As the House of Representatives debates a bill to repeal
Obamacare and start over, the Left will invoke the tragedy in
Tucson as a reason to keep the law in place. Liberal bloggers and
some patient groups are claiming that states are already cutting
mental health budgets to balance budgets, Arizona among them. They
will claim that overturning Obamacare, which offers mental health
benefits through an expansion of Medicaid, would only deepen the
danger. The New Republic’s Jonathan Cohn
provides the familiar liberal narrative: “We may never know
whether a better mental health care system would have averted this
massacre. But we can be sure that it would avert some future
ones.”
While we can’t be sure a “better” mental healthcare system
could stop an obsessed schizophrenic from committing violence, we
can be sure that Obamacare will shred mental health treatment in
America.
Cohn notes that we don’t warehouse the mentally ill in
asylums anymore. Instead, we warehouse them in jails. That’s
accurate enough to be misleading. Budgets for mental health
everywhere soared and state mental hospital spending fell when
Medicaid, in 1970, said it would pay for mental health care but not
institutionalized treatment for people between the ages of 21 and
65. State psychiatric hospitals that provided long-term care closed
and were replaced by psychiatric units of general hospitals with
fewer beds. Or by prisons.
The emphasis on community-based or residential care has
been well-intentioned and in the vast majority of cases has been
fairly effective thanks to the introduction of medications that
permit individuals to live free of psychotic episodes. In this
respect, the pharmacological revolution made it possible for states
to use Medicaid to rapidly expand treatment to millions of
Americans. At the same time, because Medicaid was and is such an
important source of money for states, it continues to skew mental
health investment away from what’s best for patients.
For example, while delivering care to people at home or at
residential centers costs a fraction of doing so in a psychiatric
hospital or prison, Medicaid won’t pay to move people
from hospitals to outpatient care and in some cases will only pay a
smaller share of the less institutionalized setting.
The savings can’t be counted. Further, if states can generate
more Medicaid dollars elsewhere — and reduce mental health
spending in the process — they will. Federal Medicaid dollars
cover about 40 percent of mental health programs and still have all
the strings attached. So states that can get the federal government
to cover a bigger share of other programs’ costs — nursing homes,
for instance, or dialysis — it will increase spending
there.
Finally, as Harvard economist
Richard Frank observed,
states have shifted much of their mental health funding into
Medicaid, leaving funding for other programs bare. So now when
states are faced with budget shortfalls it is mental health that is
receiving the brunt of the cuts.
Obamacare will speed the hollowing out of mental health
coverage thanks to its increased dependence on shoving most
Americans into Medicaid. Obamacare proponents claimed they were
protecting the mentally ill — most of whom they would cram into
Medicaid — by barring states from limiting eligibility from what
they now have.
Once again, mental health services are likely to be
chopped. If states “save” money, the law requires it give a chunk
of it to the federal government. Moreover, states can’t raise money
by imposing or raising copays on Medicaid beneficiaries.
That means two things. First, services will be cut
indirectly by cutting what doctors are paid. Fewer doctors means
the state will pay for less care.
Second, under Obamacare the cheapest drugs for Medicaid
will get the most business. That means doctors have to start with
the cheapest medication, not the medication that is right for a
patient. Several studies conducted over the last decade by
Stephen Soumerai show that such restrictions actually make
mental illness worse and expose patients to dangerous side effects.
As a result, less than half of all people in mental health programs under Medicaid stick to
their treatment plan. And since
medications are the key to better outcomes, the rationing
undermines care across the board.
As Cohn
observed, it is these people who “could benefit from therapy,
drugs, and community supports — frequently living totally normal,
productive lives — instead end up without treatment and sometimes
without homes. Inevitably some of these people end up committing
crimes, overloading a criminal justice system ill-equipped to
handle them.”
And in its infinite wisdom the Left seeks, through
Obamacare, to force states to stick to failed strategies and
refuses to give them the flexibility to do better by its citizens.
Instead, it insists upon expanding a system that debases and
imprisons, a system that is a shameful symbol of liberal
intentions.
