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Fixing the Mental Health Infrastructure in the US

| February 20, 2013
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The sad events of the recent tragedy which occurred in at Sandy Hook Elementary School in Connecticut where 20 children and 6 adults were killed painfully reminds us of two problems that are not going away in the United States: continued gun violence and untreated mental illness. As a Father I could not bear to watch the news coverage. Resolving the problem of high gun violence in this country typically leads to an emotional debate over gun control and gun rights, a debate that in the past has ended with both sides drawing the line and little being accomplished. Politicians that would like to be reelected avoid this emotionally charged hot potato like a leper colony with the hope that the Topic Du Jour will change quickly back to how they can reduce taxes, increase entitlements, or frankly any other issue that will ensure their livelihood for the current elected term. In the meantime, this stalemate is unnecessarily costing the lives of our innocent children and productive citizens that happen to be in the wrong place at the wrong time. 

The common thread to almost all of the tragic public gun violence episodes in the past few decades is that the shooter is suffering a serious mental illness. An estimated 26.2 percent of Americans suffer from a diagnosable mental disorder in a given year according to the National Institute of Mental Health (http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml). Unique amongst the developed countries is the position of the United States that those with mental illness, like those with any other disease, can receive treatment as long as they pay for it. Those that can’t or choose not to pay for it often end up in dire straits in one of our emergency rooms (the de facto health care solution in the United States for the uninsured) forcing our overworked and understaffed emergency room health professionals to deal with the problem and our hospital systems with spiraling unpaid ER bills. As a country that was founded on the principles of self-reliance and freedom of choice, we recognize the fact that some individuals may prefer not to pay for their health care by electing to not have private health insurance. Lest we become too judgmental of our fellow citizens that do not have health insurance, we should be reminded that our for-profit health insurance industry in the United States that provides the largest portion of payment for healthcare services also precludes individuals that are unhealthy from purchasing coverage. This is done by hiking premiums to unaffordable levels or simply by flat issuing a denial of coverage. So individuals with mental illness, even those diagnosed with mild depression, are often branded by the system that considers mental health issues as preexisting conditions. Which brings about the question:  How does an individual with a mental health illness in the US normally get medical treatment?

Normally, the individual sees their primary care physician, talks about the problem, is diagnosed by the physician and receives treatment, which often includes prescription medications. The individual’s private health insurance plan (or Medicare or Medicaid, depending on the age or financial qualification of the individual), covers all this with typically a small or no copay at the doctor’s office. If a medication is prescribed, the drug (often a generic) is covered typically by a small copay at the pharmacy. Further checkups and treatment are all typically covered by insurance with little money out-of-pocket.

Here are the complications to the “normal” answer regarding an individual with a mental illness in the United States seeking help:

Reasons Mental Illness Goes Untreated That Involve Lack of Access to Medical Care

  1. The individual does not have insurance.  The cost to treat the problem may be considered unaffordable.
  2. The individual has insurance but the mental illness has been ruled a preexisting condition and is not covered under the policy. The cost to treat the problem may be considered unaffordable.
  3. The individual does not see a health service provider on a regular basis and may not realize that they are sick with a mental illness or consider that it is just stress or a temporary mood change.

Reasons Mental Illness Goes Untreated In Spite of Access to Medical Care

  1. The individual considers seeing a physician for such an issue to be a hassle or too time consuming. Some primary care practices in some parts of the country require a long wait to be scheduled and then a long wait in the waiting room to be seen.
  2. The individual would like to receive treatment for their mental illness, but knows that such treatment will be recorded on their medical records and likewise have repercussions that could include such events as losing their job, tarnishing their reputation in their community, family, church, or other organization, or denying them access to a gun license, pilot’s license, medical licenses, etc. Military service people and police officers, for example can be rightfully disqualified from their positions if certain mental illnesses were revealed on a medical record. Also having a mental illness on their medical record could increase their cost to get life insurance or their ability to get new health insurance should they leave their current employer. Likewise many of these individuals may seek help “off the record” or may avoid seeking help all together and simply “man up” as expected.
  3. The individual, for reasons mentioned above and regardless of medical care access, avoids professional medical care and self-diagnoses their mental illness. Likewise, an individual suffering from severe depression may decide that they have only mild depression and based on “Dr. Google” may start a regimen of Vitamin B, a chromium supplement, and some St. John’s Wort. Self-treatment of mental illness issues with easy access to information and prescription drugs through the internet lulls some individuals into a false sense that they are on the road to recovery when their condition can actually worsen.
  4. The individual may know they need help, may have access to qualified medical help, but may be discouraged from seeking help due to a trusted family member or friend that assures them professional medical help is not necessary. I have even witnessed a loving father tell his diagnosed schizophrenic son who had just experienced a manic episode to “shake it off and be happy”. Can you imagine telling your child who suffers from a serious chronic disease such as heart disease, cancer, or diabetes to just “shake it off and be happy”?
  5. The individual perceives that continued medical treatment of their mental illness could threaten their personal freedoms, by resulting in a court ordered commitment to a psychiatric facility for example. Fearing such restrictions, the individual cuts off all medical treatment. In fact recent news is now coming forth that Adam Lanza, the 20-year-old Sandy Hook shooter, had been taken to a psychiatrist by his mother and was in fear of being committed to a facility, which may have been part of the motive for the mass shooting spree, which included the killing of his mother.

Will ACA Fix Our Maligned Mental Health Care System?

Mental health services are a part of the services provided under the Affordable Care Act. The Mental Health Parity and Addiction Equity Act, which was signed into law in 2008, also helped increase coverage that includes mental health services by requiring employers with more than 50 workers to cover them at the same level as other medical conditions offered by the insurance plan. In other words, the plan could not provide fewer inpatient hospital days or require higher out-of-pocket costs for mental health conditions. It is still possible however for larger employers to not offer mental health coverage in their insurance plans even after 2014. The ACA will require small group and individual plans however to offer the coverage in 2014 through health exchanges created under the law. An individual that earns less than 138 percent of the federal poverty level may be eligible for Medicaid coverage in 2014, which offers mental health benefits.  

It is estimated that as many as 30 million people will gain insurance coverage and likewise mental health care beginning in 2014. Some estimates are lower, with the expectation that many will forgo the mandated insurance coverage and pay the “tax” instead. Even with more Americans having access to mental health care, many will opt to forgo such care as outlined above in “Reasons Mental Illness Goes Untreated In Spite Of Access To Medical Care”. For those folks we can fault the independent American spirit, good old fashioned stubbornness, the desire to avoid any stigma attached to mental illness, or simply the desire to be unencumbered by a system that threatens to “lock you up and put you away” for your disease. As with the case of Adam Lanza, access to mental health care does not mean the disease is cured or that the patient is an obedient, willing participant.

Sadly, preventing another Sandy Hook from occurring is impossible. Whether or not the gun debate this time around will produce any results remains to be seen. Where is the limit of personal freedoms? However, with increased mental health access beginning in 2014 and with increased mental health awareness and acceptance we can hope that such events in the future will be less common.

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