This commentary is by Vicki Ward of Barnard, who holds a master’s degree in family nursing and a post-master’s certificate in psychiatric and mental health nursing. Most of her 45-year career has been in the community, including a decade providing primary care integrating mental health and substance abuse recovery services, co-created with her patients.
In the mid-1970s in New England, when I started work in health care, I worked as a mental health worker in an unlocked unit in a small general hospital. We served our communities.
Some of the neighboring towns did not offer this inpatient treatment but most, if not all, of the neighboring towns had a continuum of outpatient services. These proud community mental health agencies also treated folks with alcohol problems. They were community-supported through true nonprofit status, not the current “nonprofits” that service the top of the food chain with gobs of cash and lies to us about their tax-free non-health-care use of their money. They were not allowed to buy land/facilities and community development with their nonprofit health care tax dollars that were saved. We had not just laws but some integrity then in this arena.
Inpatient mental health care was paid for in the small community hospital system by the profits gained from surgical medicine and more profitable inpatient health care payment reimbursement systems. We also provided care to everybody, because our free health care system was obligated to provide care to all, as so much of the health care system was paid by taxpayers’ money.
We, taxpayers, built many of the hospital buildings, fund both basic research and medical/health care research, pay for medical residents training through Medicare, pay for health care training by reimbursing school loans at high-need regions for health providers, and support academic institutions that train.
We had highly skilled paraprofessionals who evaluated patients in the emergency room, consulted their families after much on-the-job training and always had telephone consultation with our psychiatrist, who would also talk with the family. We had a full continuum of services, inpatient, locked and unlocked, three-day-hold patients to give time for them to improve and choose care, children’s services, and three-day detox, five-day and 10-day detox, and 30-45 day treatment programs, both private pay and public. We had state hospitals. Police were only occasionally involved with transport. Police are not mental health paraprofessionals, nor are they trained as such, never have been.
In the 1990s, under the guise of “managed care” — by which we have managed to get everyone to pay for health care but only half able to use it — the doctors brought in the business folk, MBAs, to become more efficient and gain more power and money for themselves. Immediately, highly educated nurses with bachelor’s and master’s degrees were sidelined. Their priorities for all the people were tossed. As the MBAs got their hands on the books, they tossed aside everything that did not make money, including mental health care. The other thing the MBAs always do is load up with administrators to dominate the pyramid, so their priorities win. They pay to gain the power in the system.
As with so many U.S. failures where money hijacks all other values, the politicians agreed to defund the mental health care continuum. The insurance companies could not have been more thrilled, as they always hated paying out this benefit for “human health.”
You could not say with firm certainty that the patient had improved — unlike the appendectomy that yielded a patient free of pain after the procedure, this could not be so readily seen in mental health and substance abuse care. These human health problems did not go away; they were marginalized.
Private prisons were funded as locked units, public health dollars deconstructed for profits. Homelessness became a frequently used word in the U.S., as health care, U.S. safety nets, solo apartment housing to high-end condos, with everyone an “entrepreneur” became popular.
Primary care — the most humane, but underfunded and less respected aspect of U.S. health care — was given more and more unfunded mandates. Throw some Prozac at those mental health patients, an anti-psychotic if you are feeling adventurous and see them back in a month.
So, Vermonters, you must understand, your doctors, hospital administrators, insurers and politicians give you this version of mental health care — “tough it out,” homelessness or prison. Few remnants of the prior system survive.
I have yet to mention the consequences of 25 years of U.S. mental health destruction. Who wants to work in a field so underpaid, poorly regarded, with few work options? What happened to all those skilled folk from 1995? They want you to be content with a paraprofessional world, good as part of a continuum of care, but do you really want your hip replacement by a paraprofessional?
This is yet another U.S. infrastructure defunded for the top of the food chain to buy yet another house, another yacht, a high-end car, and fill their system with non-health-care providers we pay for but over half cannot use.
We had an entire continuum of mental health services in the U.S., some states with stronger systems than others. Vermont’s Brattleboro Retreat was not only known for outstanding care practices but had top-shelf psych educational programs for professionals. We had to have continuing education units to update our knowledge. I am certain this aspect of the Retreat paid for free care for some Vermonters, who do not even know about this. New Hampshire had some great 30-day sobriety programs.
If we want anything to be different, we must rearrange our priorities. Sadly, many aspects of even Medicare are paid for because some senator in the 1960s knew of someone who had the condition. Patronage. Politics. Human greed. A very poor mix for human health care.
