The Impact of New York SAFE Act Reporting on Gun Owners’ Health Care Decisions

Introduction

Mental health reporting laws that prevent people from owning guns are intended to prevent harm on individual and population levels. However, the literature indicates that these laws may not be effective in capturing the individuals who are likely to harm themselves or others [1-5]. It has been shown that only a small percentage of individuals with mental health conditions are violent [6]. Focusing on stronger predictors of risk may best serve the goal of reducing gun violence [2].

Gun owners are also not inherently violent, and they value the right to bear arms [7]. Loss of this right has ramifications beyond the inability to defend oneself. Potential impacts of losing of this right include disconnection from a community or support network, feeling shame or embarrassment for seeking care, and loss of a career, engaging hobby, or pride in a skill. Such impacts may cause individuals to avoid seeking mental health care when needed [4, 8-10].
 
The literature holds little information on how mental health reporting laws impact gun owners’ care seeking decisions. The purpose of this paper is to enhance knowledge about how mental health reporting laws impact health care decisions related to mental health among gun owners. The objective is to provide information that may inform efforts to support population mental health. The purpose and objective are achieved by summarizing 1. a survey among gun owners regarding the impact of New York Secure Ammunitions and Firearms Enforcement Act (NY SAFE Act) Mental Hygiene Law (MHL) § 9.46 reporting on health care decisions and 2. the effectiveness of this reporting in capturing its target population. NY SAFE Act MHL § 9.46 reporting has been explained in a prior publication and MHL § 9.46 is available online [4,11,12]. Institutional Review Board approval was not sought for this analysis because the anonymous survey did not collect personally identifying information and the data used to roll results up to a population level is publicly available. Therefore, this work is exempt under Federal Title 45, subtitle A, Subchapter A, Part 46, Subpart A, §46.104. The author had no funding, no conflict of interest, and no organizational affiliation in this work.

Method

Data for this cross-sectional, observational, descriptive analysis came from an anonymous, voluntary online survey directed but not limited to New York State (NYS) gun owners, publicly available United States Census Bureau data, Substance Abuse and Mental Health Services Administration (SAMHSA) data, and NYS Division of Criminal Justice Services (DCJS) data (DCJS, personal communication May 2024) [13,14]. A convenience sample was gathered by posting an invitation (Appendix A) and link to the survey to online platforms which the population of interest might visit, and write ups about the survey in relevant venues. Examples of these platforms and venues include r/NYguns, r/gunspolitics, r/2ALiberals, Bearing Arms, and Shooters Committee on Political Education. Peaks in participation corresponded with online posting dates, indicating that the recruitment approach was successful. Survey Monkey was utilized to administer the survey which was open to participation from February 22 through May 29, 2024.

Of the eleven survey questions, six were based on a prior survey conducted by Charder, et al. [9]. No personally identifiable information was collected in this survey. All questions except gender and age required a response to complete the survey. The survey questions and response options were: 1. Do you live in New York State? (Yes, No); 2. Gender (Male, Female, Other); 3. Age (18-34 years, 35-64 years, 65 years or more, Less than 18 years); 4. Do you own a gun? (Yes, No, Prefer not to answer); 5. Prior to today, were you familiar with NY SAFE Act MHL 9.46? (Yes, No); 6. Are you concerned about being reported to the government under NY SAFE Act MHL 9.46 if you decide to seek mental health care? (Not at all concerned, Somewhat concerned, Very concerned); 7. Does NY SAFE Act MHL 9.46 affect how likely you are to seek mental health care if you need it? (Less likely to seek care, No change, More likely to seek care); 8. Does NY SAFE Act MHL 9.46 change your willingness to report any issues to a mental health provider? (Definitely would not report, Less likely to report, No change, More willing to report, Definitely would report); 9. Does potential NY SAFE Act MHL 9.46 reporting influence your trust in mental health providers? (Do not trust, Less trust, No change, More trust, Completely trust); 10. Does loss of Second Amendment rights as result of seeking mental health care impact how likely you are to seek mental health care if you need it? (Less likely to seek care, No change, More likely to seek care); 11. Have you previously taken this survey? (Yes, No).

The United States Census Bureau estimated that there were 15,695,913 NYS adults in 2022 [13]. The SAMHSA estimated that 5.2% of the NYS adult population had serious thoughts of suicide in 2022 [14]. The NYS DCJS data, obtained through a freedom of information request, demonstrated that the annual average number of MHL § 9.46 database searches was 17,953 and the annual average number of individuals represented by MHL § 9.46 database searches was 12,156 from mid-May 2019 through mid- May 2024. A MHL § 9.46 report results in a NYS DCJS database search to determine whether an individual is in the NYS handgun registry. It is estimated that 19.9% of adults in NYS own a gun [15].

Results presented include survey response percentages for all participants and, to reduce potential bias resulting from inclusion of individuals who are not NYS gun owners, survey response percentages for NYS gun owners. Census data and gun ownership percentage were utilized to roll up NYS gun owner survey responses to a population count. SAMHSA and NYS DCJS data were added to calculate the ratio of population level response options to individuals represented by MHL § 9.46 database searches and the percentage of the target population captured by MHL § 9.46, illustrating the magnitude of effect and effectiveness of MHL § 9.46 reporting.

Results

Overall, there were 283 survey participants of which 178 responded as NYS gun owners. Because 37% of participants were not NYS gun owners and concerns about mental health reporting may not be limited that group, all responses and the subset of NYS gun owner responses are shown in Table 1. Percentages for all respondents were very similar to the subset of all gun owner respondents (data not shown). However, respondents who selected prefer not to answer regarding gun ownership displayed a larger percentage of females (10.9, 5.3), 65 years of age or more (30.4, 23.3), very concerned about this reporting (91.3, 84.1), definitely would not report issues to provider (73.9, 66.8), and do not trust providers (67.4, 56.9) compared to all respondents (data not shown). NYS gun owner respondents showed a smaller percentage 65+ years of age (17.4, 23.3) and a larger percentage of prior knowledge of MHL § 9.46 (87.1, 79.5) compared to all respondents. In addition, most NYS gun owner respondents were male (91.6%), over the age of 35 years (66.8%), and very concerned about being reported under MHL § 9.46 (83.1%). Because of NYS SAFE Act MHL § 9.46, most NYS gun owner respondents were less likely to seek mental health care (93.8%), less likely or definitely would not report issues to a mental health provider (96.1%), and have less trust or do not trust in mental health providers (93.3%). The overwhelming majority of NYS gun owners (94.4%) were less likely to seek mental health care if they need it due to potential loss of second amendment rights. (Table 1)

Table 2 shows that at a population level, a consistently large number of number of NYS gun owners were somewhat or very concerned about being reported under NY SAFE Act MHL § 9.46 (3,035,748), less likely to seek mental health care if needed (2,930,462), less likely or definitely would not report issues to a mental health provider (3,000,653), have less or no trust in mental health care providers (2,912,915), and less likely to seek mental health care if needed due to potential loss of second amendment rights (2,948,010). There were also consistently large ratios of NYS gun owners to individuals represented by MHL § 9.46 database searches for very concerned about being reported under NY SAFE Act MHL § 9.46 (214:1), less likely to seek mental health care if needed (241:1), definitely would not report issues to a mental health provider (170:1), do not trust (140:1) and less trust in mental health providers (100:1), and less likely to seek mental health care if needed due to potential loss of second amendment rights (243:1). The ratio of NYS gun owners to individuals represented by MHL § 9.46 database searches is interpreted as X number of gun owners were represented by this survey response option for every individual reported under MHL § 9.46 each year.

Combining the annual five-year average of individuals represented by MHL § 9.46 database searches with estimates for the NYS adult population and the percentage expected to have serious thoughts of suicide (12,156/((15,695,913)(0.052))) reveals that MHL § 9.46 is capturing about 1.5% of its target population.

Discussion

These results clearly indicate that NYS MHL § 9.46 mental health reporting is adversely impacting gun owner’s health care decisions. Given the similar purpose and implication of MHL § 9.46 and NICS mental health reporting laws, it is reasonable to extrapolate these results to NICS reporting as well.

These results are supported by Charder, et al. [9], who found that among their study population (n=228) 35.2% were familiar with the NY SAFE Act, 18% were somewhat or very concerned about being reported to the government, 9% were less likely to seek mental health care, and 23% were less likely or would not report symptoms to a provider because of the NY SAFE Act. However, the current analysis among NYS gun owners found 87.1% were familiar with the NY SAFE Act, 97.1% were somewhat or very concerned about being reported to the government, 93.8% were less likely to seek mental health care, and 96.1% were less likely or would not report symptoms to a provider because of the NY SAFE Act. The lower percentages found by Charder, et al. [9], are likely because that study population was individuals seeking mental health care and included only 23 gun owners, while the current analysis population was among gun owners without regard to whether they sought or received mental health care.

Similarly, another paper [4] found that each year among NYS gun owners 283,138 were less likely to seek mental health care because of MHL § 9.46, for every NYS MHL § 9.46 database search 16 NYS gun owners were less likely to seek mental health care, and MHL § 9.46 captures about 2.7% of its target population. However, the current analysis found 2,930,462 NYS gun owners are less likely to seek mental health care each year because of MHL § 9.46, 241 NYS gun owners were less likely to seek mental health care for every individual represented by MHL § 9.46 database searches, and MHL § 9.46 captures about 1.5% of its target population. The smaller numbers and larger percentage in the prior paper may be attributed to the use of results from Charder, et al., with the afore- mentioned study population differences and the use of database searches rather than individuals represented by NYS MHL § 9.46 database searches [4,9].

Given the current results indicating that NYS MHL § 9.46 reporting is capturing only 1.5% of its target population, it is not surprising that the NY SAFE Act was found to have no association with suicide by firearm [1]. The assumption that targeting individuals with mental illness will reduce gun violence is problematic because very few with mental illness are violent, care providers cannot accurately predict who will be violent, and this approach misses individuals who may become violent [2,3,5,8,16]. Further, mental health stigma contributes to the inaccurate assumption that illness means incompetent or dangerous [2,17]. Although it might be difficult to utilize stronger predictors of violence to prevent dangerous people from having guns because these risk factors are also common characteristics of many nonviolent people [2,16], the use of a weak predictor appears to be inadequate for this purpose. Efforts to reduce stigma, including structural stigma in law or policy, may improve care seeking and participation in treatment, thereby improving individual and population health [10,18,19].

A limitation of this analysis is that respondents were disproportionately male and may not accurately reflect females. There may be participant reporting bias or error. However, the number of responses showing internal inconsistency was small (7) and these were included in the analysis because small numbers are unlikely to shift results. Participants who chose to complete the survey may have been more trusting than those who did not, which may have muted the results. Even so, the results show that among the NYS gun owners MHL § 9.46 reporting adversely impacts care seeking and trust of mental health providers.

Conclusion

It is clear that NYS MHL § 9.46 is adversely impacting the health care decisions of a large subset of the NYS population and is ineffective in capturing its target population. The implication is that ending this reporting which embodies structural stigma, may increase care seeking and better serve population health.

              Table 1: NY SAFE Act and Health Care Survey Response Percentage Overall and for New York State Gun Owners

*Population Count of NYS Gun Owners is calculated as: (15,695,913 NYS population aged 18 years or older)(19.9% NYS adults own a gun)(X% NYS gun owner in Table 1). [13,15])†Ratio is calculated as: (Population Count of NYS Gun Owner in Table 2)/(12,156 individuals Represented by NYS SAFE Act database searches 5-year average). (DCJS, personal communication May 2024)

Table 2: Population Count of NYS Gun Owners and Ratio of NYS Gun Owners to Individuals Represented by NY SAFE Act MHL § 9.46 Database Searches, by Response Option for Selected Survey Questions

References

1.    Karaye, I. M., Knight, G., & Kyriacou, C. (2023). Association between the New York SAFE Act and firearm suicide and homicide: an analysis of synthetic controls, New York State, 1999â??2019. American journal of public health, 113(12), 1309-1317.

2.    McMahon, S. A. (2020). Gun laws and mental illness: Ridding the statutes of stigma. University of Pennsylvania journal of law and public affairs, 5(2), 1-55.

3.    Pandya, A. (2013). The challenge of gun control for mental health advocates. Journal of psychiatric practice, 19(5), 410- 412.

4.    Richardson, S. D. (2023). Codified barriers to mental health care, an example from New York State. Archives of epidemiology & public health research, 2(3), 260-264.

5.    Swanson, J. W., & Rosenberg, M. L. (2023). American gun violence & mental illness: Reducing risk, restoring health, respecting rights & reviving communities. Daedalus, 152(4), 45-74.

6.    Elbogen, E. B., & Johnson, S. C. (2009). The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of general psychiatry, 66(2), 152-161.

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8.    Applebaum, P. S., & Swanson, J. W. (2010). Gun laws and mental illness: How sensible are the current restrictions? Psychiatric services, 61(7), 652-654.

9.    Charder, N., Liberatos, P., Trobiano, M., Dornbush, R. L., Way, B. B., & Lerman, A. (2021). The influence of New York’s SAFE Act on individuals seeking mental health treatment. Psychiatric quarterly, 92:473-487.

10.    Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological science in the public interest, 15(2), 37-70.

11.    New York State Assembly. (2013). S02230. Retrieved March 15, 2025.

12.    New York State Senate. (2022). Mental hygiene (MHY) Chapter 27, Title B, Article 9, Section 9.46. Retrieved February 11, 2023.

13.    United States Census Bureau. (n.d.). 2022 American Community Survey 1-Year Estimates. Retrieved May 1, 2024.

14.    Substance Abuse and Mental Health Services Administration. (2023). Results from the 2022 National Survey on Drug Use and Health: Detailed Tables. Retrieved January 23, 2023.

15.    RAND Corporation. (2020). RAND State-Level Firearm Ownership Database. Retrieved on May 1, 2024.

16.    Swanson, J. W., McGinty, E. E., Fazel, S., & Mays, V. M. (2015). Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Annals of epidemiology, 25(5), 366-376.

17.    Corrigan, P. W., Watson, A. C., Heyrman, M. L., Warpinski, A., Gracia, G., Slopen, N., & Hall, L. L. (2005). Structural stigma in state legislation. Psychiatric services, 56(5), 557- 563.

18.    Purtle, J., Nelson, K. L., Counts, N. Z., & Yudell, M. (2020). Population-based approaches to mental health: history, strategies, and evidence. Annual review of public health, 41(1), 201-221.

19.    Hatzenbuehler, M. L. (2016). Structural sigma and health in- equalities: Research evidence and implications for psycholog- ical science. American psychologist, 71(8), 742-751.

Appendix

Appendix A: Online Survey Invitation
Does NY SAFE Act Impact Your Health Care Decisions?

Gun owners' opinions are important. Please participate in an 11-question survey about how NY SAFE Act MHL 9.46 impacts your health care choices. The purpose and background are pasted below. Click here to complete the survey: NY SAFE Act and Health Care Survey

Purpose

New York gun owners are invited to participate in an anonymous eleven question survey on how NY SAFE Act Mental Hygiene Law (MHL) 9.46 influences health care choices. The aggregate survey results will be used to help others (e.g., health care providers, legislators, general public) understand the impact of this law.

This survey is being conducted by the author of Codified Barriers to Mental Health Care, An Example from New York State, and is not affiliated with any employer or funding source. Survey questions were adapted from Charder N, Liberatos P, Trobiano M, Dornbush RL, Way BB, Lerman A. The Influence of New York's SAFE Act on Individuals Seeking Mental Health Treatment. Psychiatr Q. 2021 Jun;92(2):473-487. doi: 10.1007/s11126-020-09816-4. PMID: 32809110.

Background

Information about NY SAFE Act MHL 9.46 can be found at the following links.
•    NYS Office of NICS Appeals and SAFE Act
•    New York Consolidated Laws, Mental Hygiene Law - MHY §9.46 | NY State Senate (nysenate.gov)
•    New York Consolidated Laws, Mental Hygiene Law - MHY §9.01 | NY State Senate (nysenate.gov)

Mental health care services may include any assessment, diagnosis, treatment, or counseling in outpatient or inpatient settings. These services include premarital counseling, mental health screening, individual or group counseling, treatment of serious mental illness, and many other circumstances. The purpose of mental health care is to maintain or promote mental wellbeing.