky reported placing 13 and 14 children, respectively. Connecticut, the state with the next-highest numbers, reported 738 such placements, while North Carolina reported 440. Local government officials call those numbers misleading: Unlike all but two other states, Minnesota law allows parents to petition the court directly to provide services to their children. And to its credit, Minnesota's juvenile justice system is much more likely than those of other states to place delinquent children who can't stay at home in facilities that provide mental health care instead of in detention centers.

In October 2000, Minnesota Attorney General Mike Hatch sued Blue Cross Blue Shield of Minnesota, charging that the insurance company had a pattern of wrongfully denying treatment to children suffering from mental illness, eating disorders, or chemical dependency. The suit accused the company of attempting to shift "the cost of caring for such children to taxpayers and/or families, including instructing parents to have their children suffer 'legal consequences' or to make 'use of the juvenile justice system' instead of providing the care covered by the policy."

Hatch's suit detailed the efforts of a number of parents to get help. According to records in the lawsuit, six were told to turn to the juvenile justice system; this would help them "leverage" the care they needed. One was told to consider foster homes. State investigators talked to several insurance company employees who confirmed that they were told to refer patients to the juvenile justice and foster care systems. If treatment were court-ordered, the company could deny payment, one explained. If a child's diagnosis included attention deficit disorder or another learning disability, an attempt might be made to shift responsibility to the family's school district.

"There is no documentation that other forms of less intensive treatment options have been tried, such as foster placement, etc.," the insurance company's behavioral care management subsidiary explained in one case. "Conduct issues can be addressed in the legal system."

One parent was told she was "paying" for her excesses of the 1970s and '80s. Several were told that what their children really needed was better parenting. One of the children named in the suit killed herself; another suffered permanent brain damage as the result of a failed attempt to hang himself. "Insurers know there's chaos in the [family's] house," Hatch says. "These families are too stressed. Eventually they just give up."

Blue Cross settled with the state in June 2001, agreeing to quickly and automatically forward all denied claims for mental health services to a panel of three retired judges. In addition, the company repaid the state $8.2 million for the care of children who had been denied help. Six months later, in an effort to fend off a similar suit, Health Partners joined the settlement and paid $2 million to the state. (Health Partners also happened to be Molacek's insurer.)

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