Mental Health Care in America

WM: America’s Mental Health Crisis, February 2, 2022

Finance: Mental Health Care in America: Addressing Root Causes and Identifying Policy Solutions, June 15, 2021

Re-funding Mental Health

The largest provider of mental health services (including to veterans) is the correctional system. Job one is to shift from correctional modalities to new methods featuring mental health, education (including ESL programs) and addiction medicine. Warehousing young males of any race, but particularly African-Americans multiplies societal pathologies. While some forms of illness, such as sexual violence and physical violence or murder may require higher security, others can be treated as patients rather than criminals.

A pilot program could be developed to respond to certain incidents (especially those involving mental illness or alcohol) with immediate dispatch of emergency medical teams. This would require more ambulances, more mental health facilities and a pause in applying restraints until medical personnel arrive.

Funding more hospitals and ambulances would be part of this, possibly with some form of federal grant program. Private corrections facilities can also be transformed into contracted medical facilities with security contracting provided as a subcontract to mental health systems, both secular and religious. Catholic Health Association members come to mind. Both public and private educational systems would be an integral part of such facilities and be treated as an essential function, rather than the first item cut when states wish to minimize their spending by essentially torturing (and dehumanizing) inmates.

New standards of individual and societal protection must be developed. Improved standards of care and security will require much more funding than state and local governments are willing to commit to. This simply drives the problem to the correctional system, which is the largest provider of mental healthcare in this nation. The term for this practice is pennywise and pound-foolish.

It is too easy to get out of treatment and too hard to get it. Hospitalization for medication management is sometimes needed but rarely given. Often, people are released before a stable routine is established, including management of side effects. It is hard to create a good care plan in a five day hold. For both mental illness and alcoholism, it must be harder to simply sign out without a real prospect for long- term recovery. Again, the term is penny wise and pound foolish.

A final reform, which will save money and resources, is to create a plea in criminal cases of guilty by reason of insanity. Those who enter this plea would be confined in the facilities detailed above for at least the minimum sentence for their offences, with no release after that if the subject remains a danger to society. 

If relapse occurs or treatment protocols are evaded after release, rehospitalization must be automatic and last until a treatment program is more deeply ingrained. There should, of course, be protections on both sides in the decision to release subjects - both for the protection of the rights of subjects who made be held for punitive, rather than hygienic reasons and, as importantly, the interests of the victims of crime, including but not limited to the possibility of physical danger. Sometimes, exile should be a part of release.

Cost of Living

Even before the pandemic, my SSDI was inadequate for food, medicine, clothing and cable. If I owned a vehicle, there is no way I could maintain it or even buy gas. I have an above average benefit, high enough to be ineligible for SNAP or Medicaid. Many are not so lucky, even on a good day. 

Bold and underline: food prices are still skyrocketing. Part of the problem may be too much money chasing too few goods, but retirees and the disabled find (our)selves between a rock and a hard place. We need a COLA and we need it now. Most of us cannot even afford cola. Because this is a short term emergency due to the Pandemic, it should be funded out of the general fund until the normal process kicks in for next year.

The important point is that, if wage growth is considered inflation, the retired and disabled can be given not only a Cost of Living Adjustment, but also have their income history rebased for inflation. Even with Chained CPI, such an increase will take the financial pressure off of many such households, including mine. 

Low wages are endemic among the mentally ill. We need a raise, along with the rest of the working poor (and not so poor - who make more when the minimum goes up). The Minority proposed a $10 wage as a counter-offer to $15. A $12 wage for a 40 hour week puts us at parity to 1965, when the wage peaked and the war over wages started with the Kennedy-Johnson tax cuts. An $11 wage with a 32 hour week is also acceptable. With increased productivity, the work week should be shorter. The minimum wage should be indexed to inflation, including during any transitional period - which should have the goal of $18 per hour ($15 is a 20th Century goal).

Not raising minimum wages has been justified by the reactionary sector that claims that in the end, the market will sort everything out.  The perception that doing the right thing makes a business non-competitive is the reason we enact minimum wage laws and should require mandatory leave. Because the labor product is almost always well above wages paid, few jobs are lost when this occurs. Higher wages simply reduce what is called the labor surplus, and not only by Marx. Any CFO who cannot calculate the current productive surplus will soon be seeking a job with adequate wages and sick leave.

The requirement that this be provided ends the calculation of whether doing so makes a firm non-competitive because all competitors must provide the same benefit. This applies to businesses of all sizes. If a firm is so precarious that it cannot survive this change, it is probably not viable without it.

Mentally ill people deserve to have families, just as others do. Increasing the child tax credit is as essential to us as to anyone. The child tax credit level passed in the American Recovery Act should be made permanent and doubled, with distribution through private sector payrolls, unemployment insurance benefits, emergency benefits for families and paid participation in educational programs.

There are two avenues to distribute money to families. The first is to add CTC benefits to unemployment, retirement, educational (TANF and college) and disability benefits. The CTC should be high enough to replace survivor’s benefits for children. 

The second is to distribute them with pay through employers. This can be done with long term tax reform, but in the interim can be accomplished by having employers start increasing wages immediately to distribute the credit to workers and their families, allowing them to subtract these payments from their quarterly corporate or income tax bills.

Community Healthcare and Medicaid

Home and Community Based Health Care are addressed in the President’s Budget. Home and community-based care  should be funded by goods and services taxes as part of a newly created Medicare Part E. Senior Medicaid should be entirely federalized, with other clients insured through the President’s proposal for a public option. 

President Reagan’s New Federalism proposal would have removed Medicaid from state budgets in exchange for ending or block granting other federal programs. This was a good idea then and a better idea now. Medicaid Part E should be created to both relieve states and the District of Columbia (or Washington, Douglass Commonwealth) from providing Medicaid for Seniors and the Disabled and seeing to the enforcement of practice standards for nursing homes who receive these funds.

For workforce development and general recovery, Psychiatric Rehabilitation Programs, such as the Center for Behavioral Health in Rockville and Cornerstone Montgomery in Gaithersburg are essential. To make them more attractive, and to increase our ability to manage - especially in the period before disability programs kick in, participation should be paid at the minimum wage. 

People will participate in this care more frequently if their opportunity costs are met. Those with less than a full education should receive it through public and private providers and also be paid to do so.

Health care currently provided through Medicaid should be dual eligible for everyone, regardless of income and before it kicks in entirely be a public option. Instead of using a larger system, clients should have the option of receiving coverage through the PRP provider’s employee plan.

Veterans

In recent decades, the problem of veteran disability determinations has remained troubling, with the Pandemic complicating processing. When a job gets too big to manage with staff, two options remain - contract out as much work as possible, including consolidating case files and making easy determinations - and sharing responsibility for processing with the Department of Defense. The handoff from DoD to DVA should be seamless. 

The mental health and housing needs of veterans, both recent and lingering, is endemic. This is another area where coordination with DoD would prove helpful. This help must go beyond management and computer systems and include the human element of soldiers, veterans using services and those who need services can interact on a less formal, but not unprogrammed basis.

The DVA and DoD must both actively facilitate this and join state and local governments in reaching out to those who suffer, from active duty soldiers to veterans both receiving and in need of services. For those mentally ill or addicted veterans who do not trust the system, less restrictive systems should be developed - including providing camping supplies and a place to camp and a more permissive attitude to active drinking and drug use until help is sought. Such systems do not encourage use. No addict needs encouragement. They build the trust that makes recovery possible.

Digital Mental Health

Mental health care and addiction services stood up rather well during the pandemic. Zoom, and similar platforms, have stepped in nicely to continue face to face care where needed. Phone appointments and video calls have also worked in family practice settings where medication management is the only task. 

Managing my prescriptions and assisting my housemate in managing his contacts with his are much easier than a trip to our respective mental health providers.

There is one area of major concern that must be addressed, although I am not sure how we can go about it.  During this crisis, before there was vaccine hesitancy, there was Zoom hesitancy. Some of our older members simply could not figure out or declined to use video calls to attend meetings. 

I experienced this reticence myself, not wanting to download software to my phone that was unknown to me. In the beginning, I was also too ill to do much more than eat, be tired from eating, rest and then go back to bed. It was only the usual miracles experienced by those who are spiritually awake that had me download the software and attend a midnight meeting.

My housemate is not technically savvy. Without my help, and the use of my Chromebook, he would still be visiting his psychiatrist in person, where he would be taken into a room for a teleconference with his doctor. 

He is a victim of the digital divide. It inhibits him (as well as the lack of a computer of his own) to seek English as a Second Language courses, which are free at Montgomery College (our local community college). His disability, which is matched by his lack of education and equipment hamper both his treatment and his ability to improve his skills. 

This is where improvement is necessary. As I have stated in previous comments for the record, paying a stipend to undertake both computer and basic literacy training is an essential incentive to seek it. Such stipends should not count against his disability payments. If they did, they would be a disincentive toward learning. It is a conservative meme that poverty leads to self-improvement. Research has shown that the opposite is the case. It certainly is for him.

And yes, better broadband in some areas of the country would be helpful, although this would not solve the problem of digital illiteracy, especially among vulnerable populations. Most people have access to the Internet through their cable companies, although those that do not should be given free access paid for by higher cable fees. 

During the pandemic many mentally ill SSDI beneficiaries  were not going out much and did not have many places to go. Libraries and movie theaters have been closed. Some were working in tense situations and need a vacation or just help going outside. Also, to repeat the most important point - we need a COLA ASAP, not next January.