by Art Levine
Although the imminent threat of a successful congressional onslaught on Medicaid’s budget has diminished somewhat as of this writing, there hasn’t been nearly as much attention paid to the continuing dangers posed to recipients of Medicaid even if the Republicans’ frontal assaults on the program in Congress fail. Medicaid lacks the broad political support afforded Medicare, but with seventy-four million people enrolled—more than Medicare—the federal-state program is the country’s leading funder of services for the most seriously mentally ill adults and children. In the harsh era of Donald Trump, they remain especially vulnerable to the regulatory schemes promoted by the hard-liners now in charge of federal health agencies.
“These policies make it harder for the lowest-income people to get health care through the Medicaid program,” the advocacy group Families USA notes on its web page devoted to tracking the administration’s “sabotage” efforts. The new HHS secretary, Tom Price, has already signaled through rule-making and a letter to the nation’s governors a willingness to grant state officials a relatively free hand to eviscerate government and private-sector health insurance programs. Administrators of both the state Obamacare exchanges and Medicaid programs have been offered far greater flexibility to limit required health benefits and eligibility for those programs.
The federal waivers Price wants to deploy are like catnip to budget-conscious officials eager to drastically cut spending. States such as Arizona, Indiana, Kentucky and Wisconsin, among others, are seeking or have already won permission to lock out Medicaid recipients if they don’t pay premiums; require so-called “able-bodied” recipients to work to be eligible for benefits; limit Medicaid eligibility to five years; and test them for illegal drugs without acknowledging the deterrent effect on addicts needing treatment. As a result, new risks face all of the fourteen million recipients already added through the Medicaid expansion and millions more who could be denied coverage.
Indeed, at least thirteen million more children and adults who were already using Medicaid’s behavioral health services before Obamacare took effect could find such basic benefits as medications and psychiatric care sharply curtailed or virtually impossible to obtain. In part, that’s because the GOP health care bill and the Trump administration intend to place a fixed cap on all federal Medicaid spending through either “block grants” or per-person spending limits that also give leeway to states to slash their own spending on the program; these rigid federal spending limits also could prevent states from adding new Medicaid patients even in the case of a recession or a Zika-style epidemic. Even if stand-alone bills to drastically restructure Medicaid can’t pass Congress now, Price and his new director of the Centers for Medicare & Medicaid Services (CMS), Seema Verma, have plenty of power to grant draconian administrators broad freedom to clamp down on the program through “Section 115” waivers.
Verma, an Indiana health care consultant who is a protégé of Vice President Mike Pence, has had plenty of practice adapting the waiver’s authority to boot people off the Medicaid rolls under the guise of promoting “personal responsibility.” As part of a deal with the Obama administration to allow Medicaid expansion, Verma created a “Healthy Indiana” plan that required people to make seemingly modest monthly payments—from one dollar up to a hundred, depending on their income—into a personal account to ensure coverage. But if there are any slip-ups in payments, you either get punished with higher co-pays and skimpier coverage—or kicked out of the program altogether for six months. In practice, as WFYI public radio reported, the state and private insurers too often made repeated bureaucratic mistakes that left even steadfast payers without coverage. On top of that, as USA Today reported, more than half of the low-income people who qualified for the relatively top-tier version of the Indiana program were cited for failing to make a required monthly payment, forcing them into cheaper and riskier bare-bones programs, according to a state-funded survey. State officials claim that only a small portion of them were locked out altogether from receiving any health care coverage—regardless of the seriousness of their mental or physical health conditions. It is still being promoted as a national model for other states by Verma and the budgetary hit-squad at HHS.
The dystopian future awaiting the most seriously mentally ill people under a Trump administration can, perhaps, be glimpsed by looking at what happened when Tennessee, facing a fiscal crisis, used HHS waivers to cut over 350,000 people from the Medicaid rolls starting in 2005 and drastically curtailed benefits for others. These included limiting virtually all recipients to a total of five medications. With 35,000 of the most seriously and chronically mentally ill recipients losing all coverage, homelessness, emergency room visits and jailings rose sharply in Tennessee.
In fact, as many as half of the state’s most seriously and persistently mentally ill people in some counties who were theoretically eligible for the state’s “safety net” alternative to their lost Medicaid coverage couldn’t manage the paperwork obstacles and were left to drift into oblivion. One family’s obituary for their son who committed suicide explicitly blamed TennCare, as Medicaid is known, for denying him the services and medication he needed. “If you send paperwork to the severely mentally ill and require them to fill out all these forms, you’re going to lose a lot of people right off the deck,” says Gordon Bonnyman, the Tennessee Justice Center staff attorney who opposes such cuts and restrictions emerging now from the Trump administration.
In addition, millions of people who won coverage under Obamacare could be in for a rude surprise when their new mental health benefits either disappear or become so limited as to be nearly worthless. A little-known bonus of the Affordable Care Act is that it also mandated ten “essential health benefits” including drug and mental health treatment for all those enrolled in individual and small company plans, along with the millions of beneficiaries of expanded Medicaid coverage, theoretically offered on a par with medical benefits, a requirement known as “parity.” Here’s another shock: Citizens of major Democratic, pro-Obamacare states such as California and New York can’t necessarily count on their progressive governors to protect them from the same sort of harsh restrictions in the proposed Republican health care bill embraced by conservative GOP governors in the South and other red states. As Kaiser Health News reported, the deep cuts in the Obamacare subsidies that assist Americans to buy individual and small company insurance coverage in the marketplaces could make all the plans unaffordable. So to keep insurers in their states and bring average consumer costs down, even liberal governors may have to ask for waivers allowing them to omit essential health benefits or charge far higher rates to the sickest and most disturbed people.
The far skimpier coverage that could be potentially offered is a potential deathblow especially for the most troubled mentally ill people and addicts who turn to Medicaid for help. It’s disturbing that despite over 59,000 overdose deaths annually, most due to opioids and heroin, nearly three million—often mentally ill—drug addicts who got coverage for the first time under Obamacare and Medicaid could face new barriers to care; others will surely be frightened away from enrolling in Medicaid by drug-testing requirements if states win permission to do so. All these potential restrictions will be worsened by the impact of Attorney General Jeff Sessions’s determination to restore maximum prison sentences for even low-level drug offenders and Tom Price’s unscientific, abstinence-oriented opposition to using medically-assisted opioid treatments such as Suboxone, rejecting his department’s own research findings. When taken together with reduced access to treatment, the Trump administration’s extreme law-and-order response to the opioid crisis, despite Trump appointing a presidential commission to address the epidemic, could well lead to the deaths of thousands of more addicts each year.
Even the well-meaning federal parity requirements for both small Obamacare and large corporate plans are still often more a promise than a reality, due to exorbitant out-of-pocket costs and shortages of in-network mental health providers, NAMI reporte
d in November 2016. Yet many of those reforms, too, could be further undermined in the Republican stampede to repeal Obamacare and cut Medicaid spending that is finding a new outlet in arcane agency decision-making out of the public spotlight.
“It will be disastrous,” Cheryl Fish-Parcham, Director of Access Initiatives for Families USA, says of the potential passage of Trump’s Obamacare repeal in Congress. The same ominous potential remains if Republicans get everything they want through new regulations and waivers.
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EVEN IF YOU RETAIN YOUR MENTAL HEALTH COVERAGE UNDER TRUMP, most people can’t afford it: nearly half of all psychiatrists don’t take private insurance or Medicare. As Bloomberg News recently reported, they’re increasingly choosing to take cash-paying patients with easier-to-treat problems, forcing even more of the severely mentally ill to navigate the fragmented and overbooked community clinics in a desperate waiting game for help. Meanwhile, Medicaid enrollment remains an obstacle course even for the low-income people who qualify, and, of course, it will be virtually impossible for otherwise eligible mentally ill people to join Medicaid after rigid spending limits are enacted.
Hospital emergency rooms have already become the short-term treatment site of last resort. Too often the absence of any kind of care can lead to suicide, now the second-most common cause of death for Americans between ages fifteen and thirty-four, according to the Centers for Disease Control (CDC). Of the nation’s 33,000 firearm deaths a year, over 60 percent are self-inflicted.
The nation is still reeling from state mental health budget cuts of over $4 billion during the three years after the 2008 crash. In most states, budgets still remain below 2009 levels. So if the nation would just address the funding shortage, we’re told, we would go a long way towards helping the 40 percent of the nation’s ten million seriously mentally ill adults who don’t get any treatment in the course of a year. (Those with serious mental illness are defined by the federal government as being severely impaired during the past year by such conditions as schizophrenia, bipolar disorder and major depression.) The shortage of funds, stigma and lack of access to treatment have been singled out as the primary evils in the reform narrative offered by mental health organizations. But they generally don’t pay much attention to the true quality of care or overmedication or pharmaceutical corruption of the mental health system—or of the mental health advocacy groups themselves.
Of course, there’s usually little public interest in addressing mental health issues at all until there’s a senseless mass shooting that shocks the country. They’ve ranged from the thirty-two killed at Virginia Tech in 2007 and the twenty-six killed at the Sandy Hook school in Newtown, Connecticut, in December 2012, to so many others, including the largest mass shooting in American history as of this writing: the killing in June 2016 of forty-nine patrons at a gay nightclub by Omar Mateen, a troubled twenty-nine-year-old Muslim man. He was seemingly fueled by some combination of Islamic extremism, self-hatred over his bisexuality and an undiagnosed mental disturbance. As Mateen grew up, his anger flared up regularly at classmates, his first wife, coworkers and, finally, with a legally purchased assault weapon, it took aim at all the strangers that he massacred at the Pulse nightclub in Orlando, Florida.
Unfortunately, in the first half of 2016 alone, there were nearly 170 mass shootings involving four or more people shot or killed in each incident, although there’s no consensus on what portion of such killers show signs of mental illness. Estimates range from 20 percent with serious, disabling mental illnesses to as much as 60 percent, according to The American Journal of Public Health. Still others have been identified by Pennsylvania psychologist Peter Langman, author of School Shooters and creator of the Schoolshooters.info archive, as “psychopathic shooters” lacking in empathy and as “traumatized shooters” raised in abusive homes. It’s likely, in fact, that most mass killers have some form of mental illness, even if many don’t meet the narrow legal definition of insanity: the inability to tell right from wrong at the time of the crime.
By the time you read this, there will most likely be yet another horrific tragedy that stirs new calls for reform, new debates over whether mental illness or unimpeded access to guns is really at fault and concern from progressives that people with mental illness are being unfairly stigmatized since they are far more likely to be victims than perpetrators of violence.
After these shootings, right-wing and Republican Party leaders inevitably talk about mental health as the real issue to be addressed, rather than the truly insane lack of meaningful gun control. As usual in these and other public arguments on guns, liberals often decry right-wingers’ references to mental illness as a ploy to avoid gun control, while conservatives denounce gun control as a phony ruse that will disarm regular citizens and won’t stop criminals, crazy people and terrorists from getting guns. In truth, the country needs both dramatically improved and accessible mental health care along with far tougher gun control laws.
Former Arkansas Governor Mike Huckabee, a frequent GOP candidate and Fox commentator, declared after the slaying of nine at Umpqua Community College in southern Oregon in October 2015, “Do we need to do a better job in mental health? You bet we do.” When Huckabee was governor, though, Arkansas received a “D-” rating on a national scorecard issued by NAMI, which remains a valuable yardstick. When conservatives talk about mental health, for the most part they’re talking about tracking down chronically crazy people and forcing them to have treatment or locking them up somewhere—without bothering to think about who will pay for it all, let alone if it would be effective or helpful. (The hollowness of the right-wing’s emphasis on mental illness’s role in gun violence was underscored when the NRA successfully pushed—along with the ACLU and disability rights groups—for legislation that overturned in February 2017 an Obama administration regulation that closed yet another potential loophole: it required the Social Security Administration to report to the FBI background check system mentally impaired beneficiaries who were incompetent to manage their own finances.)
There is, of course, a sharp debate over the extent that seriously mentally ill people engage in violence, but they’re only a fraction of all those who commit violent crimes—and they’re eleven times more likely to be victims of violence than the general population. At the same time, untreated, severely mentally ill people are disproportionately more likely to engage in violence than the average citizen, and that is largely accounted for by the substance abuse that afflicts as many as 50 percent of them.
A recent controversial Boston Globe investigation illustrates just how inflammatory and complex the issues are surrounding mental illness and violence. It found that drug and alcohol abuse is one of the major risk factors in violence by mentally ill people, along with a lack of treatment and failure to take medications. These findings, consistent with some major psychiatric research on violence, were reported in the startling investigative series that found in June 2016 that mentally ill suspects—although some had no formal diagnoses—were involved in more than 10 percent of all homicides with known suspects across the state since 2005.
The series prompted a protest of nearly two hundred people representing mentally ill clients of state services and their allies outside the Globe building. They carried cards, pinned to flowers, featuring the names of some of the hundreds of mentally ill people killed over the years during treatment, including with such restraints as straps and handcuffs, and in shootings by police (149 such fatal shootings in the first eight months of 2016, The Washington Post reported). “They demonized us,” says Ruthie Poole, the board president of M-Power, an advocacy group for mental health consumers, as they’re known. The critics argued that the series also promoted the wrong kind of care: forced treatment and dangerous hospitalizations.
The real, nuanced truth about mental illness, violence and the role of treatment, this book shows, doesn’t align neatly with any of the highly polarized arguments.
So even The Globe’s analysis
of the problem, like most of the commentaries and reports about mental illness following high-profile mass shootings, focused on the lack of adequate funding and barriers to treatment. None of these explications, however, have probed deeply into the quality of care itself after people get access to treatment, outside of noting problems arising from a shortage of trained health-care providers.
In contrast, this book explores the underlying factors driving the failures of the distorted mental health system. Ultimately, because of overspending on too many dubious, risky medications, corporate fraud and unproven therapies, fewer funds, training and clinicians are available to offer cost-effective, personalized treatments and, for some people at certain times in their lives, carefully prescribed drugs that work. For now, however, mental health care, as currently offered by most providers and clinicians, continues to be portrayed as an unalloyed good, and supposedly even more people need to receive more treatment, regardless of the actual quality. Unfortunately, the furious political debate over repealing Obamacare has obscured the hard truth that the current mental health system is such a fiasco that even having health insurance doesn’t ensure good—or even safe—outcomes.
The improved access to care promised by the passage of the Helping Families in Mental Health Crisis Act, a reform bill introduced by Rep. Tim Murphy (R-Pa.) as a response to the Newtown shootings in 2012, doesn’t truly address these broader failings. (Neither did Hillary Clinton’s ambitious mental health plan released in August 2016, featuring such worthy goals as integrating mental and general medical health care in the same community settings.) The Murphy bill first ran into criticism from Democrats and rights-oriented mental health advocates who asserted that it overemphasized forced treatment and more hospitalization while jeopardizing the privacy of patients’ records, among other concerns. After those provisions were softened, the legislation—signed into law in December 2016—now aims to improve coordination of 112 different federal mental health programs with a new assistant secretary of the Department of Health and Human Services (HHS); expand access to crisis inpatient care; and promote early prevention and screening. Yet this authorizing legislation seemed likely to be starved of the funds needed to carry out its relatively modest agenda by budget-conscious Republicans, who also oppose Obamacare’s expansion of Medicaid and seek its total repeal. Nevertheless, after the mental health bill passed the House in 2016, Rep. Murphy dramatically declared: “This historic vote closes a tragic chapter in our nation’s treatment of serious mental illness and welcomes a new dawn of help and hope.”