A broken system

If you are a regular reader of my journal, you know that I have been critical of the health care system in the United States, especially in regards to the costs of a for-profit system. It is a simple fact that citizens of the United States pay more money for health care and yet our health statistics are much worse than places where health care costs are significantly lower. Our system is unnecessarily expensive and there are far too many centers of profit in the system. Paying more and receiving less is a problem, but a more important issue is that there is a significant percentage of our population who are completely priced out of the market when it comes to health care. People simply cannot access health care because they cannot afford it.

I’ll try to stay off of my price bandwagon today, however. I think another problem with the US health care system is that we have accepted a system that makes a rigid distinction between physical health and mental health. When a person suffers from mental illness, care difficult or impossible to receive. If a physical injury is sustained, urgent clinics and hospital emergency rooms provide care. People know that a call to 911 will result in emergency transport and care.

While the relatively new 988 Suicide and Crisis Lifeline is a significant step forward, a call to that number does not result in emergency transportation or admission to a care facility. Behavioral health, mental health, and substance abuse crises often result in victims and family members being unable to access any care at all. There is a significant shortage of psychiatric physicians. A cold call to a psychiatrist’s office is unlikely to result in being able to obtain an appointment in a reasonable amount of time.

Law enforcement agencies are often called for assistance, especially with behavioral health issues, but are ill equipped to provide care.

The issues are complex and many. The shortage of mental health care providers is due in part to a general shortage of doctors in our country. US medical schools have abysmally low acceptance rates. Selective medical schools admit a very small percentage of application. At Stanford Medical School the acceptance rate is 1.4%. Even medical schools with much higher acceptance rates reject a huge number of well qualified applicants. The University of Tennessee, for example has an acceptance rate of 8.7%. All medical schools in the United States receive federal funding. It would be possible for the federal government to pressure medical schools to increase the number of qualified students they accept, but no such pressure has been applied. Low acceptance rates are due, in part, to an organized effort by the medical establishment to limit the supply of physicians in order to keep rates of compensation high. Psychiatry as a medical specialty has far too few practitioners. Many people have no way to gain access to a psychiatrist.

The issue that is most critical when it comes to health care, however, goes beyond a shortage of doctors. In our country we have separated mental health, behavioral health and addiction services from general medical practice. Instead of having a system where emergency care for all is delivered through general hospitals and trauma centers, mental health, behavioral health, and addiction care are delivered through specialty hospitals. And it isn’t just that we have separated the places of health care delivery. More significantly, physicians are not trained to give care. An individual or family experiencing a mental health crisis cannot receive primary care from a primary care physician because primary care physicians are not trained in diagnosing and treating mental illnesses. The same goes for behavioral health and addiction. By dividing the care system we also have divided the education of care providers.

I don’t know how many times I have responded to crises in families that I serve and discovered that basic care is simply not available. I know of families that were experiencing an acute crisis who were told that the nearest place for care was 360 miles away and that there is no emergency transportation available to obtain that care. Whereas a patient in need of critical care for a cardiac illness might be transported by life flight, a patient in need of critical care for mental illness would be rejected by emergency medical transportation services. Mental health crises are not seen in the same category as physical health crises.

The tragedy of this division of services is that mental health and physical health cannot be separated. Mental health affects physical health. Rates of physical diseases such as coronary disease, diabetes, and respiratory illnesses are significantly higher in those who suffer from mental illness. Our minds and bodies are not separated. A physician who is not trained in at least general diagnosis and basic treatment of mental health is not able to provide care.

People who die from mental illness are just as dead as those who die of a heart attack, but while we have embraced a national system of training people in Cardiopulmonary Resuscitation (CPR) first aid and every first responder is regularly trained in providing CPR, there is no similar support for providing Applied Suicide Intervention Skills Training (ASIST) for first responders or the general public. Research conducted in several different countries on different continents has proven ASIST to be highly effective. However, physicians and other hospital care providers generally are not trained in this basic life-saving skill. First responders do not have the basic training required.

The tragic result is that our broken health care system not only fails to provide care to those who lack insurance and other financial abilities, it also fails to provide care to those suffering from mental, behavioral, and addiction illnesses regardless of their ability to pay.

We need to re-think our health care system at every level. Changes in deeply entrenched centers of profit are difficult to obtain. Highly controlled access to medical education that routinely excludes well-qualified students demonstrates a broken system. And the failure to provide access to basic mental, behavioral and addiction illness services means that people suffer and die unnecessarily.

Much work remains in order for us to mend this broken system.

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