The Real Crisis in Health Care?

This morning I watched all the debates on health care reform on ABC's This Week. There was a particularly heated exchange between Karl Rove and David Plouffe (watch part 1 and part 2).

As a Canadian, I watch all this fear mongering going on in the US, and can't help shaking my head. Words like "Armageddon" are being thrown around, and that if this health care bill passes, the US will collapse. This is just a bunch of nonsense.

But I'm not going to discuss the merits of this health care reform. Instead, I want to talk to you about another calamity going on right now across many states. Sasha Abramsky of the Guardian reports that homeless and mental health services in the US are being cut back as cities, counties and states run out of cash (HT: Sam):

Recently, I wrote about public education in crisis. But two other vital public services are also being hit hard by budget cuts: mental health care and assistance to the homeless.

Education is at least partly buttressed by the fact that almost everybody supports the idea of public schools. Cuts generally provoke an outcry, and politicians often pledge to do their best to restore funding as soon as the economy improves. Mental health and homelessness services, by contrast, are in some ways more vulnerable over the long-run: the constituencies they serve tend to be perceived by much of the public as nuisances at best, as societal menaces at worst; services to these groups tend to be costly; and the success rates (illnesses controlled, homeless folks moved into permanent housing) are, while a whole lot better than nothing, sometimes mediocre.

And so, as local and state government budget crunches worsen, it's no surprise many of these services are on the chopping block.

The Centre on Budget and Policy Priorities (CBPP) reports that Connecticut's governor has proposed suspending all state-funded homeless services for the rest of the fiscal year; California has eliminated funding for domestic violence shelters; Massachusetts has reduced spending on geriatric mental health services; Ohio has, according to the CBPP report "eliminated virtually all state funding for mental health treatment for individuals who are not eligible for the state's Medicaid programme"; while Virginia has reduced the amount it pays hospitals to treat people with mental health or substance abuse issues and slashed its grants to local mental health service providers.

In fact, search online for mental health cuts by state, and it rapidly becomes clear that across America the already-fragile community mental health service infrastructure is being battered.

The impacts are by no means abstract. Community mental health clinics provide not just medicines and counselling services, but an array of other support: they help the mentally ill find housing and jobs; and they work with them to navigate complex government bureaucracies and access benefits. They provide friendship to people who are frequently lonely, depressed and marginalised from the broader community. Cuts to the mental health infrastructure in Kansas have resulted in a documented increase in calls to suicide hotlines and rising numbers of people being admitted to psychiatric hospitals in a psychotic state. Communities like Santa Barbara, California, have seen homelessness spike at least in part because broke local mental health services are having to turn sick men and women away.

And, once homeless, the mentally ill – as well as the non-mentally ill homeless – face a similar scramble for scarce resources. Tens of millions of dollars have been removed from city shelters in Washington DC, the nation's capital. As winter set in last November in Minnesota, one of the coldest states in America, thousands of low-income families lost emergency financial assistance to help pay rent to avoid being evicted. The National Coalition for the Homeless estimates more than 700 homeless Americans die of hypothermia each year – and with homeless services being slashed, that number will likely increase in the years to come.

Meanwhile, New York City is considering closing the largest homeless drop-in centre in Manhattan. Activists worry that homeless residents with drug addictions, HIV, tuberculosis, or mental illnesses will find it harder to access treatment if they aren't in stable housing situations. And that, ultimately, could trigger a broader public health problem.

In cities, counties, and states across America, homeless and mental health services are being eviscerated. As a result, programmes that have been carefully built up over decades are going to close. With them will go the expertise of trained staff; the accumulated experience of caseworkers who have gotten to know the needs and behaviours of individual clients, and who might have spent years getting those individuals to trust them enough to let them provide help; and the fragile bonds, the sense of belonging, that in some instances are the only things keeping a person on the edge from spiralling into more serious illness and more intractable long-term homelessness.

There are no easy answers here: too many branches of government have simply run out of cash and of quick-fix solutions. Without more support for these programmes from the federal government, or local ballot measures that earmark funds for particular social services, it's inevitable that many of them will be cut in the next few years.

But, at the very least, this merits a frank conversation, an acknowledgment that the risks associated with dismantling this infrastructure are huge: tear down services to these groups during the down times and there is just no guarantee that a political consensus will emerge at the back end of the fiscal crisis to restore such services. After all, homeless people or the seriously mentally ill don't tend to have much of a political voice. Their needs are, too often, seen as irrelevant.

The undermining of these vital social services will have an impact that long outlives the current economic crisis. Nothing would more forcefully illustrate the phrase "private affluence and public squalor", coined by progressive economist John Kenneth Galbraith, than a booming America, its landscape littered by ever more homeless encampments, ever greater numbers of untreated mentally ill people and, in consequence, a growing sense that, for the affluent majority, public spaces are unsafe and unseemly. That happened in Victorian England; it occurred again in both America and the UK in the 1980s. It would be a great tragedy to let the 2010s and 2020s witness a repeat performance.

Treating the mentally ill is not just a US problem. In the UK, Maddy Savage of the BBC reports that GPs call for better treatment for depression sufferers:

Some 65% of doctors say they can "rarely" offer psychological therapy to depression sufferers within two months of referral, a study suggests.

The Royal College of GPs survey of 590 UK doctors also found 15% said access to psychological services was only "usually" possible in that timeframe.

The survey is part of a campaign by mental health charity Mind calling for better access to therapies.

The government says it is working hard with the RCGP to achieve this.

Depression affects one in 10 people a year, with more than half of those experiencing more than one episode.


The National Institute for Clinical Excellence (NICE) recommends talking therapies as the best form of treatment for mild and moderate depression.

Mind's campaign is being backed by the Royal College of Psychiatrists.

It challenges all political parties to make a guarantee in their election manifestos, to offer evidence-based therapies to all those who need them within 28 days of requesting referral.

In 2007, the government earmarked £173m to boost the number of cognitive behavioural therapists available on the NHS.

The Improving Access to Psychological Therapies (IAPT) programme aims to treat 900,000 extra people in England by 2010/11, with half of them moving to recovery and 25,000 fewer on sick pay and benefits.

RCGP chairman Professor Steve Field said: "There has been substantial improvement in the last few years but there is a long way to go.

"It is essential that the current programme is completed within the next Parliament with adequate funding for training and employing extra therapists.

"If we can treat people early we can keep people in work, keep them off medication and help them get on with their lives."

Mind chief executive Paul Farmer said talking therapies could save lives, and it was crucial that people who needed help received it as quickly as possible.

"Waiting months and months for urgent treatment would not be acceptable for patients with other health problems, and it should not be acceptable for patients with depression," he said.

A Department of Health spokesperson said more than 230,000 people had already benefited from the IAPT and that almost three quarters of primary care trusts now offered this service, up from a quarter two years ago.

But in a statement it added: "There is still work to do and we will work closely with the Royal College of GPs and others to achieve this."


Opposition parties have also pledged to widen access to talking therapy treatments.

Tory shadow health minister Anne Milton said: "In the same way that physical conditions get worse when not treated, a mental health condition will also deteriorate. This must be improved.

"We will make sure that GPs have better information about the effectiveness of talking therapies."

A Lib Dem spokesman said: "We are totally committed to ensuring that people with mental health problems are given guaranteed access to the treatment that they need and we want to work with Mind and the Royal College of GPs to find out what the spending implications would be of a 28-day guarantee."

The programme director for Wellbeing at the London School of Economics, Professor Lord Layard, who is spearheading the campaign, has stressed the economic as well as the humanitarian case for investing in treatment, suggesting that successful therapy can help many people return to the workplace.

"Mental illness is perhaps the greatest single cause of misery in our country," he said.

"The least we should offer is the same standard of care we would automatically provide if they had a physical illness."

So, as you listen to the news touting the historic passage of US health care reform, keep in mind that millions of people who suffer from mental illness are falling through the cracks and not getting adequate treatments for their conditions.

I should know, I see my father, brother and their colleagues on the front lines, treating the mentally ill day in and day out. Despite the popular belief that the recession causes more mental illness, my father keeps telling me that "at any one time across all populations, 10% suffer from depression". That's a lot of people in the world who need to be treated for a serious condition.

Unfortunately they're falling victims to state budget cuts and they do not have the political clout to fight for better access to treatments. In that sense, the recession has impacted millions of silent victims who struggle to cope as resources dwindle. This is the real crisis in health care that hardly anyone covers.