Longreads

Deinstitutionalization moved thousands of mentally ill people out of hospitals and into the prison system. States are cutting mental-health funding. A look at America's mental health care crisis:

"'Homelessmentallyilldeinstitutionalized was one noun in the media at the time,' says SAMHSA's Roth, who is the source of the oft-cited data point that a third of America's homeless people are seriously mentally ill (helping to rebut the misconception then that they all were). In 1984, Dr. John A. Talbott, then president of the American Psychiatric Association, apologized for the association's role in the disaster. 'The psychiatrists involved in the policymaking at that time certainly oversold community treatment,' he said, 'and our credibility today is probably damaged because of it.'

"'Think of it as haircuts,' says Roth, who watched deinstitutionalization unfold in her 37 years as chief of evaluation and research at the Ohio Department of Mental Health. 'In the age of the great gothic castle on the hill, mentally ill patients had everything taken care of. Health care, sleeping, eating, etc. When they got out, they were supposed to have everything. They got Medicare and Medicaid, but [policymakers] didn't think about food. And haircuts. Clothes. How to find a place to live.' How to do laundry; how to grocery shop. How to ensure people who need meds take them. What to do with people who had too many behavioral problems to avoid being evicted six times in a row."

A Medicare experiment is facing possible shutdown, despite its proven effectiveness. The secret? It's nurses making frequent house calls to those with chronic diseases:

"But Health Quality Partners, with its emphasis on continuous nurse-to-patient contact, did work. Of the 15 programs, four improved patient outcomes without increasing costs. Only HQP improved patient outcomes while cutting costs. So Medicare extended it again and again — now it’s the only program still running under the demo. But Medicare has notified Coburn that it intends to end HQP’s funding in June.

"Medicare’s official explanation is carefully bureaucratic. 'The authority that CMS had to conduct this specific demonstration, which predated the health care law, did not allow us to make the program permanent and limited our ability to expand it further,' says Emma Sandoe, a spokeswoman for the Centers on Medicare and Medicaid Services. 'As we design new models and demonstrations, we are integrating lessons from this experience into those designs.'"

An investigation into the complicated and costly world of medical billing in the U.S.:

"Out of work for a year, Janice S. had no insurance. Among the hospital’s charges were three 'TROPONIN I' tests for $199.50 each. According to a National Institutes of Health website, a troponin test “measures the levels of certain proteins in the blood” whose release from the heart is a strong indicator of a heart attack. Some labs like to have the test done at intervals, so the fact that Janice S. got three of them is not necessarily an issue. The price is the problem. Stamford Hospital spokesman Scott Orstad told me that the $199.50 figure for the troponin test was taken from what he called the hospital’s chargemaster. The chargemaster, I learned, is every hospital’s internal price list. Decades ago it was a document the size of a phone book; now it’s a massive computer file, thousands of items long, maintained by every hospital.

"Stamford Hospital’s chargemaster assigns prices to everything, including Janice S.’s blood tests. It would seem to be an important document. However, I quickly found that although every hospital has a chargemaster, officials treat it as if it were an eccentric uncle living in the attic. Whenever I asked, they deflected all conversation away from it. They even argued that it is irrelevant. I soon found that they have good reason to hope that outsiders pay no attention to the chargemaster or the process that produces it. For there seems to be no process, no rationale, behind the core document that is the basis for hundreds of billions of dollars in health care bills."

The man who killed Osama bin Laden is now out of the Navy, without health care, pension or protection for himself and his family:

"Since Abbottabad, he has trained his children to hide in their bathtub at the first sign of a problem as the safest, most fortified place in their house. His wife is familiar enough with the shotgun on their armoire to use it. She knows to sit on the bed, the weapon's butt braced against the wall, and precisely what angle to shoot out through the bedroom door, if necessary. A knife is also on the dresser should she need a backup.

"Then there is the 'bolt' bag of clothes, food, and other provisions for the family meant to last them two weeks in hiding.

"'Personally,' his wife told me recently, 'I feel more threatened by a potential retaliatory terror attack on our community than I did eight years ago,' when her husband joined ST6."

Meet the families who have moved from America to West Bank settlements:

"In 2010, 269 Jews moved from America to West Bank settlements, many of which are marketed as 'bedroom communities' to families and white-collar professionals in the US. The migration is called 'making aliyah,' which translates roughly from the Hebrew as 'movin’ on up.' Never mind that it’s a violation of the Geneva Conventions for Israel, as an occupying power, to install civilians in the West Bank, one-fifth of which, according to the Oslo Accords, falls under the jurisdiction of the Palestinian Authority.

"To encourage Jews to illegally settle there, the Israeli government subsidizes home purchases and offers reduced rates for leasing land, in addition to the perks all new Israeli citizens get such as free health care, upward of a 90 percent reduction in property taxes, tuition waivers for earning advanced degrees, and a payment of about $14,000 spending money for a family of five. The first installment is paid on arrival at Tel Aviv’s Ben Gurion airport—in cash."

A call for feminists to not forget their labor roots:

"While we debate the travails of some of the world’s most privileged women, most women are up against the wall. According to the Sargent Shriver National Center on Poverty Law, women make up just under half of the national workforce, but about 60 percent of the minimum-wage workforce and 73 percent of tipped workers. In the New York area, a full 95 percent of domestic workers are female. Female-dominated sectors such as retail sales, food service, and home health care are some of the fastest-growing fields in the new economy, and even in those fields, women earn less; women in the restaurant industry earn 83 cents to a man’s dollar.

"This is where most women spend their time, not atop the Googleplex. This is where feminists should be spending their time, too."

A patent for a simple medical device has made its inventors, its marketers, and a university rich—which is why everyone wants a piece of it:

"For Wake Forest University, which licensed the VAC patents to KCI, the device has meant about $500 million in royalties. Based almost entirely on the VAC deal, the university was ranked fifth by the Association of University Technology Managers in its most recent survey of licensing income, trailing only Columbia, New York University, Northwestern, and the University of California system. In recent years the KCI payments have propped up the bottom line of the university's medical center, and the VAC money has paid for research, recruiting, and construction that probably wouldn't have happened otherwise.

"As you might imagine, all that success gave KCI and Wake Forest a powerful incentive to build a fence, to protect the patents at all cost. And it gave everybody else an equally powerful incentive to find a way through the fence.

"This is the story of what happens when there are billions of dollars wrapped up in a prosaic piece of technology that at its core is closer to your kid's science-fair entry than the Human Genome Project, one that despite all the commercial success and some 4 million or so patients still has its share of doubters in the medical community. It's a story about luck and timing and the squeezing of the health care dollar. It is about betrayal and wrangling over patents. And mostly it is about invention, the tenuous and uncertain act of breathing life into an idea that may or may not have been yours all along."

A group of young doctors from the Clinical Excellence Research Center at the Stanford School of Medicine are looking for new models to make health care better and more affordable:

"Patel was second up in the presentation, a little nervous and barely tall enough to be seen behind the podium. She stated the problem in her target area: Cancer is the second-leading cause of death in the United States, with costs estimated to be $173 billion by 2020. These rising costs are unsustainable.

"And what do many poor-prognosis cancer patients get for all the money spent? 'Horrible treatment,' she said, citing a statistic that silenced the room: Seventy-three percent of terminal cancer patients never have an end-of-life discussion with their oncologists. 'Many patients are rushed off to chemotherapy without understanding the big picture. And when predictable treatment side effects happen at night and on weekends, patients who are unable to reach their oncologist end up in misery in emergency rooms and hospitals. Later in their illness, many die painfully in intensive-care facilities that bankrupt their families emotionally – and sometimes financially.'

"During her presentation, Patel’s eyes became dark pools that threatened to overflow. A few people in the audience wept silently, perhaps remembering loved ones who had similarly suffered.

"'Overall, these added services improve the quality of life of patients, giving them what they need and want without delay,' she added after describing her model. 'And best of all, we lower health insurance costs … simply by doing the right thing.'"

How the 42-year-old Wisconsin representative (and now Mitt Romney VP pick) took a leading role in the Republican Party's budget battle with President Obama:

"Three days later, the White House started a livelier debate with Ryan. In a press briefing, Peter Orszag, the budget director at the time, dismantled Ryan’s plan, point by point. Ryan’s proposal would turn Medicare 'into a voucher program, so that individuals are on their own in the health-care market,' he said. Over time, the program wouldn’t keep pace with rising medical costs, so seniors would have to pay thousands of dollars more a year for health care. The Roadmap would revive Bush’s plan to privatize Social Security and 'provide large tax benefits to upper-income households . . . while shifting the burden onto middle- and lower-income households. It is a dramatically different approach in which much more risk is loaded onto individuals.' Ryan, who had always had a good relationship with Orszag, later described the briefing as the moment when 'the budget director took that olive branch and hit me in the face with it.'

"But the confrontation enhanced Ryan’s credibility among conservatives. He became the face of the opposition, someone who could attack the President’s policies with facts and figures. Indeed, at the retreat, Obama had mischaracterized Ryan’s Medicare plan, and Ryan politely corrected him. The two men sparred again the next month, at a summit at Blair House, over the President’s health-care plan. The details of Ryan’s proposals and his critiques of Obama’s mattered less than the fact that he was taking on the President."