Missouri’s ‘Supposedly’ Safety Net [1]
Safety net. We hear the term every day. When used in health care, it often is meant to remind us that if we are “really” ill, the state has a safety net that will catch us. You can’t fall with a safety net! In fact, the American Heritage Dictionary provides a definition that makes us feel even better: “A guarantee as of …physical…security….” It is doubtful that we really have a guarantee with physical health, but where do we stand with mental health? In my conversations with Missourians across the state I see more and more holes in the net.
- Joan is 23 and lives in a very rural area. She quit school at a young age because she was so anxious. [How could her rural school have not noticed and what could they have done?] After being sexually assaulted when she was 8, she began drinking at age 9, saying, “It helped to make me numb.” Now at 23 she doesn’t drink any more, but needs medication and therapy. She doesn’t receive Medicaid which essentially means she receives no treatment. [Missouri had a way to help people in these situations, but it was cut to save money.] She often has no transportation, even if she did have Medicaid.
- Mike was 30. Diagnosed with bipolar disorder 10 years earlier, he did his best to keep a job in Kansas City. But with no car, Mike had to find a job that could be reached on his bicycle. He was hospitalized in October and again in November. With the November discharge, he was given a return appointment for February. He committed suicide in December.
- John is 40 and suffers from bipolar disorder and mild mental retardation. He worked until an injury ended any heavy physical work. He’s paranoid when he’s in groups of people, and most of his days are spent just sitting because he’s afraid to go out. He doesn’t see his therapist anymore, and says, “I guess they thought I had got as good as I could and they dropped me.”
- Sarah is 40 and lives in a rural area. She suffers from PTSD and is covered by Medicaid. But in her area she has only one mental health provider. She was assigned a therapist that perhaps wasn’t a good fit. She has no other choices and receives no treatment.
The stories are true except for the names. The situations are current, not something dredged up from the distant past. A legislator once said to me, in regard to Missourians with mental illness, “Tim, aren’t we just talking about poor people?” While this is a provocative statement on several fronts, they are not “just poor people.” Many Missourians, who happen to be poor now, were not poor before they became ill. And it helps to remember “Everybody was somebody’s baby.”
In Boone County we have half as many mental health beds as we did 20 years ago. But our county population has increased by 40%. The State of Missouri no longer provides acute care. When a hospital closes, particularly a mental health treatment center, we are tempted to think, “this is somebody else’s problem,’ since it was private care.
As we look at the cases above we are, I hope, struck by several questions:
- How could those in a school not notice that a child like Joan was so anxious that she would quit school? Her teachers did notice, but the school was ill-equipped to help her; a referral for treatment would have been 50 miles away; and who would have paid for treatment? Treatment today is fragmented; her closest psychiatric hospital is almost 100 miles away.
- Two hospitalizations in two months are a sign that the illness is serious, and new medications mean that patients like Mike can’t wait 3 months to be monitored. While the hospital was over-loaded, they undoubtedly knew that an earlier appointment was needed.
- John may not have actually been dropped by his mental health provider, but his communication skills demand a little more aggressive approach. Perhaps the agency was not unhappy that they had one less patient.
- In cases like Sarah’s, is there a rule that the first therapist must be a good fit and that the patient either makes it work or stays ill? I don’t think any therapist would say that’s a good rule, but maybe we must admit that these are the current limitations in treatment.
There are never any easy answers. But the fiction that there is a functional safety net does not help to solve the problem.
Tim Harlan
Tim Harlan is the president of the National Alliance on Mental Illness Missouri and also of NAMI Columbia. In his private law practice he focuses on Social Security disability, particularly disability associated with mental illness. Tim was a member of the Missouri House of Representatives from 1994 to 2002. His focus as a legislator was health and mental health legislation.
[1] Missouri’s ‘Supposedly’ Safety Net–A paraphrase and apologies to the estate of David Foster Wallace, “A Supposedly Fun Thing I’ll Never Do Again.”
The opinions and views expressed in this blog and/or comments are those of the author(s) and do not reflect any position of the Center or the University.
