As Suicides Rise, Insurers Find Ways to Deny Mental Health Coverage
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A friend that has been certified mentally ill stopped taking his meds and was fantasizing about killing himself, a family member and shooting up religious organizations. His doctor, family, employer and friends all called the police, talked to lawyers, mental health professionals, etc.
The end result was that he was facing sleeping in a car that was about to repossessed, and eating in homeless shelters. At that point he decided to accept free housing in exchange for seeking help.
His family’s only other recourse would have been to pay tens of thousands of dollars in legal fees to petition the court to force the police to uphold the law. This would have had a medium to low chance of succeeding.
Of course, during the months this dragged on, he missed an insurance payment or two (he had also been fired, divorced and evicted), so it lapsed.
There is a 12 (6?) month wait to get government disability insurance to kick in for this sort of thing, and the clock starts after the mentally ill person goes in for scary interviews with the government to establish they’re actually crazy.
The law used to handle this sort of thing properly in California, but Regan repealed the lions share of it as governor, and loopholes that accidentally allowed people like my friend to get health care have been progressively closed since them.
Nurses at the intake office of the appropriate mental health facility in Santa Cruz told me that most of the homeless people in the Boardwalk area there are in exactly the same situation as my friend was in, except they’ve been trapped in it for years.
I'm not sure I see a better solution to this that doesn't come with its own set of risks and downsides (involuntary commitment or counseling of someone against their will is not something to be taken lightly in any event, even if their reality diverges from your own).
Describing psychotic delusions as 'reality diverges' is something or other, I have to say.
Of course we need to respect the rights of individuals, but it shouldn't be the case that family and friends are the first, second, third, fourth and so on interventions, there can be professional resources available.
- healthcare not linked to employment
- a housing-first homeless policy
- a compassionate aid policy that presumes that people who are asking for help need help, and starts providing help as soon as it is asked for rather than after a year or more.
Those don't seem like they have any major risks other than monetary.
Threat of homelessness is basically the only remaining lever the law allows in these situations.
The other two points are spot on.
The one place I know of where a housing-first policy has been implemented, Salt Lake City (or maybe all of Utah?), doesn't just give homeless people a set of keys. They do assign everyone a social worker at the same time. The goal is to minimize the risk of what happened to your friend; that isn't good for anyone, including the person spiraling.
It's key, though, to start with a home (and a social worker). The wealthiest country in the world can do that for its people -- and it shouldn't be on private citizens, though that was generous of you.
My ex was schizo-affective (had traits of both schizophrenia and bipolar disorder). He was on disability. His doctors did not want him living by himself. Some things were simply too stressful and he couldn't do all of it. He'd only cook instant food. He wasn't good at budgeting money. And so on. For a while after we split up, he had a social worker coming to his house for wellness checks. My friend worked a similar job for another hospital: SHe'd visit mentally ill patients and help them, sometimes shopping and whatnot.
There was no recovery for him, only meds. That's it. Only meds.
I cannot fathom how stressful it would be to have your housing and your safe space be dependent on taking your meds, especially when your meds need adjustment... and paranoia strikes up again. Every stressor simply complicates things.
In my friend’s case, he had actually set up permissions for the doctor, his family, and I to initiate such a thing, but after his episode started, he fired his doctor and was quiet for a month, which nullified the paperwork he had done to create a safety net for himself.
The law has a list of things that have to happen before the psychiatric hold if there is not such an arrangement.
Basically, the mental illness has to affect some number of life areas. I think this is the list, I might be remembering wrong:
- work - finances - shelter - self care (eating, etc) - family life / marriage.
It used to be that one thing on the list was sufficient. I think the current law is that a total of three are necessary, but not sufficient.
Risk of immediate self harm or harming others is a different path, but the person basically has to say “yes, I do plan to kill myself, or that fellow over there, officer” on camera for that to count.
Anyway, my friend ticked all six of these boxes, and that wasn’t sufficient. If the person is borderline coherent, don’t think anything really is.
(Nothing in this message should be considered medical or legal advice. Go talk to a doctor and a lawyer if you might need to know any of this stuff, especially if everyone is healthy at the moment.)
(Edit: upvoted sokoloff because this is exactly what everyone with any power to provide care says.)
We have a history of using this policy in multiple countries, and in each one the system was abused to torment and commit minorities, people (including children) who were deemed an inconvenience, and political enemies.
I say this as someone with a family member who went through a very similar experience as your friend. I know just how scary and frustrating it is, and the immense burden of care and worrying it puts on people who care about someone going through mental breakdown like that.
I wish there was a solution to this problem, but I don't know what it would look like.
Rosenhan's paper itself ("On Being Sane In Insane Places") also makes for fascinating reading and is very readable even for laypeople.
In so many ways, America needs to start understanding that solutions to these problems have been explored and, just possibly, greater progress achieved in other countries... progress can be gleaned by studying outcomes from those countries.
It's easy to dismiss suggestions as having "its own set of risks and downsides", but in critical areas, America is significantly underperforming other first world countries and we need to get past the Not Invented Here syndrome.
It's Indoctrinated That Anything Socialized Is For Weak Moochers And Cannot Succeed Because It's Not Capitalism syndrome.
You then provide free legal advice, and access to mental health act tribunals where people can challenge their detention.
You have independent regulators who provide some oversight, the rpess can report on it all, and of course the courts provide a final backstop.
There are problems with this, but it's pretty good.
We have short detentions for assessment. We have longer detentions for treatment. We have police powers to take someone from a public place to a place of safety for assessment. There's another police power where the police can take someone from their home to a place of safety for assessment, but only if they have a valid warrant.
Most cities & states just try to fix the symptoms of homelessness (& crime), and not the actual root of the problem. There needs to be a federal mental health program to handle this, and maybe states & cities will stop playing 'hot potato', shipping them back and forth to be someone else's problem
Reagan was elected governor over FIFTY YEARS AGO.
Why not blame Julius Caesar, or George Washington, instead?
As for the friend from a poor family, it was horrible to watch what everyone involved had to go through. He was a happily married man in his mid 20's. Decided to go off his meds and not tell anyone. It didn't help that he had never told us about his mental illness, but that was his choice. He snapped, left his wife and vanished for a while. When he was brought home his parents could not keep him in their house as he was prone to threaten violence. He even threatened me once during this period. Since they had no insurance they could not house him at a facility. The only thing they could do was pay for him to live in a motel, one within their abilities which meant the cheapest motel they could find, one known for drug users. My friend had previously had a problem with drugs, had to go to court mandated Narcotics Anonymous, even had a mentor to help him. Despite having cleaned up for over 10 years, here he was in a motel full of drug dealers and users while in the midst of a psychotic breakdown.
The last time I ever saw him he was having a fit in a field near a mall. I stopped to help him, he was in a fugue state thinking he was in World War 3. he smelled of urine and his clothes were a mess. I drove him to a local YMCA because I had no idea what else to do. They told me there was nothing they could do, but agreed to take him in for the day and see if they could clean him up. Knowing he was prone to violent behavior I figured that wouldn't work out.
I never saw him again. A friend of five years just evaporated. But what I saw is that if you are poor and have a mental breakdown, and your family has no means to help you, you are screwed and have no choice but to live on the street.
I don't see how this gets any better with single-payer/government funded funding routes. I don't want anyone to know what I discuss with my therapist much less a soulless corporation or the government. The avenues this could open up for oppression from corporations and/or the government sends a shiver down my spine.
> The insurer can also audit your records at any time they wish, which means they have full access to any details your therapist has, including information the therapist intentionally did not include in the claim submitted to the insurance company. Any and all information, including progress notes, which can include details about what occurred during the therapy session, is technically open to the claims specialist.
[0]: https://tampatherapy.com/2017/01/25/reasons-not-use-insuranc...
Tons of vets already avoid mental health services because it's a black mark on their career and can hinder their ability to bear arms in civilian life.
Edit: btw, talking to strangers on the internet is a little like therapy. It's easier sometimes to talk about yourself when it's to someone you don't know.
Last issue is anxious of sitting in session after session trying to a)settle on a particular person b)tracking/having any sense of real progress.
*mainly it's all creative avoidance out of fear, I guess.. Good point re strangers on the internet. I hardly bring this up anywhere, especially not online - not sure what happened this am.
I faced my own issues with depression in my late teens and early twenties. Gun rights are very important to me, and I was extremely hesitant to speak to any mental health professional due to the potential future restrictions it might place on me. I did see someone, and over the course of a few years recovered to the point that I was able to get my life back on track - but even then, it was difficult to find a therapist that wouldn’t immediately demand that I dispose of all of my firearms. I ended up asking around and basically “interviewing” several providers before I chose one. I wasn’t suicidal and didn’t have anything resembling an urge to harm myself or others, for what it’s worth.
I still believe that seeking help may come back to haunt me one day. It’s something I’ve come to terms with and I believe I made the right decision, but I think my ability to introspect and make a rational decision in the face of my illness is... atypical.
I think it’s a consequence of the “do you have firearms in your home” questions during routine checkups. The current push for so-called “red flag” laws seems to validate the concern.
NB many think firearms are illegal in the UK. They are not! I was surprised to discover this when I moved out of London to the countryside 10 years ago. It's very difficult to get a firearms license in an urban location. But rifles and shotguns are commonplace in rural areas. Handguns have been banned since the Dunblane massacre, and semi automatics since Hungerford. But in rural areas few dispute that shotguns and rifles are legitimate tools.
[1] https://www.theguardian.com/society/2016/jun/22/uk-gun-licen...
[0] https://en.wikipedia.org/wiki/Firearms_policy_in_the_United_...
When you taught at college and had to deal with a deranged individual who eventually got himself expelled for stalking and attempted rape your opinion about gun rights changes.
Around the corner from my house one early morning (around 3am?) erupted a 4-alarm fire at a neighbor's home. Several fire trucks, etc later, the fire fighters tried to enter the structure when they were shot at by someone inside. They retreated and the police (SWAT) were called.
They entered the home with the fire fighters; the person inside attempted to fire again, and was shot and killed. The fire was put out, and while I never learned all the details in the aftermath, I learned enough to know something very terrible had happened.
The person that SWAT had shot and killed was the adult son of the family who lived at the home. The parents had kept numerous firearms in the house, and the son had only been living there for a few months before this incident occurred. Prior to that, he'd be virtually homeless, struggling with bipolarism and schizophrenic issues.
These mental health issues were known to the parents and family; they had originally kicked him out of the home years prior, but let him back in trying to get him better help or something like that. But they kept their weapons in the house; at one point, IIRC, they also bought him his own weapon for his birthday.
Apparently there was some kind of an argument, based on what immediate neighbors had heard earlier in the night, but they thought things had calmed down. Unfortunately for the family, they had only started. Sometime during the night, for reasons unknown, their son decided to take one of the family's or his own weapon, shot the mother and father, then his sister, and the family dog, then set fire to the house and waited in his bedroom.
The entire family - including the dog - dead inside a few hours.
It's not known (that I really know of) if the son's mental health issues played any role in the shooting deaths of his family, but they certainly can't be discounted. It's not certain that had there not been guns in the home, if the results would be different, but I tend to think fewer deaths would have occurred.
Note - I'm liberal in my views and political leanings, I also support gun rights as well. But I think that a discussion on how to temper these rights with keeping such weapons out of the hands of potentially dangerous people needs to be had. I don't know what a good solution would be in such cases. There are many issues intertwined, that we have let become a morass in our society, which may make the issue nearly impossible to untangle.
It's the issues and problems we have surrounding mental health, and healthcare/coverage in general, the stigmas and such.
It's issues surrounding guns, our culture of violence, the rights of individuals, etc.
It's our society's tendency to seek to place blame elsewhere, and not take responsibility for our problems (we claim "self-sufficiency!" as "being American" - but forgetting the other side of that coin is also personal responsibility).
It's our weird obsession with violence; how as a culture we've deemed it more fit for people to consume as media and knowledge - almost elevating it as something aspirational, especially when it comes to the military.
Simultaneously, we've deemed sexual knowledge and media to be something shameful - at least on the one hand; yet on the very other, such knowledge and media is blatantly used to sell products - so there's this mixed message "violence ok, sex is bad, but if you want to buy something - here's sex to sell it".
Our media, our politicians, and increasingly each of us - have fostered and promote an "us vs them" dichotomy amongst the population.
All of these things - and many more - are all tangled up. They are all problems we need to solve, but like a box of Christmas lights or a bowl of spaghetti, they are hopelessly tangled up, and one can't be sorted and fixed without causing problems with others, or requiring others to be fixed before or simultaneously. All the while, our attention is being demanded here, there, and elsewhere, and we never actually get any of it solved.
This of course benefits a few at the expense of the masses, but the masses have either tuned out, been satiated with some pablum (GoT, anyone?), or both - while a smaller minority "fights" among each other for control, both with agendas they believe will fix everything, when the fact is, they won't fix anything - and likely will make it worse. Or at least, that's what they say about the other side.
Meanwhile - the benefactors in all of this - they just smirk, laugh, smile, prod - and continue on, not caring about the chaos they help to create, promote, and endure.
It's a very unstable situation here in America. Eventually, something will give, and when it does, what happens next won't be pretty at all.
And yet they still were unable to prevent this tragedy. The main thing I take away is the ultimate futility of believing that top-down control can prevent tragedies if only it is given more power!
> Our media, our politicians, and increasingly each of us - have fostered and promote an "us vs them" dichotomy amongst the population.
I'm right there with you in seeing this dynamic as ultimately one of decay. In fact I think second amendment culture functions more as a crutch that enables totalitarianism. It fosters a fallacious belief that the fight for freedom is some eventual violent confrontation rather than insidious gradual creeping.
But I maintain the burden of reform is on the government - its institutions, politicians, and the media - as it is the government which is the overwhelming aggressor. An individual that eg fantasizes about defending their family from an overzealous cop isn't actually harming anyone. And tax protesters eventually get the rats on their face.
But once bureaucrats become accustomed to entrenched authority, they succumb to fallacious thinking that they are in charge, rather than servant facilitators. Even little things like all these various "user fees" need to be fully repudiated, as they are ultimately symptoms of government agencies leveraging their power-held-in-trust to generate more revenue for themselves - ultimately that same basic "go ahead and stop us" adversarial dynamic.
> while a smaller minority "fights" among each other for control, both with agendas they believe will fix everything, when the fact is, they won't fix anything - and likely will make it worse. Or at least, that's what they say about the other side.
I'm here with you as well, but I think the statement fully applies to the gun "issue" as well.
The main profiteers of mass shootings are "news" channels, and yet they continue to blamelessly fan the flames. One specific type of weapon being a little harder to get isn't going to reduce the appeal of getting on the prime time scoreboard. But it's a simplistic divisive bikeshed narrative, right up there with how other people pee, so it get focused on.
I'd call the ultimate topic that of societal mental health, from being continually bombarded by bad news. We're getting much safer, yet "so many bad things are happening". It's true we're more connected, but that is only one part of it. Most people aren't actively seeking out tragedies to bathe in the emotion of, but rather are having tragedies pushed at them because the induced panic drives their continued attention.
I don't have an answer to this, besides hoping it's merely a phase that we'll pass out of as people get numb to and check out of mass media (including mass social media). But I'll note that an assumption that a perspective is only worthwhile if it implies a straightforward answer is essentially just another way of looking at our current problems.
FTFY
If anything I would expect it to get worse, since the government has an incentive to use this in far more areas than an insurance company.
1) resource utilization 2) long term cost-effective value
A therapist can induce infinite demand on a patient, by just doing follow-up sessions ad-infinitum. In argentina for example, people go to the same therapist for decades!!
This means that the insurance model doesn't work well, because you can't do actuarial analysis on how much therapy someone might need and how to distribute that in the population.
The second part is that as a patient, if the insurance covers your cost, you might as well go to the most expensive therapist you can find, and consume the infinitely. Also, you know more than the insurance company if you plan on using or needing this care, thus you have a very strong adverse-selection situation going on with any plan that is generous on mental health.
Economically speaking, mental health should not be part of an insurance scheme. It should be cash pay. To help people that could not afford mental health and they need it, you would do better to provide state-run service, that is low-cost high-effective-value and cover the lower side of the population.
People can have mental health needs that can be improved or resolved in a finite time frame. They might have a difficult life event for example.
People can also have non-mental issues that are chronic and require lifelong attention—diabetes for example.
Also, mental health is not particularly expensive to treat itself: why put the insurance company in the middle. Pay the provider directly..
I wonder if the market offers a low cost health insurance from the moment a person is born dedicated to chronic diseases. I know life-insurance does ,and rather cheaply.
You know people who take insulin are on it for the rest of their lives, but that doesn't make it the fault of their doctors.
Therapy actually works. "Hundreds of studies have found that psychotherapy is an effective way to help people make positive changes in their lives," Nordal says. "Compared with medication, psychotherapy has fewer side effects and lower instances of relapse when discontinued." [1]
> The second part is that as a patient, if the insurance covers your cost, you might as well go to the most expensive therapist you can find, and consume the infinitely. Also, you know more than the insurance company if you plan on using or needing this care, thus you have a very strong adverse-selection situation going on with any plan that is generous on mental health.
This is a very strange American perspective on health care. If it was suddenly available to everyone, there's a perception that we'd all be like kids in the candy store getting 1 of everything at the doctors office. That's just not how it works. Nobody in Canada goes to their GP and asks for the immunotherapy and a few casts. People go to doctors because they're sick, and they need treatment and would rather be literally anywhere else.
It's not as though we're socializing the electronics section at Best Buy.
> Economically speaking, mental health should not be part of an insurance scheme. It should be cash pay. To help people that could not afford mental health and they need it, you would do better to provide state-run service, that is low-cost high-effective-value and cover the lower side of the population.
Sold, but it should cover everyone.
The bet on diabetes has to happen before it is diagnosed to make actuarial analysis. If you want to guarantee that all diabetes patients get access to insulin, what you want is charity, not insurance.
Insurance is risk pooling.
> This is a very strange American perspective on health care. If it was suddenly available to everyone, there's a perception that we'd all be like kids in the candy store getting 1 of everything at the doctors office
The science has already shown that is true. Over and underutilization of healthcare are studied effects, ones insurance companies pay very close attention to because if they don't, they will go bust. That is also why countries with free healthcare also have copays.
> People go to doctors because they're sick, and they need treatment and would rather be literally anywhere else.
I think you are have an outsider's view on how healthcare provision works. No doctor i met would ever agree with this statement.
Yep! That's why health insurance is a misnomer. There's no guarantee my house will catch fire, so I insure against it. There is a 100% chance each and every human will catch a terminal illness. That makes it at best a structured payout program. The amount of the payout can be reduced through preventative care, and yes, maintenance drugs like insulin. That's the best case for why it should be socialized.
It's not insurance, and it's not charity, it's a service in the public interest. And of course people should have access to the medication they need to live, we're not savages.
> The science has already shown that is true. Over and underutilization of healthcare are studied effects, ones insurance companies pay very close attention to because if they don't, they will go bust. That is also why countries with free healthcare also have copays.
Insurance companies get paid in advance, and their goal is not to provide the best care but to return the largest amount possible to their shareholders. Co-pays keep people out of hospital, especially lower-income folks, which allows insurance companies to make more money. Same with high deductibles. Their goal is not care, it's profit.
The UK and Canada (the systems I know best) don't really have co-payments, certainly not like in the US. The vast majority of services are co-payment free [1] (UK: "Out-of-pocket payments for general practice are limited to some services, such as examinations for employment or insurance purposes and the provision of certificates for travel or insurance", in Ontario going to the hospital you only pay for parking or 'upgrades' like private rooms - [2], [3] is the entire fee schedule). Same with Australia [4] who in 2015 rebelled over an AU$7 co-pay. You get sick, you go to the doctor, they take care of it.
Think about it, if you could access any procedure right now, what would you get done? Nothing, because it's not fun, it's not rewarding. If it's medically necessary, you'll get it done one way or the other, if it's not, literally why are you at the hospital? Yes, use goes up a bit. IMO, that can be offset by creating clinics and guiding people to them for minor ailments as in the UK.
> I think you are have an outsider's view on how healthcare provision works. No doctor i met would ever agree with this statement.
Respectfully disagree. Both my parents are doctors, and I grew up in numerous medical systems all over the world. I've benefitted hugely from socialized medical systems and not having one right now is downright terrifying even though I'm well 'insured'.
My dad refused to work in the US because he felt the healthcare system here was inhumane. He wanted to provide people care based on their needs not what they could afford. It took me until I lived here to understand he was exactly right. There's a lot of this apologist: "there must be some reason the American system is better" -- sorry, it's just not better.
[1] https://international.commonwealthfund.org/countries/england...
[2] https://www.qch.on.ca/hospitalcharges
[3] https://www.qch.on.ca/uploads/Finance/Hospital%20fees%20Webs...
[4] https://transferwise.com/au/blog/healthcare-system-in-austra...
This is what prepay's are, and HMO's. You have 2 opinions on HMO: they love it because pricing is transparent, they dislike it because they ration service. An example of that with Kaiser: they put severe barriers on their own mental health services. An industry gossip for you: one of the biggest consumer of mental health services at Kaiser is Kaiser doctors.
> Insurance companies get paid in advance, and their goal is not to provide the best care but to return the largest amount possible to their shareholders...
At the same time, insurance has an interest in controlling how much the insurance is used, something governments can fail at pretty hard. Remember Medicare insurance already costs 1k per person per month. That's the socialized system america has now, and it won't be more efficient by being bigger.
> Think about it, if you could access any procedure right now, what would you get done? Nothing, because it's not fun, it's not rewarding.
This is just not the reality. It's a well studied effect, denying it is depriving the science behind policy analysis from any legitimacy.
> Respectfully disagree. Both my parents are doctors, and I grew up in numerous medical systems all over the world. I've benefitted hugely from socialized medical systems and not having one right now is downright terrifying even though I'm well 'insured'.
They told you that patients never go to the doctor for superfluous reasons? I won't believe it. I am in the industry and I can see every case imaginable.
We have had this argument before. The U.S. socializing healthcare will not bring out-of-us healthcare results. It will get something else, because what makes healthcare suck is not private vs public, it's the regulatory framework.
You are correct. People do go more often, and to counter it programs exist in the UK which drive people with less severe issues to local centers where they can get looked at without taxing the hospital system to the same extent. [1] It's not that big an issue. All that and they still deliver better health outcomes for a much lower price.
FWIW the NHS actually offers free mental health services with no co-pays too [2]. It looks like it's managed via GP which is a good middle ground IMO between co-pays and unlimited fee-free access. Canada does not as a rule, though it's an active conversation [3] and has been for years -- and it enjoys a (razor thin) majority of support with 51% in favor. Psychiatry is covered today, therapy is not.
> They told you that patients never go to the doctor for superfluous reasons? I won't believe it. I am in the industry and I can see every case imaginable.
No, they told me the US healthcare system is inhumane. I may have misread your post if I wasn't replying to the right section :)
> We have had this argument before. The U.S. socializing healthcare will not bring out-of-us healthcare results. It will get something else, because what makes healthcare suck is not private vs public, it's the regulatory framework.
The US is already at the bottom of the OECD, do you have reason to believe it'll get worse? We've got a lot of models that show it'll be better and really nothing to point to that shows it'll get worse. Socialized systems are cheaper and control costs better, even here.
[1] https://www.newdevonccg.nhs.uk/file/?rid=109734
[2] https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-...
[3] https://globalnews.ca/news/5276022/canadians-mental-health-s...
It probably makes sense financially though.
I don't want to pay any premiums to help out people with asthma, multiple sclerosis, diabetes, birth defects, and so on if we are going to do this though.
This duality is most common in countries with socialized healthcare: allows for the affluent to spend more, and for everyone to have a base level. (An UBI for healthcare!)
The arguments you're making could really be applied to healthcare in general. Others have pointed out the comparisons to insulin, etc. I think you've basically made an argument for single-payer government healthcare.
However, it's really not true that the typical mental healthcare user is a chronic user. The modal number of visits per outpatient therapy client/patient is 1. Many people feel better after one visit, or decide they don't need it, or it's not worth it (some of it is probably related to availability too, to be fair--they'd like to come more but can't afford it or can't get into the therapist's schedule). You can extrapolate outward from that. Many people come for a few sessions, and then stop without any explanation because they're feeling better but don't want to have an awkward conversation about stopping.
The current zeitgeist with therapy is to taper off or terminate as soon as possible, and reinitiate as needed, at least in the US. My sense is the pendulum has swung too far in the shorter end of the spectrum, and a lot of people would benefit from more sessions, but even when they can afford it, are being cut off as soon as possible by therapists who are afraid of being seen as stringing people along. In some ways this is a good thing, but therapy length should really be dictated by need (short or long).
For many areas sure. Most importantly to primary care. I believe primary care should not be part of an insurance model. It's been brought to this for some good reasons and some bad reasons.
Single-payer cannot fix over-utilization. The iron triangle of healthcare: cost, quality, access. If access is unlimited, cost will go up. (Over-utilization a term commonly understood for the use of resources for very low marginal returns).
> The modal number of visits per outpatient therapy client/patient is 1
Even more sensical to make it cash pay! I would agree that cash pay in the current system probably leads to underutilization. Which is why a low(access x quality) x low(price) solution from the state would be great to help the bottom ranks and the rest can pay for it themselves.
> The current zeitgeist with therapy is to taper off or terminate as soon as possible, and reinitiate as needed, at least in the US
This brings another argument on utilization: if you look at it across cultures, it's going to be radically different. It's not something reasonable to insure against.
Long term, freeing therapy from insurance works in the favor of therapists: as a political body I would ask tax exemptions that match what insurance companies get and be on your own. (I would recommend the same strategy to primary care doctors, and they are already doing it with the DPC model).
But I have to say that this purely market economic view of life-saving healthcare, concluding "there is no economically viable way to ensure that everyone has access to life-saving aid, because participation has to be voluntary and that means insurance will be prohibitably expensive" is deeply cruel. Honest question, is it broadly representative for Americans to take this view without considering the human consequences to someone who is unlucky with genetics, family or circumstances? Or is the question just ignored until a problem hits?
It's really very simple to solve this in a humane way. Government pays for all healthcare that's necessary to survive and thrive to a humanely minimum standard of care, either providing the services themselves or employing private-sector partners to do so. This is paid through taxation of everyone, spreading the cost on the entire population. Private insurance or paying for elective procedures is still an option for those who have the means and wish to do so.
There will be some upheaval because the insurance sector and treatment centers will be in a dramatically worse negotiation position, but it's worth it for the public good.
I don't think so, but what is unique about americans and the healthcare market is very unique sensitivity to quality and access: the idea that you could to a second rate doctor goes very contrary to american culture, but is common currency in socialized health systems, where you are numb to quality as everything has the same price. The US has a private offering called HMO which basically covers everything, and it's had mixed results: even Michael Moore made a documentary where people said "HMO's are evil". Why? Because the idea that you have to be put on a waiting list or might be denied care you want on utilization is unthinkable for americans.
That is one cultural aspect, but there are many more that make America Health system unique.
> Government pays for all healthcare that's necessary to survive and thrive to a humanely minimum standard of care...
It's a solution. Maybe because of the above, no democrat has put it forward: it would be unpopular to tell people they will get free sub-standard, sub-access care. This solution already exists: the VA is basically that. A very low quality service but highly effective.
I don't have much sympathy for H. insurance, but if the state wanted to abolish them, they should buy them, not outlaw them. This is so out of how America operates that I don't think it could go through the senate.
Personally, i think insurance is the last thing to look at in the space..
Edit: missed a word.
Again, this is simply a "what if", please don't go all HN on me. tia
This is damning.
IMO, it's criminal what these insurers are doing.
Also, there was a post here, I believe, about a successful therapist (in Australia, I believe) that was quitting because of the BS he was putting up with from the insurers. It was a youtube video where he laid out all the reasons. It was just heartbreaking to watch.
And sometimes you can find a good one and watch them, over the span of 5-10 years, turn from good to bad. Then you're back and in the market looking for a new person to divulge your innermost thoughts and intimate experiences to only to realize they're all actually shit now.
/endrant
Mental health is getting worse because the economy is getting worse, simply.
By liberalism here, I mean the original (and only sensible) meaning of a system of individual freedom in social, religious, and economic spheres, equality before the law, and democratic representation, not the New Left's utter misappropriation of the term to represent tribal resentment and mob justice.
Mental health services in the "good old days" were shrouded in a thick fog of Freudian bullshit and couldn't do much for really troubled patients besides keep them warehoused and docile. Before that, they didn't really exist at all.
The feeling of a collective mental breakdown has been in the public consciousness since at least WWII. The loss of meaning and religious faith after such large-scale horror and the response in postmodern aesthetics and philosophy, the isolation beneath the surface-level perfection of the new suburbs, the invention of mass market consumerism, the constant threat of nuclear annihilation, struggle and upheaval around gender/sexuality/race, the Kennedy assassination, the Vietnam War and Nixon-era loss of faith in institutions, stagflation, you name it.
To be fair, most healthcare doesn't. Primary care being part of insurance is ridicolous.
It’s the cheapest to provide and saves a lot of “downstream” costs
It is also bad for the pcp to be so transactional with insurance: it should be a relationship, which is proven to give better medical outcomes..
Then I sure wish people didn't say that if they don't mean it.
It seems like everyone is seeing a therapist nowadays. Why are suicide rates still increasing?
Is there any real scientific proof that therapy or mental health coverage does anything?
Why was suicide lower when nobody was using therapist? Why is it increasing now that so many people see therapist?
What's with the neverending drive to get people to take more drugs, spend more on counseling, etc? Every week there is an article about how depressed we are or how lonely we are and all the pharmaceutical or therapy that can help.
I had to ask family for help and one by one after a time they began to resent me and abandon me. I was denied SSDI. I was denied nearly everything I applied for and buried in bureacracy. I lived abroad for a time and had a much better quality of life and access to healthcare, but I couldn't legitimize permanently (still a fantasy at times) and had to come back to the USA. I now live, and who knows for how long they will allow it, with resentful family, isolated in rural Murica with no transport or access without much more expense and effort. No insurance. Limited income based medical care. Living on 600 dollars a month from a partial pension I was fortunate to have. Hearing every day how it simply has to be my fault and treated as if I am a loser who chose and continues to choose this. I am the same person I was when I was a public servant and seen as doing good in the world, but now that I have lost my autonomy I am lower class and shamed.
There was a time when my root issues would have been addressable and I could have had a decent life, but there was no help and things got worse. There was a time I though if I could just find someone to give me the "right" job that would work around my issues I could have a survivable life, and finally a kind and caring soul did that after years of nothing, but those two buckets I mentioned above poured in and things got worse and I wasn't able to do it. Now I have no idea what if anything can save me. How is one supposed to survive since "suicide is never the answer" when you have a miserable, painful life and no realistic way to dig yourself out? I cannot magically become a citizen of a nation with social support and healthcare. I don't have the bootstraps to pull on and rebuild. I cannot endure decades more of this yet anytime I discuss it I hear "seek help" or other shallow pearls of wisdom. Hotlines and calling the police seems the default response if someone brings up the topic. Everyone feels good like they did something and pats themselves on the back. The patient might get sent to hospital and that results in tens of thousands in medical debt and a worse problem. So it goes. No real solutions happening.
In cases like mine, which are a majority of suicidal people in my experience professionally and personally, it's rooted, situational stuff (often from multiple angles) and not some primary mental illness that Prozac and CBT mitigates. It's not simply about insurance (or the lackthereof) and what it will and will not pay for. I have been to a lot of doctors in my day and not a single one has improved my quality of life, most in fact the opposite. It's about there being no willingness to solve root causes and the eventual response being victim blaming and turning a blind eye when the bandaids don't work. Until society addresses the fact that many people end up in bad situations through no fault of their own (and honestly even those to blame somehow are still human beings who deserve help and not some abstract calculations on a moral or financial ledger) and provides a safety net and path to rebuild as much life as possible (something friends have accomplished in nations with such support), you will find more and more people choosing to quit living. We don't want to...we have no options...most especially not in America where all the things we need to stabilize and rebuild are even more costly and unattainable...where the only places we can afford are isolated with no services...where we are further and further cut off. Everything that would give me a chance is the opposite to where and what I am living now. Can't win.
Godspeed.
I'm sorry, friend, but it's strikingly obvious that you're not. I hope you can be, again, someday.
Your root cause - is it loops of mental and physical pain? If so, have you by chance experimented with psychedelics for "rewiring neural pathways"?
Sorry if this has been asked of you before - just not worth missing potentially benefitting someone.
You seem highly intelligent, so I'm assuming you have explored this avenue thoroughly. But just in case not, have you investigated the immigration terms of all countries that have socialized healthcare? I was thinking there could be a chance that one would be able to give you permanent residency. Honestly, it seems as if there should be a policical asylum (no pun intended) quota for this kind of thing.
I read a local newspaper story of an American who was able to immigrated to Norway some years ago, motivated by the fact that his American insurance didn't cover a very important back operation or something like that.
If you are capable of holding a Norwegian 80% job of 40*0.8 hours per week with the 4 or 5 weeks standard holiday (probably with some local-doctor sanctioned sick leave in there), a working visa would qualify you for medical aid here immediately, and give you permanent residency after 3 years, if I read the regulations correctly. Should probably be double-checked by a local lawyer.
https://www.udi.no/en/want-to-apply/work-immigration/skilled...
Please feel free to reply if you'd like to investigate this further. I'll give you my contact information. (My profile is normaly pseudonymous due to political comments and other stuff, so the info is not in my profile).
1. Have a mental health problem
2. Seek help for a mental health problem
This leads to insures being able to deny this, and it not seen as a negative, because it's denying something that's weak. And weakness in the USA is the ultimate sin. Homelessness/Joblessness also fall under this same belief system.
And frankly, compared to Facebook posts from Fox News or indeed any other news outlet, the "savagery" on HN is downright pleasant.
Maybe I should have told the people slamming my back into hooks repeatedly that and they would have stopped. Or the people who refused to hire me. Or the people who refuse associate with me. Maybe you should tell the associates I have who accidentally let slurs slip out of their mouth with me right in front of them. Just look at the slang internet shitheads use. "Retard" and "Autist," are super common.
Just because you're blind to the stigma out there doesn't mean it doesn't exist. Mental illness causes many problems and often the easiest way for somebody to deal with those problems is to not deal with the mentally ill person. Even if its not right. Stigma is practical. People in the developed world give a lot of lip service to how mental illness shouldn't be stigmatised I guess.
I'm curious if you believe the developed world doesn't have sexism or racism anymore.
I talked with my doctor about a referral, he essentially just said "find somebody in your network" and gave no direction. Of course, finding psychiatric care in my network was a no-go, so I ended up paying out of pocket.
Even with the diagnosis and subsequent medication prescription, the out of pocket price was $189 for 30 days for a generic medication! Only with a coupon app was the price lowered to ~$50.
It's no wonder the black market for drugs is so strong considering the barrier to entry, not just monetarily but logistically.
There's no one to catch you if you fall.
It could happen to you, or your loved ones next.
Try to have some empathy, and fucking VOTE
We could vote to build more housing. Oh wait, SB50 just got rejected by the appropriations committee - which is full of non-elected government officials.
I know, we could completely re-elect all of our local government officials to shake everything up, oh wait that's the promise of our last N mayors who haven't done anything.
I'm disgruntled, if any of these points are incorrect please let me know - it's very frustrating and I feel helpless as a voter (in SF).
A year later, she said she’s still studying the proposal.
She’s happy about voting for those expanded pentagon budgets though!
Technically legal? Sure, they're the legislature, they can do whatever they want. Incredibly disappointing as a voter.
[0]: https://www.politico.com/story/2019/02/11/utah-medicaid-expa...
Except for staying in office if the voters vote them out.
The problem with mental health care is that such providers either don't exist or are very rare, meaning there is little to no effective care to be had for any amount of money. Simply throwing more money at this problem will not do anything to solve it.
On the other hand, if an individual provider can rely on getting a fee for service without crazy overheads of private insurance approvals/unapprovals, then they can make a business commitment to supplying that service. This costs far less overall when you don't have to price risk and extra work into the service rendered.
As I responded to your sibling commenter, I don't think my original point was clear. I'm asserting that those existing provider services suck and are ineffective, and that what is needed is a paradigm shift in how mental health care is formulated and delivered, not a spread of those existing services.
The funding societally is so poor now that the common end path is people ending up in prison. And, as the article indicates, it's not like the private insurance companies are picking up the expenditure.
My solution is to introduce salary caps. So that NGO's cannot compensate any employee more than some modest amount. Bonus if the state or local gov could give people tax breaks (fed would never go for this) for working on an NGO. So, say a lawyer or accountant could take a few months off their high-stress, white-collar job and work for an NGO for part of the year, make enough for rent, reduce their tax bill, reduce their stress levels for a while, and help the community, then go back to "real" work.
Sounds like what ever metric is used to determine these are good people to elect is broken and needs to be adjusted.
It is a sort of prisoner's dilemma, and while you can say you will choose to do what you think is the right thing regardless of cost, you will find that most people will only follow that so far (though they will not likely admit it to avoid the social damage admitting such will do).
In the cat analogy, not offering services is just pretending the cats don't exist thus solving the problem once and for all. The cats are still there and so are all the negative consequences associated with a large population of feral cats. This is sorta head-in-the-sand thinking, right? The problem needs to be solved nation-wide.
In the cat analogy, you are correct because other cities won't go about shipping their stray cats to you (if they round them up they will just kill them). But there has already been numerous cases of cities sending homeless people to other areas. This is where the hungry cat/homeless analogy breaks down.
To go through this system and think "well it couldn't possibly get any better than this" makes me think one's capacity for either self delusion or idiocy knows no bounds.
When the ACA was going through Congress, there were accusations of "death camps" flying around that the new healthcare system was going to round up and exterminate old people. These rumors were sometimes pushed by congressional candidates and high-level party officials.
Fast-forward to today, and you see opponents of the ACA claiming that they're trying to protect preexisting conditions coverage too, when they're absolutely not.
Our political system rewards lies and disinformation, and when a significant portion of the population believes these lies without any skepticism, then we're no longer debting rationally.
I know it's the topic under discussion, but today your statement applies to virtually everything under debate. We are in a very bad situation, that only seems to be spiralling downward, to what end is anyone's guess.
The fact that it's the 21st Century, and despite all the progress of science that religion still exists, should give you pause.
Plus we have had decades of propaganda about public sector waste, that doesn't care about or ignores private sector waste.
Yep. Just look at health care and related salaries in other countries. There are many fewer people in pharmaceutical sales in the EU or in Asia. Likewise, while being a doctor is a comfortable career in EU countries, no doctor earns $400k+ per year, like some surgeons/specialists in the US do. The problems aren't unique to any specific role in the US system, they are ubiquitous.
I am generally opposed to any major health care reform that the AMA, the AHA, PhRMA, or AHIP is in favor of.
That is, the myth perpetuates the energy that permits the men running these insurance companies to make billions. All reinforced by the whimsical meth-addled pipe dream that “I could be king too, one day” of the legion of white men of lesser caste.
—Ronald Wright
Reinforced yearly, daily, and minutely by the constructs of media.
On a seriously everything including regulations have a place in civil society.
At least that's how it seems to me, and why for some people on the left, healthcare isn't the most important issue to tackle. Having humans die in agony or poverty is terrible, but having it happen to your fellow countrymen is unforgivable.
1: That's not to say there aren't exceptional people that are wealthy, just that being exceptional is not a prerequisite to being wealthy, or even becoming wealthy (but I'm sure it helps in that case).
Your life might be miserable due to poverty, but you might still view that as a preferable situation compared to another even poorer group getting the same universal benefit as you, even if that universal benefit would make both of you better off.
https://psmag.com/social-justice/taking-freedom-capitalism-d...
Lots of people don't want to pay for problems they don't have control or influence over. You don't have to be racist, just a bit myopic.
Segregation and redlining have led to people of color living in marginalized communities in "food deserts" where there are few to no fresh food options, so people that live there (who are too money-poor or time-poor to travel for groceries) have to rely on processed and shelf stable food, leading to a very poor diet and the health problems associated with it.
Just because the immediate observation isn't related to racism doesn't mean the root problem isn't racism.
I just get tired of bad faith racism interpretations.
In South Africa, public hospitals are terrible and private hospitals are generally good and operated as far as I understand in a similar fashion to the US counterparts.
This may suggest that our future should look like the US's present. But it is a complicated subject. To start off with, many of the doctors at public hospitals are good doctors, paid well and respected. However, by a combination of being a new nation, having diverse cultures, having a high Gini coefficient (or <insert here coefficient>), having terrible rural schools (and excellent middle and upper class schools), etcetera, our public health care is frankly terrible. The hospitals are not well stocked, you'll wait for hours, they'll amputate your leg unnecessarily.
In our scenario we have both the European "socialist" model, which worked well during South Africa's past. However, once the hospitals had to cater (and rightly so) for the full population, including poor and formerly disadvantaged, the system could not cope. So now we also have the American "money driven" model, but of course it is expensive and you have to have a medical fund or you are out.
I don't think it is a question of idealogy. It's a simple premise. There is the world of sick people (which you are lucky if you join only a few times a year). And there is the world of healthy people. The premise is that sick people need to be treated. However you get there is perhaps politics, but I see it simply as a resource and logistic problem that need to be approached with commitment and expertise.
This simple premise: to heal the sick, is how I see the early doctors that came to Africa [1].
Of course OPs topic is more complex, mental health, but my point is that idealogy is often lost on people (including myself) that have more obvious challenges in their midst. And mental health in South Africa is an even more pressing issue. [2]
[1] See for example: https://en.wikipedia.org/wiki/Albert_Schweitzer
[2] Not going to share a link since they all seem written according to rather Trumpian standards. But about 90 mental health patients died in SA in one incident in 2017 due to what can maybe be termed "bureaucratic incompetence".
For the vast majority of Americans, their only interactions with the federal government are through social security and through medicare--two of the most widely popular functions of government. Government has plenty of failures, but that's the nature of enterprise writ large.
This is largely true.
Notice how easily our government, "with the stroke of a pen", can fully fund state-sanctioned violence and institutions of violence.
And we the people have no problem with this; some of us even cheer it on; some encourage their sons and daughters to join up to these institutions of violence. Others shake the hands of those who already are a part of it, and say "thank you for your service" - in almost reverent fashion.
I'm not saying we don't need these people or those institutions - they do serve a needed purpose - but let's not pretend that need is anything but ultimately for terrible violence.
Yet - we and our government somehow has a problem fully funding things like healthcare, education, infrastructure, and a whole host of other programs, which again could be easily done, "with the stroke of a pen". But we'll hem and haw on that all day long...
...our teachers will never be thanked "for their service" in reverent fashion.
Unless of course they were veterans of those institutions of violence.
It's easy to say "it's too hard, and the government will futz it up," but "the free market" produces predatory companies pursuing profit.
The current healthcare environment is not a free market, government is involved heavily at every level. Which is the main reason it sucks.
How do you explain all of the successful socialized medicine in other countries, if government involvement = healthcare sucks?
Don't get me wrong, it's a young man's system. You pay in when you are young, so you can have it when you are old. This is clearly the UK model after WWII and why its so popular here as an idea as our sister-mother country.
Flawed? Maybe ... terrible? no.
I think rebranding it as 'care' was a real slick move by some marketeers and absorbed by the media. Every time i see the word repeated i feel like they won their little subliminal game. Recently i read someone using the words "climate disruption" instead of "climate change" which i rather liked.
https://news.ycombinator.com/newsguidelines.html
Edit: this account unfortunately has quite a history of posting like this—and we've warned you before—so I've banned it until we get some indication that you intend to follow the site guidelines in the future. We're happy to unban anyone who gives us reason to believe that they want to use HN as intended: for thoughtful, curious conversation, not political or ideological or national battle. If you'd like to commit to that, you're welcome to let us know at hn@ycombinator.com.
https://twitter.com/AllOnMedicare/status/1124042436345569286
Moneyed interests are pulling the levers:
It's worth noting in relevance, because the politics in Healthcare reflect the policy of public opinion as well as legislation around other tangent issues our country is trying to reconcile what it wants to do (if anything) about it.
What definition for suicide does the US use?
What definition for suicide does Japan use?
EDIT: and you don't have anything like half the rate. Comparing across countries is hard, but Japan has a rate of about 17 per 100,000 while the US has a rate of about 14 per 100,000.