Friday, April 20, 2007

Deinstitutionalization Hasn’t Worked

I am pursuaded that the tragedy at Virginia Tech was a preventable event.

Hundreds of thousands of vulnerable Americans are eking out a pitiful existence on city streets, under ground in subway tunnels, or in jails and prisons due to the misguided efforts of civil rights advocates to keep the severely ill out of hospitals and out of treatment. The images of these gravely ill citizens on our city landscapes are bleak reminders of the failure of deinstitutionalization. They are seen huddling over steam grates in the cold, animatedly carrying on conversations with invisible companions, wearing filthy, tattered clothing, urinating and defecating on sidewalks or threatening passersby. Worse still, they frequently are seen being carried away on stretchers as victims of suicide or violent crime, or in handcuffs as perpetuators of violence against others.
All of this occurs under the watchful eyes of fellow citizens and government officials who do nothing but shake their heads in blind tolerance. The consequences of failing to treat these illnesses are devastating. While Americans with untreated severe mental illnesses represent less than one percent of our population, they commit almost 1,000 homicides in the United States each year. At least one-third of the estimated 600,000 homeless suffer from schizophrenia or manic-depressive illness, and 28 percent of them forage for some of their food in garbage cans. About 170,000 individuals, or 10 percent, of our jail and prison populations suffer from these illnesses, costing American taxpayers a staggering $8.5 billion per year.

This prescient op-od was written eight years ago.
In the intervening years we have managed to swell the size of that population to include economically advantaged individuals with access to more up-to-date methods to act on their broken and lethal impulses. A growing number of individual and mass killings should be a wake-up call to every thinking person that some part of our system is broken and dangerously in need of repair.

In 1965, Congress excluded most payments to state psychiatric hospitals and other "institutions for the treatment of mental disease" (IMDs) from Medicaid because the Federal Government did not intend to take over what historically had been a state responsibility, and because it intended to implement a system of community mental health centers that would replace the state psychiatric hospital systems. (LINK)

I have no way to validate my suspicions, but my instinct is that this initiative, well-intended though it has been, was quietly promoted by both pharmaceutical and insurance interests, which after defence contractors and agri-business are two of the most powerful (read "well funded") of all special interests.

Patrick Moynihan saw it coming. His was one of the brightest minds that ever served in the Senate, but unfortunately he seems to have no successor to fill his shoes.

The source of the above quote is from a site advocating for more effective treatment for people who cannot pay. I have no problem with that, but I would argue that a greater challenge that has been added to the effective management of deranged people comes from a well-intended but dangerous over-sensitivity to issues of "privacy" and "due process." It's easy to discover plenty of arguments for keeping dangerous people medicated, thanks to the tawdry history of what we once called "insane asylums." Those sites are easy to spot because they are plastered over, very much like the evening news, with advertisements for drugs.

My time is limited this morning, and my thoughts are still in a state of confusion. But the more I think about it, the more I believe that we are missing something. When medical records are not available to their parents and others in loco parentis because of "privacy issues" there is something wrong. When individuals whose behavior indicates they may be a danger to themselves or others are identified, it is better to err on the side of safety than to yield to the fear of litigation.

Do some homework.
Search for "deinstitutionaliztion" and see what comes up.
Join me in learning what works and what fails.
Take a look at HIPAA. Learn about that monster and ask yourself whether the protection of medical information is as important to the community as the dangers that it might engender.
And as you read and learn, ask yourself these questions:
If I were in the insurance business, how might I feel about the costs involved with covering this problem?
If I were selling prescription drugs, would this kind of thing help me to sell more drugs at a higher price or fewer drugs at more competetive (i.e. lower) prices?

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