It’s a beautiful (and hot!) Memorial Day, and even though I’m using it mostly to catch up on odds and ends and hang out with my family, I know it is important to remember the day’s original purpose—to honor the memory of those who have died in war. What do you think of, when you think of war and warriors? Do you think of the immediate injuries of battle? Or do you remember the slower, more painful losses of those who return home? Far too many of our veterans eventually succumb to their wounds of PTSD and related mental illnesses, years and even decades after the formal military hostility has ended.
Today, I think of a lovely man, once a family member by marriage. He fought in the Vietnam War and came home wounded more deeply than anyone knew at the time. He was an engineer, a father, and a marvelous carpenter. We still have a wooden lamp he made us by hand, 20 years ago, in his own design. We shared many family dinners and stories and watched our young children play together. When his war injuries finally got the better of him, no one could stop it—he became estranged from the family, disabled, and finally, one day we got the call that he was gone.
I count his death as both a casualty of war and of the failure of our mental healthcare system. Whatever the inadequacies we encounter in the US healthcare machinery, the situation for mental health is many times worse. Some of this is just because no one in the world has found cures for the most serious of mental illnesses, but much of the problem is in our failure to deliver treatments than can and do help. In honor of those who have returned home from a military war only to die as a consequence of mental illness, let’s review Section 204 of HR 676 on Mental Health Services.
As you can see, it is short and sweet. Part A says: “The Program shall provide coverage for all medically necessary mental health care on the same basis as the coverage for other conditions. Licensed mental health clinicians shall be paid in the same manner as specified for other health professionals.”
This is basically “parity”—saying mental health is part of health and can’t be treated differently seems to me a no-brainer, but it continues to be a root problem in our system. Our main attempt at parity, despite SAMHSA’s very optimistic wording, continues to fall short. The truth is that we have multiple separate and UN-equal systems of care. For those with private insurance, panels are limited to certain providers. Many policies under Alabama’s largest insurer do not cover therapy unless it is by a PhD, leaving out large groups of very qualified and effective therapists who have other professional licenses.
Even when a family is fortunate enough to find a skilled therapist their loved one can relate to, the whole relationship can end if the employer insurance policy (and thus the provider panel) changes. Many of the policies I see in our office have “carve-outs” for mental health—the insurers pay a set portion of everyone’s premium to another insurance organization, so that patients must deal with an entirely different agency for mental health. Typically, these specialist insurances have been very hard to deal with. They use their own criteria for hospitalization, for instance, which are different from the standard-of-care published criteria the doctors use. We can usually get little help from the patient’s main insurer in dealing with the behavioral insurer.
When there is a carve-out, pediatricians and other primary care docs get left out of the loop in treating milder conditions like ADHD or uncomplicated depression and anxiety. I’ve recently had several children who had been stable and thriving in my care for their ADHD—they had to switch to a psychiatrist for medication monitoring, because their insurance policies have changed and do not have primary care doctors on the behavioral panel. It made so much more sense for me to care for these children as whole humans—the asthma, the growth and development, and the ADHD are not really such separate issues. It was easier for the families too, but now they have to add extra appointments to their overloaded schedules.
Many private providers require up-front cash payment and tell the families to file for reimbursement from the insurer. This allows the providers to charge whatever they want to, leaving families to do battle for uncertain payment. Many families who have private insurance cannot afford to plunk down $200 a week for therapy and wait months to get some of it back. So they don’t go. They come back in a few months with the same problem I tried to get them help for, except it is worse and now harder to treat. Quick help for mental illnesses is critical—the longer the brain goes on in a dysfunctional state, the higher the chance of long term illness and disability.
For those who have public insurance through Medicaid, in Madison County the options are limited. Alabama Medicaid wisely allows primary care doctors to be paid for mental healthcare, but when the patients’ problems are beyond our training in psychopharmacology or when they need real counseling, they must go to the county Mental Health Center, now overloaded and underfunded. Waiting lists are long. Even though our MHC here tries hard to manage on a shoestring and has a director who truly cares about clients and families, it has not been able to keep a board certified child/ adolescent psychiatrist on staff. For adults, budget cuts have led to a move towards group therapy instead of individual therapy for most patients.
The split in private and public systems has had other consequences, on the provider end. Most of the families I know through NAMI who have loved ones affected by the disabling mental illnesses like schizophrenia or other psychotic disorders have wound up using public insurance, when their loved ones could no longer work. This means that many private psychiatrists and therapists today have much more experience and skill with the “worried well” than they do with full-blown psychosis. Many of them no longer even see hospitalized patients. Patients in public care often see therapists in training, who leave once they have finished that training.
There is little patient choice in either the private or public system. Competition between insurers won’t help, because the insurers must satisfy their shareholders and bottom line—they will continue to find ways of limiting access as a form of cost-control. The only kind of competition that matters in mental (and all) health has to do with quality of care, and the only way we will ever see the fruits of such competition is for all patients to have access to any licensed provider. Any form of cost-sharing at the point of service (co-pays and deductibles) would be especially detrimental in mental health—it is the treatment families in my practice seem most likely to put off until they can afford it. Needing mental health care is still embarrassing for many families, and having an excuse to wait is dangerous. Payment needs to be in advance, as in the Medicare for All plan, where we all pre-pay through taxes.
Part B of this section says the program will favor “community-based care” and that “in all cases the highest quality and most effective care shall be delivered, and, for some individuals, this may mean institutional care.” If you held your breath (or picketed with us) as Alabama considered closing almost all our state psychiatric hospitals this year, take note of those words! We cannot continue to put our most vulnerable citizens at risk because of floundering state economies.
I do not know if my former family member would have lived—or lived well— had he been in a country with a more integrated and accessible mental health system. Some problems will always be beyond our reach. We should not put our young men and women in the armed forces into combat for frivolous reasons—we should all know the human price of our votes for those who will make these decisions.
Honor the memory of those who have lost their personal battles with mental illness today by doing something for those who have yet to fight. Do something concrete—share this post with friends, call or email your legislators, or talk with a neighbor. Tell them why we need Medicare for All.