Editor’s Note: The insurance industry is a time-tested, formal and powerful resilience mechanism that has used financial incentives to drive individual and public safety improvements historically. In April 2024, I (William Braniff) spoke at the International Forum of Terrorism Risk (Re)Insurance Pools (IFTRIP) conference in Washington, DC, about eight things the insurance industry could do to facilitate targeted violence prevention:
- The insurance industry can create financial incentives for organizations with prevention programs–such as lowering premiums. These can include employee wellness programs that increase protective factors, training employees on reporting and referral mechanisms for concerning behaviors, and instituting behavioral threat assessment and management programs. CP3 can help with these.
2. Insurance companies can provide liability coverage for professionals engaged in BTAMs and treatment. If we provide clinicians with liability coverage we can increase the number of these prevention practitioners comfortable taking referrals.
3. Insurers could explicitly cover civil litigation and licensure complaint legal fees for licensed health and education professionals who have claims against them for good faith disclosures of information with the intent to warn about or prevent an act of targeted violence.
4. Insurance companies could ensure that there is funding during a given threat assessment to conduct a clinical diagnosis. If there is a diagnosis, medical insurance companies can cover the appropriate treatment to manage the risk they pose to themselves and others. Absent a diagnosis, there is no treatment.
5. Individuals assessed above a certain level of threat could qualify for the “medical necessity” requirement and therefore be able to pay for mental & behavioral health services through their insurance.
6. Insurance companies can directly support or participate in BTAMs, serving as brokers for all relevant parties. BTAM brokers can ensure that at-risk individuals have access to medical coverage that will pay for treatment, ensure the those managing the client have liability coverage, help the relevant school or employer manage their risk through insurance policies, and ensure best practice around risk reduction for each client.
7. These investments in prevention before an act of violence have a second order benefit for the insurance industry in that it creates dense referral networks between institutions, clients, and direct service providers. These dense referral networks lead to greater resilience and faster recovery after an act of violence, meaning less business interruption and long-term trauma, both of which create significant personal, corporate and societal costs.
8. Who is better placed to provide an actuarial accounting of the ROI for good prevention practices, than the insurance industry? An industry ROI study would help decision-makers recognize the massive upshot of investments in prevention. Whereas some people are quick to critique prevention by asking – how can you assign a value to things that didn’t happen? – the insurance industry does this as a matter of practice. Assigning a value to prevention will help foster uptake in prevention programming and therefore decrease portfolio risk in the process.
I shared these with my team at the DHS Center for Prevention Programs and Partnerships, and our Associate Director for Field Operations in the Mountain Region, Tiffany Sewell, leveraged her knowledge and networks to drive the groundbreaking effort she describes in the case study below.
If scaled across Medicaid providers and adapted by the private sector insurance industry, this and similar initiatives could drastically improve the availability and quality of targeted violence prevention resources, saving lives and money.
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When I began working in the targeted violence and terrorism prevention field one of the most frustrating challenges I encountered were situations in which the warning signs were clear: a young person had been making concerning statements, teachers were worried, parents were overwhelmed and the behavioral threat assessment and management (BTAM) team had done exactly what they were designed to do, yet the individual needed a referral for behavioral health support and there was still no one to help.
The team would ask “who could help this young person? What services did they need, and how could they access them?” All too often, there were no answers. Not because practitioners didn’t care or because the risk was not real but because the youth was not connected to a system that could help or they did not have insurance that would cover the cost of care for violence risk. This was true for many of these young people insured through Medicaid, and this is where prevention began to stall.
The only paths to services were to have the young person become involved in either the child welfare or juvenile justice systems or somehow take on private insurance. I watched the promise of prevention fail not because we lack insight or will, but because we lacked infrastructure. Colorado needed to do something different. We had to fundamentally change the way BTAM teams, clinicians, Medicaid, and insurance providers worked together.
As the field of targeted violence prevention evolved and adopted a public health-informed approach, practitioners came to understand that youth on the pathway to violence are not fundamentally different from youth with the same diagnoses who are already being served within the child welfare and or juvenile justice systems. Like those on the pathway to violence, children already in the system often struggle with depression, trauma, impulsiveness, hopelessness, and instability in their families and social lives. Many experience social isolation and suicidal ideation. The risk factors they present mirror those associated with youth violence and self-harm more broadly. What was different was not the need or diagnosis but the hesitancy from providers around serving this population.
As I continued in this work, it became clear that youth on the pathway to violence needed to be treated the same as other vulnerable youth. In Colorado, we made a deliberate decision to train clinicians and treatment providers to recognize shared risk and protective factors and to understand that threat related behaviors fall within the same scope as other evidence-based care for violent behaviors, such as cognitive behavioral therapy.
Providers began to see that young people on the pathway to violence struggled with the same needs as others: connections to a caring adult, a sense of belonging, or inclusion in a social group. Providers began to believe in their ability to treat these specific individuals the same way and with the same methods as other youth dealing with other harms. Providers recognized they already had the tools to help with the treatment options they were already trained to do.
Rather than treating targeted violence as something exceptional or another demand added to an already overloaded system, we needed to apply a public health framework that connected youth violence prevention, suicide prevention, and behavioral health. This work started happening here and there, but training alone was not enough to scale this approach. The barrier was not clinical capability but the fear and perceived liability that accompanied working with someone who one day may be linked to a tragedy. Many wanted to help but felt legally and professionally exposed when taking on threat related cases. Asking clinicians and other providers to participate in prevention without addressing liability was both unrealistic and unfair.
After socializing clinicians to their potential role in targeted violence prevention, lack of insurance coverage for at-risk individuals and liability coverage for clinicians were the next barriers for us to remove. Many young people referred through the BTAM process were insured through Medicaid. Poverty, exposure to trauma, housing instability, and limited access to early intervention are all well documented risk factors for violence and self-harm. Yet Medicaid had not historically been integrated into targeted violence prevention strategies in the same way it had been for other behavioral health and system level prevention efforts.
To address this, we invited senior leaders from the Medicaid community to sit in on a BTAM team meeting in a school setting. These leaders could see that we were identifying risks among our most vulnerable youth, but that we were without the services in place to reduce it. They understood that our prevention efforts needed to be aligned in the insurance/Medicaid system to scale the approach. Clinicians willing to take referrals for violence risk were provided the training described above, and our Medicaid partners agreed to compensate them at a competitive hourly rate through the existing systems that work for other forms of harm.
Behavioral threat assessment can serve as a gateway to appropriate diagnoses such as conduct disorders, mood disorders, posttraumatic stress disorder, or reactive attachment disorder. Once a diagnosis is established, Medicaid and insurance systems can function as designed by covering the cost of treatment. BTAMs can identify genuine clinical needs and allow us to intervene early.
We recognized that in our training we needed to frame this work as a necessary, shared and system-wide responsibility, and to provide clear guidance on liability protections, ensuring providers felt supported. When education, reimbursement, and liability protections came together, prevention began to function as a true partnership. Providers became willing to participate. BTAM teams had referral pathways. Youth received help earlier. Families felt less isolated and no longer believed their child had to enter the criminal justice or child welfare system to access care.
We know we cannot arrest our way out of this problem. We cannot “legislate away” all harmful social media, or rely on punishment to prevent harm. Instead, we need to invest in prevention models that have worked for decades. Targeted violence must be treated as public health issue, one that acknowledges shared risk and protective factors, ensures Medicaid or other insurance funding during assessment and evaluation, and provides liability protections for clinical providers. Prevention works when we support the people willing to do it. It is imperative that we tailor the existing system that allows providers to do the work they are trained to do and compensated through a system designed to do that.
