The death of Mental Health care

The House passed the health care bill - you know the one: everyone agrees that it's massively flawed and "needs to be fixed" in the future. It's the one that raises taxes for ten years, while only providing benefits for six, so one of the things that will have to be "fixed" is the huge gaping hole in the budget. A bunch of the budget fixes are wildly unpopular, so Congress is unlikely to do any of them, so the financial hole will be deep.

So let's think about what the Fed.Gov will have to do. If it can't raise revenue, it will have to cut costs - indeed, all the talk about "Death Panels" (if you're on the right) or "bending the curve" (if you're on the left) amount to the same thing: costs will be cut, probably in a crisis atmosphere, because there won't be any alternatives.

As a thought experiment, pretend that you're a CEO at a troubled company. Your balance sheet is an exciting shade of crimson, and the Board of Directors and shareholders are insisting that you turn things around. Looking at the annual budgets of your six departments, you see this. Which departments get the most of your attention?
Departments A, B, and C make up almost 85% of your cost. Any turnaround has to begin (and maybe end) there. As Willie Sutton answered when asked why he robbed banks, that's where the money is.

Do the new Department of Health will have a massive - maybe $200B a year - fiscal hole, and it will have to fix it. Bending the curve won't just be a good idea, it will be unavoidable. They'll start with the areas where there's the biggest expense and the smallest number of people served. And that area is Mental Health.

Consider Depression:

The total cost per patient was estimated at € 5,500 (95%CI € 5,000—6,100) over six months in 2005 prices. Direct costs were estimated at € 1,900 (€ 1,700–2,200), 35% of total costs, and indirect costs at € 3,600 (€ 3,100–4,100), 65% of total costs. The cost for antidepressants represented only 4% of the total costs. [emphasis mine]

You can't blame Prozac - it's just not a big part of the cost, which is almost $15,000/year per patient (conversion rate €1 = $1.30). Or Schizophrenia:

After 2 years, the rate of patients treated successfully is 82,7% for LA risperidone, 74,8% for olanzapine and 57,3% for haloperidol depot. The 2 year-cost per patient treated by LA risperidone is 14,055 Euro. [emphasis mine]

That article is interesting, because there were several other treatments in the study, some of which were twice as expensive. That's a lot of money. And so it will be cut, because it will have to be cut. What happens then?

David over at Fighting For Liberty had a post regarding mental health in his town:

This morning, I received this news:

Teenager’s killer released from psychiatric hospital

The parents of a 14-year old girl who was shot and killed want to know why their daughter’s killer is free to walk the streets.

…But just 5-years after he killed the steele’s daughter Jasmine, and seriously wounded a woman, James Mann was released to a halfway house not far from where the Steele’s live.

He’s now somewhere in my quaint little hometown.

Understand, this town isn’t big. Most everyone lives within two square miles or so. This … creature … is now my neighbor.

David, that's not a creature. That's someone's son: [See Update at end]

I've seen real demons, in someone's eyes, the window to their soul. Something is strange, and then there's a realization that something's there. Literally, the hair stood up on the back of my neck, and time slowed down as adrenaline flooded my system. My dog growled, and then fled. I don't blame him; I would have fled myself if I could have.

...

Today, we have ... what can only be described as wonder drugs. I remember ancient times, back around 1970. A man described how Lithium changed his life. But Lithium was delivered as a salt, because that was the only way the body could absorb it. I wonder how his life went, with the Lithium salts slowly poisoning his system. Now that I've seen a demon myself, I guess it beat the alternative. The drugs are a lot better now, but nobody quite seems to really understand what goes on with brain chemistry.

I remember how people talked about the "weird kid". It's better now, but not a lot.

All that's fixin' to end, because it's going to have to end. There just won't be the money to pay for all this. Sure, there will be money for the meds (some of them, anyway - remember, Prosac was only 4% of the cost). There won't be money for the doctors to monitor the patients and make sure that the patients take their meds. And so a ticking time bomb will be sent out to live with society. Some parts of society - like David - will think about the "Old Yeller" cure:

He should have fried in the chair. And I don’t want to hear this righteousness about no capital punishment for mentally unstable. This creature murdered a 14-year-old girl. You don’t give murderers a bottle of pills and let ‘em roam free.

David's a friend, and what he writes isn't wrong. But there's another side to the story. I've witnessed the "switch going off". I've seen for myself how the new meds keep the switch from going off - I'm not joking that these are Wonder Drugs, because they help balance the brain chemistry, and keep the Demon at bay. But it's not cheap, or easy, to keep that Demon chained:

Harry, three, and his sister Elise Donnison, two, were found [dead] in holdalls [carseats] in the car in Heathfield on Wednesday.

Their father Paul Donnison said: "Their lives have been taken away in the most cruel way. I am unable to understand."

Their mother Fiona Donnison, 43, of Lightwater, Surrey, was arrested on suspicion of murder. She remains in hospital [after an apparent suicide attempt] and is yet to be questioned.

Medical innovation will go out the window, which means no new Wonder Drugs. Listen to the talk about "savings" from eliminating "me-too" drugs. Well one of those "me-too" drugs had different side effects from the first one, side effects that didn't cause convulsions. It costs more, though, so there will be less of it, because there will have to be less of it.

Stephany writes about the many failings of the current mental health care system. To read her archives is to see just how vulnerable these people are - to themselves, to others, and to the government. Soon there will be many more of these people. What happens to them?

I'm told that despair is one of the deadly sins, but it's moments like this that bring it bubbling right up to just beneath the surface. I do think that many - maybe even most - of the people who have passed this bill have good intentions, but they've parked their car on a steep hill, with the wheels straight and without the parking brake set. They think that they can run to stop the car if it slips out of gear. I don't think that they can.

I also hear that taking the Lord's name in vain is a sin, and so I will not say more about those who have just paved a super highway to Hell with their good intentions.

UPDATE 22 March 2010 10:36: It's important to point out that David's a friend, and a good man. It's unlikely in the extreme that he's the only one in his town worried for his family. He's probably rational to be worried.

Thre's been a great advance in the public's perception of mental health over the last 30 years, for which I'm profoundly grateful. This sort of situation jeopardizes that advance, and is likely to become all too common in the years ahead. The "Old Yeller" solution is particularly horrifying to me, because there is no retribution associated with it; it's purely a safety measure. It's depressing beyond words to think that this sort of thing may become popular, because it's the only option left to the people.