American Psychosis (32 page)

Out of a half-century of chaotic funding, several lessons have emerged that should be incorporated into any system of future funding. One such lesson is that turning mental illness services over to for-profit providers does not work. Some fiscal conservatives have argued that the profit motive makes human services more efficient and have thus recommended the privatization of mental health services to for-profit companies. What such people fail to note is that this has largely already been tried and failed. Some of the original community mental health center grants were given to private, for-profit entities. As psychiatrist Alan Stone observed, this development produced “a series of self-interested grabs by our colleagues to build fancy offices to pursue private patients [and] to avoid the seriously mentally ill and to exploit the federal monies.” Then, in the 1970s and 1980s, for-profit corporations opened nursing homes and board-and-care homes to provide accommodations—and usually not much else—for seriously mentally ill individuals being discharged from state hospitals.
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The results, as detailed in preceding chapters, have been scandalous. Rather than being the wave of the future, the for-profit privatization of mental illness services has
been a present-day tsunami. Anyone who doubts this need only visit North Carolina. In 2003 the state decided to privatize their entire state mental health system, which a decade earlier had been comparatively highly regarded. The results have included the closure of almost all public psychiatric beds; jails and prisons filled with mentally ill prisoners; an increase in mentally ill homeless persons; emergency rooms overflowing with mentally ill individuals waiting for nonexistent beds; board-and-care homes with thousands of largely untreated patients; and a predictable series of homicides and other tragedies attributed to individuals with untreated severe mental illnesses. Since 2003, no state has more aggressively privatized its mental health services than North Carolina, and no state has had its services deteriorate more dramatically.
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A more recent example is Pierce County, Washington, which in 2009 contracted for public mental health services with a for-profit company, OptumHealth. The outcome has been a massive overcrowding of the county jail with seriously mentally ill individuals, a 30% increase in mental illness-related calls to the county Fire and Rescue, and an increase in violent episodes, such as the shooting of three shoppers in August 2012 by Laura Sorensen, who was suffering from inadequately treated paranoid schizophrenia. One should never underestimate the ability of the for-profit sector to take responsibility for easy-to-treat patients and discard those who are difficult to treat, and thus more expensive, to the streets, jails, and prisons.

Scull has astutely pointed out that the for-profit privatization of mental health services currently underway in the United States is a repeat of what happened in England and, to a lesser extent in this country, during the early nineteenth century. At that time, local towns and counties turned mentally ill persons over to the highest bidders, usually private madhouses, for safe-keeping:

In an age that saw the triumph of laissez-faire capitalism, the insane enjoyed the dubious privilege of being among the first souls (other than slaves) to have their fate heavily determined by the marketplace. The experiment was not, on the whole, adjudged a success—save perhaps by the madhouse keepers themselves, whose business was often lucrative. Indeed, it was precisely the abuses to which a profit-oriented system was prone that led to a campaign for “reform” and to the establishment of those very state asylums against which the decarceration movement is now directed.

We have thus come full circle, having emptied the asylums, which were built to reform the abuses of the for-profit system, and are again turning mentally ill persons over to the highest bidders. As Aldous Huxley noted, “That men do not learn very much from the lessons of history is the most important of all the lessons that history has to teach.”
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7. For-profit funding of public mental illness services has been tried and does not work.

Another lesson that has emerged from a half-century of disjointed funding of mental health services is that it is essential to prioritize the patients for such services. As previously noted, studies have consistently shown that a relatively small subset of seriously mentally ill individuals are the ones who are repeatedly rehospitalized, become homeless, are regularly victimized, and end up in jails and prisons. One estimate of this subset is that approximately 10% of all seriously mentally ill individuals account for most of these problems. If services were to be prioritized for the 10% subset of individuals who are problematic, then most of the tragic consequences resulting from non-treatment would be avoided.
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Recent studies support the necessity for such prioritization. In Philadelphia 2,703 individuals were identified who were chronically homeless. Researchers calculated the cost of their medical, psychiatric, social services, public shelter, and jail costs for a year and reported that 20% of them accounted for 60% of the total group costs. Among the 20% of high users, almost all (81%) had schizophrenia or a major affective disorder. This finding is consistent with anecdotal reports from many parts of the country. The most highly publicized such report was about Murray Barr, a “chronically homeless mentally ill man” in Reno, Nevada, who in the 10 years before he died in 2005 “cost the county at least $1 million,” including “at least $100,000 in emergency room fees in 6 months in one Reno hospital.” Murray Barr became well known because he was portrayed in a profile, “Million-Dollar Murray,” in the
New Yorker
, but in fact every urban area in the United States has several untreated, severely mentally ill, and very expensive Murray Barrs. Providing adequate psychiatric treatment to just this small group of individuals would produce enormous savings.
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Medicare and Medicaid data also suggest that a small number of seriously mentally ill individuals account for a strongly disproportionate share of the total costs. A study of Medicare patients who were rehospitalized within 30 days following hospital discharge reported that patients with psychoses (schizophrenia and bipolar disorder) had the second-highest rate of rehospitalization costs, behind only individuals with cardiac problems. Similarly, a study of Medicaid costs reported that “nearly 60 percent of Medicaid spending is incurred by just 5 percent of the program’s beneficiaries” and that “mental illness is nearly universal among the highest-cost, most frequently hospitalized beneficiaries.” Another study of Medicaid costs for individuals with one of nine different chronic diseases reported that individuals with psychoses were the most expensive, more than three times more expensive than those with diabetes or hypertension. In still another study of individuals with schizophrenia covered by Medicaid,
it was estimated that the failure of these individuals to take antipsychotic medication cost Medicaid $1.5 billion in one year.
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It is clear, therefore, that prioritizing services for a small subset of seriously mentally ill individuals is not only humane and in the best interests of the individual but also economical and in the best interests of society. Indeed, even the 1961 report of the Joint Commission on Mental Illness and Health recommended that individuals with “major mental illnesses . . . should have first call” on available psychiatric services. Despite what would seem to be common sense, the prioritization of the sickest and most problematic psychiatric patients has been tried only occasionally in the United States and never with much conviction. The most ambitious attempt was in Oregon in the 1990s, when a panel of experts, appointed by the governor, prioritized by diagnoses the psychiatric services to be covered by Medicaid. When the plan reached the state legislature, however, it was promptly disemboweled by “local political wrangling” and by advocacy groups that complained, for example, that post-traumatic stress disorder was just as important as schizophrenia. Despite the support of the governor, who was a physician, political will in the state legislature was lacking.
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8. Services for mentally ill persons must be prioritized to ensure that those who are sickest, pose the greatest risk to themselves and others, and incur the greatest cost receive services as the first priority.

Another problem associated with the prioritization of patients is access to information. Very commonly, police and sheriffs, who are now the frontline mental health workers, are asked to assess mentally ill people but have no access to the person’s history. As early as 1990, in an article titled “What Do Police Officers Really Want from the Mental Health System?,” police officers “indicated that they most needed access to information about an individual’s past history of violence or suicide attempts.” Many of the sickest and most dangerous mentally ill persons travel from state to state, but critical clinical and legal information usually does not cross state lines. For example, Henry Lee Brown, with untreated schizophrenia, drifted between Mississippi, Georgia, South Carolina, Ohio, Texas, and California, “living in homeless shelters and serving jail time in mental hospitals for bizarre crimes that were increasingly violent” for 20 years before he was killed by police.
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The problem, of course, is confidentiality laws that prohibit the disclosure of psychiatric information. Such laws have become increasingly stringent during the same years in which untreated mentally ill individuals have increasingly flooded the community. The privacy laws have been used by mental health agencies to protect themselves when things go wrong, as they increasingly do. As one observer noted: “One of the problems in
this entire realm is that of state/private agencies constantly taking the Fifth Amendment against self-incrimination by hauling out ‘patient confidentiality’ to say nothing at all.” It is not the patient who is usually being protected but, rather, the agency.
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There are indications that our obsession with psychiatric privacy and confidentiality may be ameliorating somewhat, as we weigh the needs of individuals against those of society at large. In May 2011, the governor of Kansas signed a bill “that allows police to get more information on a suspect’s mental health. . . . The new law is intended to give police the information they need to take mentally ill offenders someplace where they can be treated rather than to jail.” That same month in Albuquerque, the chief of police announced that “the department is working towards building a database to catalogue where mentally ill people live . . . based on information voluntarily provided by family members.” This announcement followed yet another fatal encounter between a mentally ill man and a policeman. States have supported sex offender registries, available to the public, for many years and are now in the process of introducing public registries for first-degree murderers and drunken drivers. Given this trend toward making more information about potentially dangerous individuals more publicly available, the Kansas law is likely to be replicated in other states.
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9. In selected cases, psychiatric information on mentally ill individuals who have a history of dangerousness should be made available to law enforcement personnel, because they are now the frontline mental health workers.

The final lesson that has been learned from the past half-century of amorphous and anarchic public psychiatric services is the most important—somebody must be held ultimately accountable. Until the passage of the 1963 legislation creating the federally funded community mental health centers, states had for over a century been ultimately responsible for mental health services. Responsibility was clearly assigned, and if things went wrong, people knew in which direction to point.

All that changed after 1963, when federal officials began funding local mental health agencies directly, without going through the states. The clear message was that states were no longer responsible, which was fine with them. The states proceeded to empty their state hospitals and shift the fiscal burden to the new Medicaid and other federal programs. The states thus rapidly proved the veracity of John Talbott’s warning in his 1978 book
The Death of the Asylum
: “Society will shuck off responsibility both for the state hospital system and the chronically mentally ill if given half a chance.”
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The withdrawal of state responsibility for mental health services created a vacuum in accountability that continues to exist today. NIMH officials were happy to give away
federal funds but had little ability and even less interest in monitoring how the funds were spent. Realistically, there was little capacity at the federal level to oversee the expenditure of federal funds in centers that were geographically spread from southern Florida to northern Alaska, which is why so many of the funds were so poorly spent. For human services in general, the federal government is too distant to oversee a country of 308 million people.

At the local level, city and county governments had no interest in assuming responsibility for mental health services that had traditionally been a state responsibility. The only exception to this was the few states, such as Iowa and Wisconsin, in which some responsibility for mental health services had traditionally been assigned to the counties. Thus, throughout the United States, beginning in 1963, mental health financing and services developed in a totally unplanned, random way because nobody was in charge and nobody was responsible. Money for the services arrived—and still arrives—under various federal programs such as Medicare, Medicaid, SSI, and SSDI but with neither coordination nor accountability. The tragic consequences are everywhere visible.