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A man sits in a doctor's office, three year old copy Sports Illustrated in hand, waiting for his cardiologist to come in and let him know how the results of his EKG. The guy is only 57, but his dad keeled over from a cardiac arrhythmia at 60 and his dad's dad died in his late fifties because his aorta was clogged with plaque that was as thick as tartar sauce. He got yearly checkups from his regular doc for a while, but had a “minor heart attack” a couple of years ago and started seeing a specialist at Mercy. Eventually, the doctor comes in and sits down on his little backless swivel stool, letting our man know that all of his vitals look good. Since the hospital started him on some beta blockers two years ago, the plaque buildup had all but stopped and his heart function has been solid. The only problem is, now the cardiologist had to tell him that his insurance would no longer be covering his heart medications because there was a 24-month lifetime cap on them. He would have to either, find a way to cover the full cost of the meds himself or try his luck with the body God gave him and hope for the best.

Now, if this situation ever occurred in reality, the heart patient would promptly go out, hire an attorney and sue his insurance provider for millions of dollars. All 50 states and the Federal government have a number of minimum coverage requirements that insurance providers are mandated to follow and, not covering a client's life-saving heart medication definitely breaks those requirements. However, as far our nation's health care laws are concerned, not all diseases are created equal. Mental health and substance abuse issues have historically been treated as the discarded stepchild of American medicine, quite literally sent off to the asylum to rot in squalor while those with “real diseases” get treatment. For the first two hundred years of our nation's development, our mentally ill were cordoned off in Almshouses, often with the poor, indigent and senile members of society who were deemed unfit for inclusion with the general population. In a Report on Pauper Insanity  presented to The Baltimore City Council in 1845, Dr. Stephen Collins acknowledged to his audience that it was “universally admitted” at that point in time that Almshouses are ill-equipped to handle the needs of the mentally insane, going so far as to label them, “as sepulchres, in which the mind is entombed almost as hopelessly as in the solitude of the grave.” And, if anyone reading this report had occasion to doubt this fact, Dr. Collins encouraged them to walk through the Almshouse and pass by the cells, “which are the receptacles of living death” (emphasis his). In the mid-19th century, as germ theory was forming and surgical knowhow expanding, mental illness lay in darkness.

Photograph of a woman in a Baltimore County almshouse circa 1909

We often speak of American Exceptionalism with great reverence, as it encompasses all of the unique attributes in our nation's character that have enabled us to become “the greatest country on earth”, or whatever Manifest Destiny-laden nugget of jingoistic hyperbole we might choose to believe. When it comes to our pioneer spirit or mythic class mobility (mythic both in that it is part of the folklore of the American Dream and that it really doesn’t exist), Americans are all too ready to embrace exceptionalism. The same cannot be said for exceptionalism in our health care system. While the example of Dr. Collins’ report on the hellish contents of Baltimore’s almshouses was an extreme example, it represents the core elements of exceptionalism in mental health and substance abuse. These men and women have been excised from the community and placed in dark, dank cells away from the gaze of society and the influence of modern medicine. When the standard mode of care transitioned in the latter part of the 19th century from the almshouse to the state asylum, the isolation of the mentally ill was retained. For the next hundred years or so, psychiatry and the mentally ill were seen as categorically different than traditional medicine and the physically sick.

It is only recently that we have seen efforts to integrate mental health into the general health care community, beginning in earnest with the creation and implantation of Medicare & Medicaid in the 1960s. Over the past 50 years, our conception of mental illness has expanded beyond that of Ken Kesey’s domesticated invalids to encompass depression, anxiety, bi-polar disorder and a host of less severe conditions that necessitate care The growing body of knowledge concerning the biological mechanisms and long term health effects of mental illness has, with the aide of mental health advocates, resulted in a series of parity laws designed to ensure that insurance coverage of mental health issues is at least equal to its physical health counterparts. This view of mental health as part of mainstream health care is reinforced by the implementation of the Affordable Care Act, which includes mental health and substance abuse coverage as one of its 10 essential health benefits, and emphasis from the Surgeon General the United States was moving to a public health model in its treatment of mental illness, due in large part to the gross underestimation of health burdens caused by depression and alcoholism/addiction.(2)

And yet, mental health and substance abuse services are still routinely dismissed by health insurance companies, sloughed off as non-necessary care that isn’t covered under plans where a physical ailment would be. Just this winter, the state of Maine made a change to the pharmacy coverage of MaineCare, the state’s Medicaid provider. Beginning on January 1, 2013, those suffering from opiate use disorders had a lifetime maximum of 24 months of coverage for methadone and buprenorphine maintenance treatment. Maine has taken an evidence-based, long term treatment that successfully enables residents to recover from opiate addiction and they have arbitrarily cut them off from it after two years. This decision was not made based on any research that showed opioid abusers had better recovery outcomes if they were taken off of medication assisted treatment after 24 months. This decision is based on stigma. It is predicated on the idea that patients with opiate use disorders are out to game the system and get high off the government’s dime. It is baseless and it is the type of decision that keeps substance abuse and mental health services outside the mainstream, regardless of the Surgeon General’s statements to the contrary. Could a state government put a lifetime cap on insulin or antibiotics? Answer that for yourself and you’ll have an idea if mental health and substance abuse treatments are integrated yet.

Originally posted to Virally Suppressed on Fri Mar 08, 2013 at 10:19 AM PST.

Also republished by Mental Health Awareness.

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Comment Preferences

  •  Republished to Mental Health Awareness (3+ / 0-)
    Recommended by:
    drnatrl, splashy, Cassandra Waites

    I thought Mental Health parity required mental health to have the same treatment limitations and freedoms as physical health?

    "Mitt Romney looks like the CEO who fires you, then goes to the Country Club and laughs about it with his friends." ~ Thomas Roberts MSNBC

    by second gen on Fri Mar 08, 2013 at 10:56:38 AM PST

    •  Parity laws require it in theory... (4+ / 0-)

      ...but practice is a diffent story.

      When the Wellstone & Domenici Mental Health and Addiction Equity Act was passed in 2008, it wasn't equipped with the rules and regulations necessary to enforce parity on a large scale. So, while the law does say that mental and physical care needs to be equitably cared for, there's no one out there enforcing the laws so there is no punishment for insurance companies should they break them.

      Plus, there are a number of other ways around parity, like behavioral health carve outs where insurance providers outsource behaviorial health care to a third party provider. And, Parity only applies to large group employer-funded programs (50+ employees), state-regulated plans and managed care Medicaid plans. If you're an employer of less than 50 health care eligible employees or just an individual buyer it doesn't apply to you right now. That is supposed to change in 2014, when Parity applies to small group and individual plans purchased through state health exchanges.

      Basically, it's a hot mess that won't get sorted out until law suits are filed in all 50 states against insurers for violating existing parity law.

      •  I picked my insurance policy when I started (3+ / 0-)

        working BECAUSE of its generous mental health benefits. I'm glad I did, because I've taken advantage of them. Now that I'm on disability, I pay a lot more for insurance than I might have to, because it includes those generous benefits. The other policies available to me at the time had the 20 visits per year limitations, etc. Mine did not.

        I don't think I'd be even close to the sanity I have now, which is still lacking, if it weren't for that.

        "Mitt Romney looks like the CEO who fires you, then goes to the Country Club and laughs about it with his friends." ~ Thomas Roberts MSNBC

        by second gen on Fri Mar 08, 2013 at 11:36:07 AM PST

        [ Parent ]

  •  Mental illnes *SHOULD* be treated differently. (0+ / 1-)
    Recommended by:
    Hidden by:
    anodnhajo

    If somebody has a broken arm, we can look at them and see the problem.

    Unfortunately, a diagnosis of mental illness is often subjective. Because it is possible to receive financial benefits for being mentally "disabled", some patients have a strong inventive to appear depressed, anxious, crazy, etc.

    The current state of science simply cannot define what it means to be "mentally ill" and often cannot distinguish real illness from malingering.

    Until the science gets better, we should judge claims of invisible, unprovable maladies by a stricter standard. This doesn't mean deny all claims, but we just need to be more careful.

    I am a landlord, and I have seen too many tenant applications from people "on disability". They are bright, limber, and spry. They bound up the steps with ease, and ask intelligent, informed questions about the property. They seem normal in every way -- except that they do not have to work for a living.

    Here is an article by a doctor in Pittsburgh on the subject. It is not a peer-reviewed paper, but it captures the feelings of a taxpayer compelled to pay support for those too "depressed" to work.

    •  I'm sorry, but that characterization is offensive. (8+ / 0-)
      I have seen too many tenant applications from people "on disability". They are bright, limber, and spry. They bound up the steps with ease, and ask intelligent, informed questions about the property. They seem normal in every way -- except that they do not have to work for a living.
      Honestly, that's the kind of description I'd expect to see on a right-wing message board, not here.

      "Seem normal" is the key phrase. I know plenty of folks with various mental ailments who "seem normal" at first glance or in the right situations.

      I fit into that category well enough myself, though I'm not on disability. But I can go from fitting your description of a bright, limber, spry, intelligent-question-asking person to being uselessly depressed quite quickly.

      I'm also reminded of a friend of mine who IS on disability, because he has seizures that can't be controlled with medication, on top of severe depression and related problems. Would you expect him to have a seizure on the floor while showing him an apartment, before you personally decide that he's indeed disabled?

      Should these people be monitored 24/7 while in your apartments to make sure that signs of disability are indeed manifesting at some point?

      Now, you do raise some valid points. I'm sure there ARE plenty of people who stay on disability longer than needed, whose mental conditions are not severe enough to remain on disability. The article you linked suggests annual reevaluations, which I'd completely agree with. Mental health disorders obviously ARE vaguer and harder to accurately diagnose.

      But the point is that YOU as a landlord should not be thinking "hey, that guy doesn't look disabled, he must be mooching off the system!" Seriously, that's just horribly stereotypical and misguided.

      •  I'm not making the diagnosis. (0+ / 0-)

        I'm not qualified to decide who's ill and who's not. As a landlord, I don't care where the money is coming from.

        I am speaking as a taxpayer and voter. It just looks wrong for there to be so many "disabled" people in the USA all of a sudden. It defies common sense.

        And, when we ask the mental health industry for proof that so many millions of us are truly in such bad shape, they can't deliver! They have no proof -- only subjective judgements for which there is a strong incentive to find illness where there is none.

        Mental health practitioners need to concentrate on increasing the reliability, reproducibility, and validity of their science. Then and only then can they claim more tax dollars.

        Argument-by-anecdote isn't the best way to decide anything, and I realize that that's what I'm doing. I'm letting my personal, subjective experience with a dozen or so tenants color my judgement of a Big Issue. But talk me down, here! Is there any solid research showing that friggin' 26% of us have a mental disorder?

        C'mon!

        •  Right, but you're pushing the meme... (2+ / 0-)
          Recommended by:
          splashy, Cassandra Waites

          of the fake-disabled "mentally ill" person on SSDI. That's not constructive to getting help to those who actually DO need it, even if there are a few who are gaming the system. (As there will be in ANY system.) Your thoughts and ideas do influence others...and somewhere other than DK, people might not be so quick to call out your views, but might embrace them instead.

          That's the real point I'm trying to get across. And you're right in noting that it is based on your personal experience rather than being a proper sample. (Nor do I really begrudge you for seeing those seemingly okay folks getting money, when that's what you've primarily experienced as a landlord. But again, realize that you should simply be accepting that they have a disability, not questioning it unless there's hard evidence to do so. It's hard for us mentally ill folks when folks shrug it off as too intangible to be recognized!)

          As for 26% of the population having a mental disorder, well, I'd say it's impossible to state what the number is. Some people might say 0%. Others might say 100%. (Since it's kinda fuzzy as to where "mental illness" begins, or what constitutes one.)

          I agree that the mental health system is a mess, and that there is a lot of overdiagnosis going on. (Just in general, and not particularly towards SSDI; I'm mainly talking about things like handing out antidepressants like candy, or deciding every energetic kid must have ADHD.) But, that cuts both ways, with plenty of people who aren't diagnosed and treated properly. Many of those underdiagnosed people end up on the streets or in jail instead.

          And I'd agree that mental health professionals need to do a better job of trying to make their science more reproducible, but really, until we can map the human brain that's unlikely to happen. But there have been interesting advances in things like using fMRI scans to show similarities with mental illness. (Not to any level of diagnostic usefulness, though, but it's a start for research purposes.)

          Here are some better numbers I found:

          Of the 3.3 million people who received SSDI in 2009 due to a mental disorder, there was a wide range of diagnosis:
          798,354 (about 8.9% of all SSDI recipients) had been diagnosed with mental retardation
          2.5 million-representing about 27.5% of all SSDI recipients for 2009-had been diagnosed with other mental disorders including organic mental disorders, psychosis, affective disorders, anxiety, somatoform disorders, personality disorders, addiction, autism spectrum disorders, or other developmental disability disorders.
          So we have about 0.8% of the country on disability for mental illnesses of a primarily subjective nature (and even that includes things like development disabilities that can be objectively measured to some degree.)

          I don't know if that number is too high. Maybe it is, maybe it isn't, but I'm also not a doctor or public health researcher to make that call. Again the point; unless you are a doctor, you shouldn't be judging those folks as "not really disabled", even to yourself. Accept that they have a disability, and that you may or may not be able to see it...

    •  First of all, your tenants' disability is none of (9+ / 0-)

      your business.

      Second, you are not a health-care professional.

      Third, we are holding mental health care to a higher standard.  That's not exactly going very well for us.  There's another landlord who sees a lot of mental health patients: the jailor.

      •  Thank you holeworm and suzq. Ignorance abounds re (2+ / 0-)
        Recommended by:
        holeworm, splashy

        mental health. Sigh.

      •  I don't use... (1+ / 0-)
        Recommended by:
        holeworm

        ...real or purported illness when making rental decisions.

        In fact, a guy "on disability" is usually a good bet as a tenant. They get a steady, verifiable, government-backed income, which is more than most Americans can claim.

        But as Progressives, we need to consider the political effects. What does a couple making minimum wage on 2 jobs think when their neighbor lives for free -- and has no visible (to the untrained eye) signs of disability?

        What do voters in Pennsylvania think when they read the letter-to-the editor I linked?

        This is the kind of thing that makes Liberalism look bad. Can't we tighten up the requirements for mental healthcare? There may be unintended benefits. As Dr. Fischbach noted:

        "If disability has not yet been granted, the initial symptoms seem to worsen, then to improve only after the first disability check arrives. That is, the patient has a vested financial and psychological interest in not getting better while still applying for disability.

        Indeed, I have seen none of my patients improve, and most deteriorate, while disability is still being processed. They then remain symptom-free but are unable to resume working for the remainder of their lives."

        Now I realize that this is just one person talking. It's not statistical or scientific. But politically it kills us.

        The mental health industry needs to clean up their act. Or at least look cleaner. Then they'll get more respect.

        •  It's a difficult question, but tightening the (2+ / 0-)
          Recommended by:
          splashy, Cassandra Waites

          requirements is not at all a solution. Then we'll have fewer people who actually do need help receiving it.

          Yes, it can look pretty bad to our cause when someone who isn't visibly disabled is getting a nice monthly check, and that minimum wage couple next door isn't.

          I think a start would be to make mental illness more recognized and less stigmatized. I think much of the reason that the minimum wage couple might feel resentment is that they don't UNDERSTAND mental illness. They likely thinks the person on disability just needs to get more sunshine and exercise. Much of this has to do with how we present and perceive mental illness in our culture...which we don't do very well.

          I personally think a basic income guarantee would solve the problem nicely, since then we could just get rid of SSDI and most other aid programs entirely. Obviously that's not at all realistic or feasible until sometime well in the future, of course. (Need to make lots of technological advances to reduce labor needs first...)

          •  Basic income guarantee... (0+ / 0-)

            ...is an excellent idea.

            We already have one really. We will not let anyone starve in the street. If we just admitted that fact and gave everyone something, there would be less incentive for scams.

            •  We really don't...but glad you like the concept (0+ / 0-)

              We have a vague, broken minimum income guarantee of sorts, with all kinds of strings depending on where you live and what your family composition is. (E.g., single adults like myself are basically screwed if put in that position, particularly in a reddish state like I currently live in.)

              But the fact is, people are happy to let others starve on the streets. As long as it isn't on THEIR street. (And even then, it's just a nuisance corpse to call someone to collect.)

              But I'm glad you agree on the basic concept: give everyone something. We would indeed have no more scams, and the efficiency should be significantly increased by not administering a ton of different semi-overlapping programs (thus allowing us to provide more benefits for the same amount of money.)

              It's really just a pipe dream at the moment, though; we need a more advanced civilization and a very different outlook on the economy to even consider implementing something like that, I think. Maybe in a few decades.. :)

              The real side benefit I like from a basic income guarantee is that it should theoretically get people to start lots of small businesses and innovate on their own! Best of capitalism and socialism combined, in my opinion.

        •  Funny thing (0+ / 0-)

          that this psychiatrist never seems to have considered the stress and anxiety a person is under while while going through the process of applying for disability, with no money, terrified of the future, talking to strangers who hold his fate in their hands, and waiting months for the outcome. Or the monumental relief when they finally get approved.

          How divorced from the reality of his patient's lives does he have to be not to see that OF COURSE they feel better after they get on disability? This guy sounds pretty dense to me.

          And why doesn't he at least admit the possibility that some of the people who appear symptom free would go to pieces if they attempted to hold down a job?

          The need for being on disability is not determined by how well someone is when they aren't working, but how sick they would be if they tried to work.

          We decided to move the center farther to the right by starting the whole debate from a far-right position to begin with. - Former House Majority Leader Tom DeLay

          by denise b on Sat Mar 09, 2013 at 12:27:32 AM PST

          [ Parent ]

    •  Do you know how much the maximum monthly payment.. (5+ / 0-)

      is on SSI?

      The most anyone can get on Supplemental Security Income is $710 a month in 2013. Do you know what that equals over the course of a year? $8,520. So your typical, lazy mooching SSI recipient is living off of an annual income that is less than 70% of the poverty level.

      And, if you decide that you do want to work despite your disability, then the maximum you are ever allowed to earn in a given month is $1,040. If you earn more than that you kicked off the rolls. So, the absolute most someone can game the system for, provided they get the max SSI payment of $710/mo and earn exactly $1,040 a month is $21,000 a year.

      Not to mention the fact that if you're on SSI or making up to 133% of the poverty level starting in 2014 then you're automatically on Medicaid, making the parity issue irrelevant.

      You have chosen to focus on a tiny corner of an extremely far reaching issue because it fits your distorted view that a tremendous number of Americans are faking mental illness to gain access to "free cash." Of course, I'm sure no one ever fakes physical injuries to win money in automotive collision lawsuits, just as no one in this country goes doctor shopping for physical pain to chiropractors and orthopedists.

      Do you know how many people committed suicide in 2009?

      It was 36,909. 36,909 Americans took their lives in one year and you're saying we should question people's reported mental health symptoms because you have tenants who appear to be, from a distance during the limited interaction you have with them, faking mental illness to get a $710 check each month?

      According to the National Institute of Mental Health, 57.7 million Americans suffer from some type of mental illness every year. I'm sure 1/5 of the country appreciates you telling them that their issues deserve stricter scrutiny than someone with arthritis because you think they're faking.

      •  If you combine the SSI... (0+ / 0-)

        ...with Section 8 and food stamps, the benefit becomes greater. But that's not the point.

        The point is how does it look from a common sense-point of view?

        They say 57.7 million of us are sick, but they can't show any physical symptoms, no blood tests, no brain scans, no EKG results, nothing but the word of some guy who talked to them for a few hours. (And at the end of the talk, both doctor and patient get a check).

        I would like to see some better science before we label such a huge number of people as "ill".

        •  It wasn't that many years ago (3+ / 0-)
          Recommended by:
          susanala, holeworm, denise b

          you could say someone had a bad heart, but provide no measures in terms of degree of atherosclerosis, or percentage of heart muscle compromised, or whatever measure. The science needs to evolve to measure what is seen & felt, not deny what is seen & felt until we have the science to support it.  
          Tuberculosis used to be a moral issue, until we had the science to explain bacterial infection.

    •  You cannot know by looking at someone (0+ / 0-)

      Whether they have a mental disability.

      Seriously, I can't believe you are saying that. You obviously have no idea how the brain works, and should refrain from showing your ignorance so blatantly.

      Unless you really like looking totally uninformed.

      If so, then proceed... (waves hand)

      Women create the entire labor force. ---------------------------------------------------------------------------------------- Sympathy is the strongest instinct in human nature. - Charles Darwin

      by splashy on Fri Mar 08, 2013 at 01:32:07 PM PST

      [ Parent ]

    •  That letter spews false and misleading information (0+ / 0-)

      and you deserve a donut for spreading it further here and adding your own heartless and uneducated slant on it.

      "just one more mile to go"

      by anodnhajo on Sat Mar 09, 2013 at 06:46:41 AM PST

      [ Parent ]

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