“Will Single Payer and Mental Health Advocates Ever Join Forces?” II – revised
A Summary in Two Parts:
An Appeal to Solidarity
Out from Under the Carceral State
Jack Carney, DSW, Coordinator
North Country Access to Health Care Committee
November 29, 2021
#PassNYHealth — #buildamassmovement
I — An Appeal to Solidarity
Preface: The question posed above is more complicated than one might suppose and requires an equally nuanced answer. Mental Health and single-payer advocates have high ambitions, to effect fundamental changes in the US healthcare and mental health systems. We need one another to accomplish them. A confounding factor is that the mental health system and its medical overseer, psychiatry, have become integral parts of both the US Healthcare system and the enormous U.S. carceral system, the latter charged at present with supervising the lives of 6.6 million Americans.
Most single-payer and healthcare advocates have little awareness of these complex relationships because an interesting phenomenon occurs when mental health and healthcare intersect — healthcare, disappears from view and healthcare practitioners reflexively question whether the problem being presented is delusional or real. Munchausen’s syndrome, that old medical school chestnut, meant to signify a factitious or self-invented physical disorder or problem, enters the examining room, no matter how briefly, and medical care suffers, short-shrifted or neglected. A barrier has been raised, one not easily breached, putting the person seeking treatment and the mental health peers and advocates helping her/him in the position of “outsider”, both familiar and unwelcome.
The paper’s objective is to spell out the barrier, actually barriers, in detail and propose alternatives or bridges to surmount them, however speculative. My intended audience – healthcare and mental health practitioners and peer advocates. I believe I’m in a fortuitous position to attempt this, thanks to my forty-year long career in mental health, which includes twenty-plus years developing and directing an Intensive Case Management program in New York City.
For those of you who may not be familiar with the term, “single-payer” healthcare in the U.S. is so called because the government, whether national or state, becomes the sole payer to treatment providers for the costs of all medical services, including dental, optical, pharmaceutical and mental health, incurred by their subscribers. It’s a role now played by the Center for Medicare and Medicaid Services (CMS) for persons 65 and older who are recipients of Medicare and for those who are recipients of Social Security Disability Benefits. When and if single-payer is enacted, commercial or private for-profit health insurance companies, the primary healthcare payers for their subscribers for the past fifty years, will no longer play that role; which explains, in large part, the fierce opposition to single payer’s enactment. Billions of dollars are at stake.
At present, the national single-payer healthcare program being proposed, with the Federal Government as payer, has been titled Medicare for All (M4A): identifying it as a part of Medicare and signifying that all residents of the US will be eligible for this program. Several states are also considering their own single-payer programs: in New York State, the NY Health Act (NYHA), with the State government’s Health Department as payer and all NYS residents automatically subscribed once the NYHA is passed by the State legislature.
I – Introduction: Two or so months ago, prompted by the need to recruit more folks to our struggle to pass and enact the New York Health Act, I began to take a look at our current cadre of activists. In a paper I recently wrote, “The Cork in the Bottle: the Road to Single-Payer Goes Through New York (www.paddlingupstream.org/northcountryforum-recentposts, Sept. 2021), I noted that among those assembled in our periodic leadership meetings, only one person, and that only recently, had identified himself as a psychiatric survivor. I wasn’t clear why this was the case – fear of stigma; little awareness or understanding of single-payer health care; outright indifference; so I decided to contact some of the folks, mental health advocates, I’ve known for years and ask.
Their collective response can be summarized as “Diagnosis, Medication, Hospitalization,” a three-word characterization of their personal experience with psychiatry and the U.S. healthcare system. To me, these words signify the three-headed hydra that has come to dominate both: Big Insurance, Big Pharma, Big Medicine. Which essentially means that neither the advocates nor the folks they represent trust the healthcare system. For starters, they find that all mental health treatment requires the assignment to them by psychiatrists and other mental health professionals of diagnoses that have no scientific bases yet fragment their identities and reduce them from persons to pejorative labels. Further, these diagnoses or labels complicate the access of those that have them to needed medical treatment.
Which should lead us to ask, what is “mental health” in actual clinical practice. It is crucial that single-payer advocates have some knowledge of this. Seth Farber, Ph.D., in his paper “Institutional Mental Health and Social Control: The Ravages of Epistemological Hubris”, offers a definition …
“There is a widespread misconception in society that Institutional Mental Health [a term intended to cover all “mental Health professionals] provides valuable services to individuals in need of health and generally attempts to foster personal change or ‘growth.’ I argue in this paper that the praxis of Institutional Mental Health is based on a model that is not oriented primarily toward generating change, but toward maintaining social control. Thus, this model is problematic on ethical as well as epistemological grounds: it understimates the individual’s capacity for change and it consequently undermines this very capacity” (The Journal of Mind and Behavior, Vol. 11, #34, 1990).
To which the advocates would surely add, and I would agree, that this model is fundamentally coercive, holding over the individuals caught up in it the threat of forced hospitalization or criminal justice incarceration should they fail to comply with the treatment orders issued them. It’s important to always keep in mind that incarceration, which includes removal to jails, prisons, mental hospitals and immigrant internment camps, even nursing homes, of all persons considered “other”, i.e., found troublesome because of their caste or ethnic membership or their gender or religious identity, is an integral feature of US society. An era of mass incarceration was launched by Nixon’s War on Drugs in 1971; exacerbated by the Rockefeller Drug Laws enacted in 1973 which called for the harshest penalties in US legal history; Reagan’s War on Drugs, embodied in his Crime Bill of 1984, which dramatically increased Federal penalties for drug possession and sale and established the corrupt-from-the-outset Drug Enforcement Agency (DEA) ; and culminated in Clinton’s Crime Bill ten years later, setting off a Federal prison construction boom to house all these drug offenders.
The modern American carceral state had been established with a vast societal presence. At present, 6.6 million Americans, the great majority poor, preponderantly men and women of color, are currently under carceral system/criminal justice supervision, 2.2 million of whom actually incarcerated: 750K in jail; 1.4M in prison, over 300K of whom estimated to be ”mentally ill.” In addition, 1.4 million live in nursing homes, removed from family and friends; 60K reside in State mental hospitals, the residue of deinstitutionalization; as many as 500K persons are held during the course of a year in immigrant detention facilities; 120K American residents are estimated to live on the streets. (All data, from various sources on Google, for 2019-20.) In sum, removal of socially undesirable persons from society, deprived of their civil rights, has become an American commonplace.
The advocates also know that the neuroleptic medications prescribed so cavalierly to persons deemed seriously mentally ill to control their presumed psychoses will, if prescribed long enough, cause serious damage to their hearts and livers, a condition known as metabolic syndrome that will eventually kill them. The classic study completed in October, 2006, by the National Association of State Mental Health Program Directors, reviewed the case histories of thousands of Medicaid-insured individuals treated long-term with neuroleptic medications in Boston mental health facilities. The findings revealed serious cardiac ailments coupled with diabetes II, i.e., metabolic syndrome, in the great majority of those whose charts were studied, and a loss of life expectancy averaging 25 years (“Morbidity and Mortality in People with Serious Mental Illness,” (NASMHPD) Medical Directors Council, Alexandria, Va., 2006). Thirteen years later, a European replication, albeit with a smaller cohort of individuals with similar characteristics, revealed nearly identical findings (“Dying Too Soon: Excess Mortality in Severe Mental Illness,” Front Psychiatry, Vol. 10:855, 2019).
What, then, explains the advocates’ reluctance to involve themselves in the single payer struggle? It’s evident to me that their involvement, their wealth of firsthand experience, which matches and more so that of most other single payer advocates, will increase our chances not only of establishing single payer healthcare in NY State and throughout the country but of changing corrupted healthcare & carceral systems that fragment and refuse to acknowledge those admitted to them as unitary persons.
II – Out From Under The Carceral State
Reform & Its Barriers — Pushback & Counter-Pushback: A long-awaited pushback from reform advocates has begun, driven by the same forces that launched deinstitutionalization – concerns about the civil rights of those incarcerated and the increasing consequent costs. Many states have responded, legalizing marijuana for recreational use; expunging the criminal records of those incarcerated for simple possession of illegal drugs and charged with low-level felonies; granting early release for these same individuals; closing prisons and reducing the number of psychiatric inpatient beds.
In New York State, correctional facilities’ (c.f.’s), have declined in population from a high of 70K+ inmates in the 1990’s to approximately 40K at present. Since 2009, 23 CF’s have been closed, with at least 6 three slated for closing in 2022 The populations of NYS psychiatric centers, the State’s long-term psych facilities, have shown similar recent declines – less than 3,000 patients are currently filling 5,600 beds.
On another front, State-certified acute in-patient beds have been reduced from 6000+ to 5400 over the past 20 years. Private non-profit hospital providers have begun to challenge the cuts. The NYSNA (NYS Nurses Association), in its article “Key Findings on NYS’s Mental Health Emergency” & white paper “A Crisis in In-patient Psychiatric Services in NYC Hospitals,” August, 2020, contends that these cuts are calamitous, given the rise of State and NY City populations, and emanate from Gov. Cuomo’s push to cut Medicaid spending. (For those interested, NYSNA’s White Paper spells out the Governor’s political deal-making with Trump’s CMS and the resulting conflicts between him and the providers in great detail.)
I can understand the nurses’ position, fighting for their patients’ well-being; but, from the perspective of those of us who oppose the carceral state and want to see it taken apart, NYSNA’s position supports the status quo and would be a sure point of contention for the advocates this paper is addressing. We think there are better, non-coercive, alternatives – Soteria House, replicated successfully throughout North America and Europe, comes to mind as a model In short, a potential deal-breaker and a good illustration of the barriers that could keep us apart, yet one that also contains its own resolution: use single-payer healthcare to fund Soteria respite houses not more psychiatric beds, all within the US Healthcare system and not the Carceral system. To be continued …
In 2004 and 2009, Governors Pataki and Patterson, respectively, repealed the worst elements of the Rockefeller laws, dramatically eliminating mandatory sentences for drug offences and reducing the length of drug sentences overall. Many other states have followed suit. Other reforms approved by the NYS Legislature: in 2020, bail reform, to reduce the number of persons incarcerated in jails because they can’t meet bail requirements (Center for Court Innovation, “Bail Reform in New York: Legislative Provisions and Implications for NY City,” April, 2019); and passage of the HALT law – Humane Alternatives to Long-Term Solitary Confinement – in 2021, ending the use of long-term solitary confinement, euphemistically termed Special Housing Units (SHUs), for those inmates who are “hard to manage”, another corrections euphemism applied to those in the general prison population who become depressed or appear “out of control”.
In short order, a counter-pushback has begun and largely succeeded in altering, even blocking, these particular measures, spearheaded by the State’s upstate conservative district attorneys, the State’s and City’s Corrections Officers unions and the NY Police Department’s rank and file police officers’ union, most of whose members are staunchly conservative. Unsurprisingly, they all reflexively tootled the old canard that these prison and bail reforms largely benefit Black and Brown New Yorkers.
It’s important to know that mental health peers and professionals had pursued similar objectives less than ten years ago, focused not on police reform but on the adoption by the US Senate of a UN Human Rights initiative, “Convention on the Rights of Persons with Disabilities’ (CRPD). Their principal objective was to prevent the involuntary hospitalizations of persons in severe emotional distress. In fact, in 2013, as consequence of testimony by American peer advocates led by lawyer and psychiatric survivor, Tina Minkowitz, before the UN Commission on Human Rights in Geneva in March of that year, the UN’s Special Rapporteur on Torture declared psychiatric hospitalizations against a person’s will acts of torture. This occurred after the US Senate refused to ratify the Convention, which would have given it the force of law in the US, despite two concerted attempts by then Secretary of State John Kerry to secure its ratification.
I assume advocates will continue focused on this human and civil rights violation, possibly the most detested intrusion into the lives of psychiatric survivors. For those interested in this issue, Ms. Minkowitz published several articles in MIA around this time that detailed what was at stake and described her and her colleagues’ experiences in preparing for and then testifying before the UN’s Human Rights Commission. I should also note that the HALT Law is similarly grounded in UN Human Rights Conventions, specifically the Mandela Rules, which spell out the human rights of persons who are incarcerated regardless of the crimes for which they have been convicted. In 2015, those rules were updated to include solitary confinement, stipulating that involuntary seclusion lasting beyond 22 uninterrupted hours constitutes psychological torture. The HALT Law conforms to those standards.
Solidarity Forever — Summary & Conclusions: First, I’ve concluded that the ruling class and its surrogates are unified in opposition to us. We need one another.
Most pertinent to this paper, mental health, particularly the “institutional mental health” that Dr. Farber identified at the outset of this paper, is more a part of the US Carceral State than it is of the US Healthcare system. Just to remind the reader, institutional mental health follows all the rules set down by psychiatry, the government and insurance payers about the centrality of diagnosis and medication and the consequences of treatment defiance. Accordingly, mental health advocates want no part of either system, both of which endorse these rules, and are opposed to any initiative that would tie them more tightly into what they regard as the sources of their oppression.
Interestingly, Will Hall, widely respected survivor advocate, recently urged his brother and sister advocates to follow the lead of Black Lives Matter, recognizing that Black Americans know more about white Americans – and the consequences of white supremacy and white privilege – than anyone else; further, that they have more experience and more audacity in successfully opposing American white supremacists than any other Americans; and, lastly, that they have developed the paradigm of opposition to oppression that all other American outsider groups seeking to secure their civil and human rights have followed (Hall, W., “Why Mental Organizations Should Endorse the Movement for Black Lives,” https://medium.com@willhall, Sept.19, 2021).
He anticipates pretty much what I say in “The Cork in The Bottle”:
“The power of the pharma and medical industry lobbies is too great: only with comprehensive political change can we ever hope to make mental health reform happen… the Movement for Black lives is a leading part in a deeper challenge … that can make real social change possible … for all of us … We will never get real mental health change without real social change …” (W. Hall, ibid.)
I’ve drawn the same conclusion. The first half of “… Cork …” is spent listing the array of powerful opponents that single-payer has attracted. The stakes are enormous, $3.8 trillion or almost one-quarter of the US annual gross domestic product (GDP), the amount spent on health care in 2019, and constantly rising. A mass movement is called for.
The Federal Government heads the list of those raising crucial obstacles to reform. Taxpayer monies – at present, close to $1.5T annually, have been used to enlist Big Insurance, Big Pharma and Big Medicine to implement programs designed to selectively ration healthcare while generating huge profits for themselves and concurrently undermining Medicare. As a consequence, US Healthcare has become a wholly capitalist enterprise, where relationships between health care providers and between them and their patients have become transactional rather than collaborative, a venue for winners and losers. Healthcare professionals, particularly nurses, have been leaving in increasingly large numbers; Covid is apparently the final straw, but nursing flight has been occurring for years (Gellasch, P., “The Driving Forces Behind Nurses Leaving the Profession,” Nurse Leader, 2015).
Wall Street, financial capital of mega-capitalist America, has sniffed out the privatization underway, the investment opportunities present in the healthcare system; has loosed its private equity and hedge funds, sharks in the water, and begun to gobble up and spit out vulnerable providers. Between 2006 and 2021, as per the American Investment Council, private equity firms have invested nearly $1 T in healthcare and now own 4% of US hospitals and 11% of nursing homes (“Private Equity is Buying Up US Healthcare …”, Blue Ridge Public Radio, September, 2021).
To make matters worse for ordinary Americans, the Federal Government, via the Center for Medicare and Medicaid Services (CMS), has given the green light to private for-profit insurance companies to develop Medicare Advantage programs. Presumably an identical Medicare facsimile, it has lower premiums than Medicare supplement programs, and offers more benefits than standard Medicare. Forty-two percent of all Medicare recipients have been persuaded to switch.
At present, CMS is preparing to drop the final privatization shoe, designed to impact all subscribers who have stayed with Medicare, realizing the pitfalls with MA plans that lay ahead for them as they aged. CMS has decided to develop hand-in-hand with for-profit insurance companies what it terms Direct Contracting Entities, DCE’s. Which will be assigned specific regions of the country to serve and will offer insurance coverage to all current Medicare subscribers as well as those who are Medicare-eligible and have refused enrollment in MA plans. The kicker here is that CMS is considering not offering these individuals a choice but simply assigning them to the DCE that serves the area where they live (Kemble and Sullivan, “The Latest Attempt to Privatize Medicare September 12, 2021,” One Payer States).
Should this come to pass, it will mark the end of Medicare as a publicly funded safety net program, will limit choice of providers and will adversely affect all persons who suffer from serious and long-term illnesses, many of whom will be psychiatric survivors or currently involved in mental health treatment. Most significantly for me as a proponent of single-payer health care and my single-payer colleagues, Medicare for All and its State replications like the NY Health Act will be kaput: with single payer’s titular model effectively erased, Medicare for All will be a misnomer, and a crucial social reform will reside only in our memories as a what-might-have-been.
Will Hall and his psych survivor colleagues and their peers also appear to know that they can’t win their freedom from the Carceral state that continues to entrap them – and all of us – by themselves; which is why he’s urged alliance with BLM. They know, as do many in the single payer movement and in other anti-fascist organizations in this country and around the world that the US is on the path to becoming a rogue country. As I wrote earlier, the US government, contrary to UN Human Rights conventions, continues to support the incarceration of emotionally distraught individuals in hospital-based detention facilities against their will; to submit emotionally distraught individuals to psychological torture via involuntary isolation in prison holding cells as a management strategy that benefits their custodians.
In October of this year, the Mandela Tribunal, the investigative arm of the Spirit of Mandela Coalition, an international organization whose mission is to investigate human rights abuses, convened in Harlem, in the same hall where Malcolm X was assassinated; and after hearing testimony from a wide range of individuals and organizations …
“unanimously found the United State guilty of the following five counts, which … fit well within the internationally accepted definition of genocide:
- Police violence and killings
- Mass incarcerations
- [Incarcerating without trial] Political Prisoners and Prisoners of War
- Environmental Racism
- Public Health Inequities”
(“Panel of International Jurists Render Verdict that US is Guilty of Genocide,” https://Spiritofmandela.org/panel-of-international-jurists-render-verdict-that-u-s-is-guilty-of-genocide.)
Taking Will Hall at his word, I invite him and all psych survivor advocates and peers, particularly my fellow members in Mind Freedom International, one of the oldest and largest peer advocacy organizations in the world, to join us in what promises to be an all-encompassing struggle. Bring along with you whoever else is willing.
To close with Baldwin …
“It has always been much easier . . . to give a name to the evil without than to locate the terror within. And yet, the terror within is far truer and far more powerful than any of our labels.” Nobody Knows My Name, 1961.
Having named our fear, we will not be afraid.
Jack Carney, November 24, 2021
(A comprehensive version of this article, replete with citations and historical references, will shortly be found by interested readers on my website, https://paddlingupstream.org/north-country-forum/)