Frankly, My Dear, They Don’t Give a Damn

From the Editor

It won’t be long now. The travesty that we substitute for a thoughtful national discussion of critical issues in a presidential election (not to mention for Congress and state and local government) will soon be over. Does anyone really think we are making election decisions based on the very real and important need to address festering problems? Not me, and I think to a large degree, the responsibility for this, as I’ve said before, lies importantly with ratings-driven media decisions. I haven’t heard almost any discussion about health care, or particularly mental health issues, while the focus is on walls and emails. Two disparate things caused my tolerance to be exceeded once again, and I’ll mention both of them.

Last month, one of the major cable 24-hour news channels was heavily advertising hour-long shows featuring profiles of the 2 major party candidates. The commercials emphasized segments “from those who know them best.” This might lead one to believe these would feature professional associates, or prolonged interviews with the candidates themselves. But, no, the people featured in the commercials were the candidates’ children and spouses. Those certainly will shed a lot of light. While many decry the pitifully personal and negative caricaturist focus of the campaigns, the TV channels eat it up. Bread and, mostly, circuses for all, I guess.

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In contrast, at the end of August the Boston Globe, unfortunately read by orders of magnitude fewer people than watch cable news or listen to talk radio, wrote a very lengthy and distressing, to say the least, front page review about the deteriorated public and private mental health care system in Massachusetts.¹ Those of us trying to provide care should not have been surprised at the tagline:

Behind the fragmented state of mental health care here lies a political system failure that spans decades-and continues. State and federal leaders abandoned their promise to replace psychiatric institutions with reliable community care. Despair and preventable deaths were the predictable result.

The lengthy Globe report, a cover story over 4 pages long, reviews how the promise of governmental support for community-based care for psychiatric disorders never came to be. What was especially troubling to me is the fact that Massachusetts was historically held out as an example of “enlightened” implementation of mental health managed care when disastrous changes were sweeping the country in the 1990s.

It is well known, as the Globe highlighted, that not even 50% of the envisioned federally funded community mental health centers were ever funded. This represented a flawed implementation of the federal legislation and of the legislation itself, with plenty of blame to go around at the local, state, and federal levels. One of the major reasons for the failure was that federal legislators assumed that state governments would shift most of the prior funding from state-supported psychiatric hospitals to community-based care. But this never happened.

Even in a state viewed as progressive in health care matters, Massachusetts and federal government leaders, as the Globe stated, “cut hundreds of millions of dollars in mental health spending over the last 50 years.” Massachusetts alone has cut almost half the support for in-patient psychiatric care, almost $161 million dollars, according to the Globe. But, as the Globe’s own Spotlight team discovered (yes, the same group as in the movie), “per-capita spending on outpatient care by the state Department of Mental Health barely budged.”

As bad as the Massachusetts story is, it’s likely better than in many states. My own state of Kentucky, for example, went from being a nationally recognized leader in community mental health care in the 1970s to one that received a failing grade recently from the National Alliance for the Mentally Ill because of repeated budget cuts over the past several decades to what once was a national model network of publicly funded community mental health centers. And, to make matters worse, our present governor is requesting a new federal waiver to reorganize and roll back many of the benefits of the Affordable Care Act–funded Medicaid expansion carried out by his predecessor.

Does anyone really think we are making election decisions based on the very real and important need to address festering problems?

Another problem, and less likely to receive favorable attention from government at any level, has been the proliferation and growth in the for-profit mental health industry in the past 50 years.² This is not a system known to be user friendly to clinicians or, more importantly, to the patients those companies are supposed to be serving.

It has been known since managed care came to psychiatric care in the 1990s that inordinate profits were being siphoned away from paying for contracted care. No one talks about that much these days, but with all the government cuts, it would be worth looking at whether the obscene profit margins of the 1990s persist. My guess is that some reduction has occurred, but not likely what most neutral observers would consider adequate.

I’m skeptical because we all know the large insurance companies pleaded with Obama to remove the requirement to spend at least 80% of premium dollars on paying for care, saying they couldn’t afford it. Luckily, the President refused to alter the requirement. We know, also, that even without a formal analysis, the idea that there is true parity in coverage for psychiatric disorders is more of an ideal than an actuality.

Almost no psychiatrists in private practice in my hometown, Louisville, are willing to take patients with either Medicaid or commercial insurance. My guess is that this is more the norm for similar population centers than the lower level of refusal the Globe found in Massachusetts.

It’s clear to me that most politicians don’t give a damn about their constituents with psychiatric illnesses. Those who claim they have to cut support for psychiatric care because of budget crunches aren’t making similar cuts for cancer care or any other kind of care at the same level-and to me they are simply being disingenuous.

But there is a presidential election going on, and elections for thousands of other positions whose office holders will be responsible for government mental health policies. So I hope our readers look seriously at what the candidates have to say, or if they say anything at all, about addressing the current and increasing disaster in the mental health system before casting their votes.

References:

1. The Spotlight Team. The broken covenant. Boston Globe. August 28, 2016.

2. Torrey EF. Fraud, waste, and excess profits. Psychiatric Times. 2015;32(11):1, 24. http://www.psychiatrictimes.com/cultural-psychiatry/fraud-waste-and-excess-profits. Accessed September 12, 2016.