Current-System Joe

Let’s call him Joe. Joe lives in a purple-ish state and works irregularly. Uncle Sam estimates he pulled in about $30,000 last year. It’s almost enough to get by. For the remainder, Joe is known to depend on the kindness of strangers. One stranger is President Obama, whose Affordable Care Act (ACA) subsidizes Joe’s health insurance. Instead of paying an arm and a leg, Joe just pays his nondominant arm. His purple state expanded Medicaid, and if he was a little less industrious and decided not to work, perhaps he’d qualify. But Joe was raised to believe in the dignity of work. So he takes jobs where he can find them, and he buys into a private health care plan from a for-profit health insurance company with the help of the federal government.

Let’s paint Joe’s person with some broad strokes and common features. Joe just turned thirty. He’s unmarried, and has developed some unhealthy habits increasingly typical of his demographic. He prefers an opiate, but will settle for a benzo, line of coke, pipe of grass, or pack of smokes. Joe is, and he’d be the first to admit it, an addict. We won’t reduce him to just that, though. The trouble started earlier. It’s important to bear in mind the time Joe watched his mother die from cancer when he was fifteen, the two weeks he spent in the hospital at twenty-one after he was stabbed at a party for laying the mack down on the wrong guy’s girlfriend, and his six friends who have overdosed and died. These things weigh on Joe. The opiate helps soothe the pain. The cocaine helps him get through a long shift of dishwashing. And when he’s in the spirit, the grass helps to kick the dope.

But Joe has some fight left in him yet. Having just celebrated his thirtieth birthday, Joe decides to try and take this life straight. He gets through an opiate withdrawal on his own and decides to stop using cannabis. Seven days in, as sober as can be, Joe starts experiencing what the medical system calls “mental health symptoms.” He becomes obsessively fixated on a former friend who he swears is after him due to some unpaid debts. Joe stops eating and sleeping. A textbook psychosis sets in: hallucinations, delusions, disorganized thinking. Finally one day, while contemplating taking his own life, reason rears its lovely head and Joe presents himself at an emergency room. He is admitted to a psychiatric unit due to his being a harm to himself.

The modern inpatient psychiatric stay has one goal: psychiatric stabilization. So the first stop of Joe’s tour will focus on relieving the psychotic symptoms, ignoring almost entirely the history of substance use and trauma so essential to understanding Joe’s present condition. The hospital staff will treat Joe’s psychosis with an antipsychotic drug and perhaps a benzodiazepine to calm the nerves. After a few days of this, Joe’s delusions diminish and his hallucinations vanish. His thinking is still a bit disorganized — nonlinear, Godard might say — but after another day or two of meds, food, and some half-decent sleep, Joe becomes more stabilized.

The hospital starts to consider discharging Joe. After all, psychiatric beds are a hot commodity these days. Not to mention the insurance company has been hounding the hospital about Joe’s condition under the guise of a “utilization review.” So the social worker asks Joe what he wants to do next. Joe, after dreaming last night of his mother with knives for arms, says he wants to go to rehab.

“Rehab?” the social worker says. “Don’t you think you should focus on your mental health symptoms?” There is a wall in the health care system separating “mental health” and “chemical dependency/addiction.” It’s as if the two cannot exist on the same planet, let alone within the same person. Professionals are trained to distinguish between the two and steer the person in one direction or the other. Happily the ACA opened the floodgates for addiction treatment, but if the insurance company or medical system suspects even an ounce of “mental health symptoms,” then you’ll need to get your depression in order before they can help you with the needle poking out of your arm.

The social worker responds that Joe’s urinalysis upon admittance showed only a positive result for cannabis. Joe explains his history of substance use, saying that he only stopped using the harder stuff a week or two before he was admitted. The social worker is inclined to believe him, but again urges Joe to focus on his supposedly separate “mental health symptoms” instead. “Why not discharge from the hospital back to your studio apartment,” the social worker suggests, “and come to the hospital for an outpatient group to learn coping skills two hours a day three times a week? We’ll deal with the addiction after.”

But Joe stands his ground. Unlike so many patients stuck in psychiatric limbo, he advocates for himself and fights for prioritizing his substance use in the order of operations of treatment.

For the social worker, the hospital’s outpatient program as Joe’s next move is an easy and logical linkage, both bureaucratically and mentally. The hospital social worker is beyond overworked, and like the rest of us has fallen into patterns designed to make his workday easier. But now his job becomes much more difficult. He must find a rehab for Joe. Were Joe in sunny California or Florida, this would be an easier task. But Joe’s overcast purple state is not a prime rehab destination. There are far fewer facilities, and plenty of people lined up to get into them.

After finally finding a rehab with an open bed that accepts Joe’s insurance, the social worker sends over Joe’s clinical records. This creates a problem because the records present a psychotic patient who during his first week at the hospital showed no signs of drug addiction. The facility says they are not really equipped to take people with “mental health symptoms,” so they will need to interview Joe and talk to the attending physician.

This takes a few days. Hospitals make snails look like racehorses. Eventually Joe aces his interview and the physician reports a total remission of Joe’s psychotic symptoms. He is medically cleared to go to rehab. But at the final hour the insurance company relays to the hospital that there is a lack of “medical necessity” for a residential rehabilitation program because Joe’s drug test is clean, aside from the cannabis, and he reports that he has not taken a drug in several weeks. Residential rehab is for people trying to get off of drugs, and the insurance company is happy to report that it appears Joe has already kicked his habit.

Since Joe can’t afford it without insurance, rehab is now out of the question. So Joe is discharged back to his studio apartment with a plan to go to an outpatient group about “coping skills” at the hospital two hours a day three times a week, and to supplement that with some twelve-step meetings of his own finding.

“What about my medications?” says Joe. The hospital has put Joe on an antipsychotic, a sleeping aid, and a blood pressure medication. They tell him that he has an appointment in thirty days with an outpatient psychiatrist at the hospital, but after that he needs to find someone in-network with his insurance. They give him a list of providers. He calls all of them. The earliest appointment is four months out.

“How about a therapist?” They look at Joe as if he were a child who just asked for a lollipop with a side of world peace. He’s going to need to call his insurance company for that — which he does and is provided a list of therapists, each with a waitlist longer than the next.

Joe is out of luck. He returns home, and while the meds have stabilized his psychosis, his depression is worse than ever. He lost a decent job during his stay. The hospital brought back memories of his mom dying, and he can’t stop thinking about it. He’d sent some strange texts during his psychosis, and now feels isolated from what few friends he has.

Finally he screws up the courage to reach out to someone. He calls an old buddy he knows is holding, and asks for the one thing he’s certain can take the pain away.

Single-Payer Joe

Now let us look at Joe’s journey from the single-payer perspective. This story will be a lot shorter, because the insurance piece will be taken care of by a national plan that Joe pays taxes into and automatically receives like everyone else. In this scenario, only insurance has been fixed. The US health care system still has plenty of problems caused by for-profit actors like greedy hospital management companies and the pharmaceutical industry that flooded Joe’s town with his drug of choice in the first place.

Joe presents himself at the hospital for psychiatric stabilization. His hospital stay likely goes in a similar way. The tendency is still to tackle and focus first on the most serious presenting problem — and in Joe’s case, that is psychosis and suicidality. However, once he is stabilized and Joe starts asking for rehab, the social worker is presented with a different scenario. Without the interference of a third party, he has a more functional working relationship with rehabs and other resources. His job is guided by medically informed, not insurance-informed, options for Joe’s discharge. What’s more, with sourcing from one single entity, the wall between mental health and chemical dependency has begun to break down.

Joe successfully transfers from the hospital to a rehab, and begins a thirty-day residential treatment program. There is a psychiatrist on staff who starts to consider the effects of Joe’s hospital medications in the context of a less-intensive addiction treatment. The psychiatrist and other staff are afforded time when not pressed by “utilization reviews.” Treatment becomes more thoughtful, less formulaic. As he begins to tell his story and his history of depression rises to the surface, Joe is weaned off the antipsychotic in favor of a low dose of antidepressant.

Joe’s thirty days of rehab are filled with individual and group therapy. Because the rehabs have access to a large funding source, these sessions are run by trained therapists and professionals, not untrained technicians receiving an unlivable wage, as is currently the trend. Throw in some twelve-step or other community support group meetings in the evenings, some exercise in the mornings, and a community of equals all working toward the same goal: recovery. Joe’s starting to feel better, like the fog is finally lifting.

When it comes time to leave rehab, this is where a single-payer source can really revolutionize mental health treatment. After all, many insurances cover hospital stays, and the ACA has improved inpatient addiction-treatment access, albeit inadequately. But the inability for an average guy like Joe to get meaningful outpatient psychotherapy is the original and bigger problem.

Joe was self-medicating his trauma and depression with drugs. If he could drop $150 or $200 a session to see a therapist, then he might have been able to find some peace around his issues without his addiction spiraling out of control. But Joe didn’t have that kind of money, and his options through his insurance amounted to nothing. (The reasons why therapists avoid insurance panels in favor of private pay are outside the scope of this essay, but suffice it to say that single-payer health care helps not only the patient, but the therapist too.) In a single-payer system, not only is it possible that far fewer people will need rehab at all, but when they do there would be an accessible trained professional waiting for them on the other side to help them sustain their recovery and address their emotional pain.

Joe leaves rehab and begins an intensive outpatient treatment program consisting of groups in the evenings, individual therapy weekly, and psychiatric appointments monthly. The latter two continue at length, but not ad nauseam, to work on addressing his underlying depression and trauma as Joe finds his footing. He enters his thirties full of dignity and hope.

The Way Forward

In the current system, health care is paid for by private companies that have a profit incentive to deny claims. This poses problems in all areas, but perhaps especially so in mental health care, where treatments are complex and outcomes are often less quantifiable. We want Joe to come to terms with the impact of his mother’s early death and other traumas on his ability to self-soothe without drugs. Talk therapy can absolutely help him heal, but it’s not always easy to prove the case to insurance companies.

If we were to smooth out the trajectory of treatment for someone like Joe, the chances of his recovery would increase exponentially. Single-payer health care is critical to accomplishing that. It would allow resources to be maximized, modernized, and localized. The effects would be profound at every juncture. The social worker at the hospital’s job becomes less stressful when he is not searching to match Joe with an insurance-appropriate resource. The rehab becomes more effective knowing that the aftercare Joe will receive will be sufficient and available. The ongoing therapy while Joe reintegrates into society becomes more available, less commodified, and more humanized. Joe’s psychiatric medications are viewed less as an insurance-approved “quick fix” than as supplemental to a more interconnected and holistic mode of treatment.

Medicare for All is the way forward for our country. The fight has fallen somewhat out of fashion on the US left in the wake of the Bernie Sanders presidential campaigns, especially as our attentions turn to the momentum of the labor struggle. But these are interconnected issues, as unions are hog-tied by insurance concerns and spend much or even most of their energy fighting for benefits that should already be guaranteed. And millions of people like Joe have little hope of being able to work a unionized job unless they can receive the treatment they need.

The COVID-19 pandemic laid bare the grave inhumanity at the heart of our health care system. Ironically it also dampened the momentum of the movement, which had just been at its all-time peak, to transform that system. The time has come for a revival. Millions like Joe are suffering, spiraling, and falling through the cracks. Too many of them are dying. We don’t have any more time to waste.