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Letter from Bazelon: Alabama’s Mental Health Funding Crisis

Interesting letter to Governor Bentley from the Bazelon people.  This is the law firm involved in the Wyatt vs. Stickney case– if you don’t know about that, there is some good background on it by Dr. Fuller Torrey’s group.  It is the lawsuit that resulted in the tragic consequences of deinstitutionalization in prior decades– the burgeoning population of homeless mentally ill, the dumping of sick people into prisons, and the loss of sick persons to suicide.  It was intended by some involved to force hospitals into better standards of treatment, not to abandon patients entirely– but the consequences were disastrous.

The letter is a clear threat that if Alabama doesn’t fund our mental health, we are about to get sued– again.  Bazelon says Bentley should apply all the funds initially intended for Bryce to use for transitional planning and they seem to think this will be enough.  I am uncertain of that– we need not only funds for transition, including capital costs and training of new personnel, but also for the ongoing expenses of our current and future services.  Using one-time funds may not cut it– we won’t know until DMH releases a clear plan and estimated expense.

Bazelon’s insistance on closing all the hospitals may be misguided– the Olmstead decision says that we should place people in the least restrictive setting possible, and to integrate them into the community if it can be done.  Some people are too sick to make it in the community, no matter how hard we try, until we have a real cure.  More will be intermittently very sick, since relapses happen even while on previously effective medicine, and they must have a secure, safe place to get treatment.  It is possible we could replace the hospital with local crisis stabilization units– we should be open-minded– but they would have to have capacity to keep people until they are REALLY ready for a lower level of care.  Here’s a brief breakdown of what Olmstead requires and does not require, from Iowa– note that it does NOT require all hospitals to be closed!  It just says that people can’t be kept in the hospital longer than they need to be there, if it is possible to serve them in a community setting.  The pitfalls of over-reliance on community settings are severe.  Bazelon is hurting us by over-interpreting Olmstead.

Bazelon has an ulterior motive that conflicts with reality.  They do not believe in commitment, even to outpatient care– they think all patients with mental illness should be left to their own devices unless they are right about to kill someone.  The reality this conflicts with?  There is a well-studied phenomenon in serious mental illness called anosognosia.  People who have this are incapable of understanding that they are sick or need treatment, the same way as some people after a stroke will not be able to believe they have a left arm.  It is part of the illness itself.  Real advocates for loved ones with mental illness have a more realistic approach.  We are definitely not in favor of restrictive setttings when they are unneeded, and we fight for the inclusion of patients in making their treatment decisions whenever possible.  We want our loved ones to be as independent as they can be and to have fulfilling lives.  None of that is possible if they die from suicide or undergo permanent brain damage as a result of inadequately treated illness.

Torrey’s site has a good explanation of why we need approximately 50 hospital beds for each 100,000 population (same as my prior estimate of 140 beds needed for Madison County alone) and a list of capacities per state– notice Alabama is far short.

Bentley and Baugh have promised that they will not close the hospitals until local infrastructure is ready.  If they keep that promise, the transition could go well.  The reason many of us are not reassured by their words is many-fold.  There have been multiple and rapidly changing plans issued from DMH since February, so we are uncertain anything they say is going to remain in place.  They have not yet told us how they will pay for it or how they will apply the 2012 proration to DMH without hurting outpatient services.  At our regional meeting last week, we were told that DMH couldn’t guarantee a timeline because it depended on funding– which is in direct conflict with saying the timeline depends on having infrastructure prepared.

The threat of lawsuit may be the only thing that saves our mental health system.  Will Bazelon be just as ready to sue on behalf of those who become homeless or commit suicide because they have inadequate care as they are to sue for what they consider excessively restrictive care?  Don’t hold your breath.

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Waiting– and Ready– for Real Healthcare Reform

Big news this week– the 11th Circuit Court of Appeals ruled the individual mandate to buy health insurance unconstitutional.  Although they didn’t invalidate the rest of the Patient Protection and Affordable Care Act (PPACA), if the ruling stands it
will render key provisions unworkable. Without a mandate, insurers have a fair objection to protest coverage of pre-existing conditions, for instance. So we’ll have to wait and see what happens once this case makes it to the Supremes.

While waiting, Medicare for All advocates should be busy preparing.  When PPACA hits the fan, we’ll have another chance to get real healthcare reform. We have the data on our side—what we need are better ways to educate the public and more convincing responses to our opponents.  Today I’m going to tackle waiting lists.

Some countries that have enjoyed national health insurance for decades, such as Canada, have had problems with waiting lists for certain specialty procedures like hip replacements. This is not a problem everywhere.  Waiting lists are less a function of the payer than of specific decisions about physician supply and distribution.  In the United States, because we choose to pay surgeons disproportionately high rates, we have more of these specialists and not enough primary care doctors.  In consequence, patients in the US wait much longer on average to get an appointment with a family doctor than patients in other developed countries do.

It is true that if we woke up tomorrow with Medicare for All, there would be serious physician shortages in primary care (we have an abundance of specialists to perform hip replacements). People who already have a doctor would be ok, but the newly insured
would have a hard time finding a doctor with openings for new patients.  They would not be able to get preventive care right away, and they might rely on the ER for minor illnesses. ER’s would need to respond by improving their triage systems, so that patients with life-threatening emergencies are always at the front of the line.

Just for the sake of argument, though, let’s pretend we are really worried about wait times.  It’s as if we had a large banquet hall with a buffet and a line of hungry folks ready to fill their plates.  Over to the side, another group can’t get in line at all because they don’t have meal tickets.  They will stay hungry—their wait time is indefinite. The kitchen is only prepared to feed the ticket holders
anyway.   If everyone suddenly had meal tickets, all diners might have to take somewhat less on their plates than they wanted.  Some would have to wait longer for dessert, until the kitchen caught up.

Some might say only those who already have meal tickets should get their promised meal, and those without can have the leftovers, if there are any.  They will point out that if everyone had worked harder, they could have bought their own tickets.  They are more willing to take the chance some people will die of starvation than they are to risk leaving the banquet hall a little hungry themselves.

Using waiting lists as an objection to universal health insurance is really a way of saying we should let some go without care so the
rest of us can get it more easily.  Even those who believe healthcare is a privilege, not a right, can’t defend this position.  After all, they constantly tell us that America is the land of opportunity and that health insurance is a personal responsibility.  If they were
right and managed to motivate all the uninsured to “think and grow rich”, we’d have exactly the same waiting problem.

We can address waiting lists without depending on some patients never getting in line.  We can plan physician supply more intelligently, to meet the needs of everyone in our country.  This has absolutely nothing to do with whether we want private payers or single payer.

I was told in a Facebook comment last week that I have a “habit of implying” those who disagree with me are “selfish, lacking in compassion, not good Christians, and perhaps even less evolved or brain damaged.”  And that this habit of mine is “tiresome.” If
our opponents proposed alternative plans clearly designed to gain equitable healthcare for all of us, I would offer only practical information on cost and quality, and I would quit dwelling on ethics.  As long as they continue arguing on selfish principles, I suppose I’ll resign myself to being tiresome.  Medicare for All—everybody in, nobody out.


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letter to editor

In case you don’t get the Huntsville Times, thought you might like to read the letter from me they published today.

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Criminalization of the Mentally Ill

This post is not from either a left or right political perspective– it is political only in one of Webster’s definitions of politics as the total complex of relations between all people in a society.  But as a NAMI member (National Alliance on Mental Illness, an advocacy group comprised largely of family members of people with serious mental illness) and also as a general pediatrician who cares for some children and teens with serious mental illness, I feel obligated to speak up.

The shootings in Arizona last weekend were tragic from every angle.  I do not know if the shooter will turn out to be diagnosed with a mental illness that caused him to act this way or not– I am not his doctor.  But in any case, there are some very important things we need to know.

First, studies have been done on the percentage of mentally ill people who commit violent acts compared to the percent of non-ill people, and it is actually about the same.  The difference is only that mentally ill people, if they commit violent acts while ill, are likely to have done so as a direct result of their illnesses.  So we do not need to be afraid of people who are mentally ill, in general, more than we are afraid of any other group.  Humans have the unfortunate capacity for violence (thankfully, we also have a great capacity for compassion).

Second, if people with mental illnesses get the appropriate and timely treatment they need, they are very, very unlikely to be violent.

So what we need to do as a society, to lessen the risk of such violence, is to work for easily accessible and effective treatment for mental illness.  We need to know the warning signs of possible mental illness, so that we can recognize them in others, and we need to know what to do if we suspect a problem.  But this will not be possible, I believe, unless we also work to reduce the terrible stigma of mental illness.  Because of this stigma, persons and family members not only lack knowledge about what to do, but they are often too embarrassed to seek help.  The possibility of being judged and socially penalized if others find out is real.

Young adulthood is a high risk time for people to develop illnesses like schizophrenia.  Families may not understand what is happening– some try to get help but can’t afford or find it, and instead live in fear that their loved ones will do something terrible that would never happen without the illness.  When bad things do happen, others who don’t know them often blame these suffering families.

Please go to and educate yourself.  Donate if you can, and join a local chapter. There are so many things we could do to improve mental illness treatment in our country.

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Patient Protection and Affordable Care Act, Part 13

This week, I’m looking at Section 2951, Maternal, Infant, and Early Childhood Home Visiting Programs.  This is really a public health section, but if public health is well-funded and well done, we can make some inroads into cost control.  In fact, a public health model is really the best and most appropriate way to address community wide risk factors, rather than doing it all at the patient/ personal physician level.  For instance, if a community has an E. coli (diarrhea) outbreak from a contaminated pool (newsflash– those swim diapers really don’t block the poop), it is much more effective to get public health involved, locate the source and get it cleaned up instead of only treating whoever gets sick.  This is a separate issue from the source of health insurance financing, but it is certainly relevant to our discussions.

So, this section would make funds available to states who apply for grants supporting home visiting programs.  To apply, a state would need to do a statewide needs assessment, looking for communities with high concentrations of premature babies, low-birth weight newborns, and infant deaths (including those from abuse and neglect).  The needs assessment would also measure risk factors  including poverty, crime, domestic violence, high school dropouts, substance abuse, unemployment, and child maltreatment.  The state would assess its current capacity for home visiting programs for at-risk families, uncover gaps in service and measure the extent to which current programs are meeting community needs.

Once grant money is given, states have to measure several outcomes.  These are supposed to be quantifiable outcomes including maternal/ child health, death/ injury and abuse rates in children, school readiness, crime, family “economic self-sufficiency”, and improvements in coordinated referrals for other resources.  Reports on these outcomes are due after 3 years of operation.  The home visiting programs must use a proven, evidence-based model.  The outcomes listed sound good, but let’s see how exactly they turn into something that can be counted with a number.  Obviously death and injury/ abuse rates can be measured– although sometimes when services become more available, abuse gets reported more (lots of abuse we never know about), which could be a problem.  There would have to be specific measures of maternal and child health– birth weights and prematurity could be measured more easily, but much of health is hard to put in terms of a number.  School readiness and the other items depend on so many factors that it would be hard if not impossible to tell if a change was specifically related to a single program.   Measuring outcomes outside of a test tube can be very very tricky.

The home visiting staff would give families education– I don’t see actual healthcare listed in the services.  The education would be targeted at improving maternal health during pregnancy, and early infant and child health.  The details aren’t specified but it sounds like this would include things like nutrition and hygiene.  Parenting skills and early childhood learning would also be included.

One point that this section reminds me of is that the health of a population depends in great part on “health equity” factors entirely separate from health insurance.  If a child lives in a dangerous neighborhood (some of my patients tell me about having a hard time sleeping because of gunshots), doesn’t have a safe place to play outside for exercise, doesn’t have access to clean housing (mold, peeling paint), doesn’t have access to good adult role models in the community… that child will have a hard time staying healthy no matter how much health insurance he has.  If he lives in a city with high levels of air pollution, he is much more likely to be in the emergency room (or die) with asthma.  This is true even in countries who do already have universal health care– remember that’s the rest of the developed world–and it is important to remember.  That doesn’t mean health insurance isn’t important, just that it won’t solve every problem in the world.   We need to complement (not replace) our efforts for equitable health financing and access with good community public health.  That’s for all of you who thought I was preaching Medicare for All would keep our toilets from clogging up!

Now I’m looking at how much money would be available, because philosophy only takes us so far.  The Act says there will be 100 million available starting this year, increasing each year up to 400 million in 2014.   I did not find an end date, but further funding would have to be cleared through Congress after that.  So how much would this cover?  If all 52 states applied and the money were divided evenly (which is not specified and I suppose could depend on how many poor communities a state had), each state could have 1.9 million in the first year.  At first that sounds like a lot, but let’s say Alabama got that amount and picked only 20 communities to fund programs for.  Of course we know there are far more than 20 communities in our state which are suffering.   That would be 95K per community.  Then it depends on how many families in a community need help, which would determine how many staff members need to be hired.  Home visits take time to be effective, and there’s driving time as well.  I don’t know how many home visits a single employee typically makes in a day.  But I’m wondering if 95K would pay for enough staff members at the level of skill/education necessary to help enough families to show measurable improvements?

Looking at the Children’s Trust Fund website for Alabama, there are currently only 9 programs in our state receiving CTF money, with $239K this year.  Huntsville’s Child Advocacy Center is listed as receiving $27.5 K for its home visiting program, and the CAC website says that last year they served 76 families in this program.  The entire CAC budget (for a large range of services including child abuse medical exams, counseling programs and so on) was listed as around $3 million.  So I don’t know how much of the total budget, because it wasn’t broken down, was also spent on the home visiting program.  But of the total CAC budget, $1.9 million (about 2/3 of the total) went to personnel.  It is expensive to hire and train high quality personnel, and the success of any home visiting program would depend on that.

Anyway, let’s say theoretically it only took 27.5K to serve 76 families with home visits and no more than that came from the rest of the CAC money, which I somewhat doubt.  In our newborn nursery, my partners and I take care of at least that many newborns from at risk families in a month’s time.  So if we were going to have a program that would serve even just those families, we would need 330K a year.  I’m sure 95K would help and we wouldn’t want to turn it down, but it might not go as far as we hoped.  My friends who are in the teach a man to fish camp (while I’m the feed him a fish while he is learning camp) should support more funding for programs like this that effectively educate families.  You can go to and donate!

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Patient Protection and Affordable Care Act, Part 12

I have four sections to review today– one with more to talk about and then three brief ones about the Indian Health Service.  If you have time please read the last part also, because I am uncertain about some of the IHS section and would like some help with it.

Section 2707 is the Medicaid Emergency Psychiatric Demonstration Project.  These will be pilot projects states can apply for, to be federally funded.  Emergency is the key word– this only applies to patients who have suicidal/homicidal thoughts that make them dangerous to themselves or others.  So a person could potentially have significant/ severe symptoms that might be better treated in a hospital, but if they aren’t dangerous this doesn’t help them.

The project will pay for non-public facility inpatient evaluation and stabilization of Medicaid patients who are suicidal/homicidal, and it will monitor whether this is cost-effective, as well as whether the patients have fewer subsequent emergency room visits.  It will track the effectiveness of discharge planning, an important task.

Right now, Medicaid doesn’t pay for inpatient services for psychiatry, for people between ages 21 and 65.  It’s not that they can’t get services at all– there are state run hospitals but these are run through money budgeted through a different fund than Medicaid or Medicare.  At least in Alabama, access to state inpatient services is extremely difficult– long waiting lists, etc.  And our oldest state psychiatric hospital, Bryce, is soon to close.  I’ve had a loved one who stayed at Bryce for long periods of time and really could not manage life in the other places that were tried, so I don’t know how well the new plans will work out.  We have hopes.

This part of the Act says that the services can be provided in “non-public” facilities now, as a trial, with funding coming straight from Medicaid.  It sounds like this would relieve some budget issues for the state regarding mental health– ideally, those resources would be freed up for increased mental health outpatient services, but maybe the budget would just wind up being cut.  The overhead in state facilities is lower– I wonder if it would be better to have had Medicaid funding go to the state hospitals to improve and expand them instead.  Will this be a handout to the private hospitals?

Another word to look at is “stabilized”.  This doesn’t mean “in remission”, and it doesn’t necessarily mean that the person will do just as well moving to outpatient treatment (although it can).  All it means is that they no longer fall into the dangerously suicidal/homicidal category anymore.  And what happens now is that people get stabilized, leave the hospital, get un-stabilized, and round and round.  So I would like to see how the discharge planning part gets handled.

As a board member of our local NAMI chapter (National Alliance for the Mentally Ill), and a family member of more than one person with severe mental illness, mental health care reform is very personally important to me.  I think it is totally ridiculous to subdivide our bodies so that some parts are treated differently in how we can access medical care.  Seems to me like the brain is the most important organ in our bodies, and if the care is different it ought to be that it is even better than for the other parts.

The single payer plan would not discriminate between coverage for mental health issues and coverage for other body parts, and we would be able to jointly finance excellent care for loved ones with serious mental illness, without  all these shenanigans.

The next section, 2801, is just a provision to improve and monitor the “MACPAC”– this is the “Medicaid and CHIP Payment and Access Commission”.  CHIP is the Children’s Health Insurance Program (AllKids in Alabama) that helps cover some children of working poor families.  The MACPAC will be expanded to include health professionals, employers, third party payers (grrrr), family members and patients– it will review policies concerning how well eligible children are able to access the system.  A completely unnecessary and expensive bureaucratic layer if we all had the same insurance coverage.

And the last two sections, 2901 and 2902 are about the Indian Health Service.  First, there will be a special rule that Indians (this is the term used in the law, not Native Americans) who make less than or equal to 300% of the poverty level will have their care completely covered (no copays or deductibles).  It also gets rid of the expiration date for Medicare Part B coverage of services by IHS clinics and hospitals.

Here is the part I don’t understand fully– it says that the IHS can bill 3rd parties like Medicaid and Medicare for services provided but that the IHS is the “payer of last resort”.  So what does this mean– that if Caid/Care won’t pay, the IHS is holding the bag?  Is this only for patients who actually aren’t eligible for Caid/Care or something else?  The “concordance” I’m using didn’t explain it, just repeated the language.

Under single payer, people in the IHS would have access to the same services everyone else could have.


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Casting Out Demons: A New Metaphor for Eliminating Private Health Insurance

Just got back Sunday from a PNHP planning meeting in Chicago– a very intense, all day event, packed with ideas and information.  I’m still working to digest it all and figure out how to incorporate it into what I’m doing.

We talked a good bit about what the private insurers are already doing to subvert the new law and what they will probably do as we go along.  You’ll love this one– there are regulations about gradually limiting the amount of premiums insurance companies can spend on overhead.  Well, it seems that “overhead” is a flexible term!  So, with some companies, that conversation between you and the insurance company where payment for a certain treatment gets denied is… you guessed it, a medical expense.  Not overhead.  It is nigh unto impossible to regulate these entities.

I heard one person, in frustration, say she wished she could “demonize” the private insurers.  I thought that was a little funny, because they seem to be doing a pretty good job of demonizing themselves without our help!  Usually I don’t like the idea that you have to have an enemy to rally the troops– if an idea is good, it should stand alone without having to create a bad guy.  And I certainly wouldn’t want to call the employees of an insurance company demonic.  But after really thinking about it, I decided demon wasn’t a bad metaphor, for the corporation itself.  I searched online and found a great definition of demon: “a source or agent of evil, harm, distress or ruin.”  And private health insurance corporations have indeed been an agent of harm, distress, and ruin, if not evil.  This is a demon, to carry on the metaphor, that has “possessed” our society.  Not a metaphor you’d want to use for all audiences, of course.

I’m ready to cast out the demons of corporate health insurance!  Will you help?

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