A CARE Act for the Mentally Ill

This is going to be a long posting, so either fasten your seat belt or click onwards.

I worked for a long time as a lawyer on behalf of those with HIV.  When I first started, it was mainly comprised of doing deathbed wills for people with AIDS.  I brought some early discrimination suits in 1984-5.  It was hard work because really, the system that was supposed to be there to support healthcare for those facing AIDS, failed those stricken due to the stigma associated with the illness.  As a result, a shadow set of services evolved – one that had to replace the traditional with a grassroots, patient-oriented system. 

Eventually, when the federal government caught up to what was happening (and it was a long wait), Congress passed the Ryan White CARE Act to provide block funding to states so that they could cope with the burgeoning epidemic.  Since then, the CARE Act has provided funds for comprehensive services, but just as important, subsidized access to medical intervention, particularly the pharmaceutical miracles that turned around the mortality of the epidemic in the late 1990s.  Today it is the backbone of support for people with HIV.  Its impact has been immeasurable. 

In part, the CARE Act is based on the premise that it is in the public health interest to subsidize access to life saving medications that preserve the immune system, rather than pay for the costly care that people will incur by losing their immune system.  This finally leads me to my point.  Why not a system that helps preserve the mental health of our citizens rather than let it degrade?  Is this in the public interest any less than the HIV epidemic?  I don’t think so. 

There is an epidemic of mental illness in the country.  If you have ever visited New York or San Francisco or any other large metropolitan area, you have probably stepped over it.  On the corner of my office at 17th and L Street, there is a man who each day, sits on the corner asking for money while looking at new home catalogs, in between bouts of shadow boxing.  He has been there for years.  It is evident when watching him that drugs, therapy, or a combination of the two, could probably move him from that corner and to something more productive than looking at pictures of a home he will never have.

But not only is the system not set up to help these people, it is set up so that it exacerbates their condition, rather than resolve it.  And the cost, both human and in dollars, is huge. 

Jails have become the largest mental health "facilities" in the nation.  The Los Angeles County jail system is the nation’s largest.  That is because its inmates do not have access to care or to pharmaceutical therapy that they need.  The cost is profound.

As mentioned in an earlier posting, for the most part, when a person with a severe mental illness is arrested and put into jail, they lose their access to Medicaid.  When they lose that access, the lose their meds.  When they lose their meds, they are unable to support themselves in housing or life and they are more apt to commit a crime.  This might be robbery, but it might be talking to themselves in public or some benign act or an aggressive act.  In short, the lack of access to their meds sets off a chain of events that means that the former inmate victimizes others and victimizes themselves.  Many, if not most, jail systems do not have case workers that get those discharged from jails linked up to their benefits upon discharge.  So they get stuck in a cycle of arrest.

Many others don’t lose their access to meds or to a psychiatrist because they never had it at all. 

A CARE system could have a tremendous impact on this cycle.  If the federal government would generate block grants to the states to ensure a safety net for the mentally ill, in the way that they have for people with HIV, it would have a dramatic impact on the cycle of recidivism, on the costs associated with jailing the mentally ill, on the quality of life of those afflicted and on crime statistics.  Case workers could be put into jails to reconnect the mentally ill to their benefits – access to psychiatric care could be bolstered – systems to incentivize psychiatric training could be put into place.  In short, a better system could be the result.   An investment upfront would forestall a large payment made thereafter. 

As a taxpayer, I would rather my dollars go toward this, than toward many things such as bridges to nowhere or rebuilding train tracks in the path of Hurricane Katrina that have just been rebuilt, also using federal tax dollars.  The investment made in either of these projects could fund an ample pilot study to bear out the theory of this investment.  The cost is minimal compared to the cost of many tax subsidies given industries that don’t need a tax benefit. 

Pharmaceutical companies would do well to join with mental health advocates and others to make this happen.  The constituencies who would support it are many – from crime victims to advocates for the mentally ill; from pharmaceutical companies to the law enforcement agencies, all should be in favor. 

I know I am.