This one is for all you health policy wonks out there. It is also open to any aspiring politician, already entrenched elected leader, agency bureaucrat, party regular or reformer, do-gooder or just any concerned American citizen who wants to make a difference.
Lest we pretend or make this into a legislative or a governmental problem, I wish to personally invite all insurance executives, brokers and agents in the sound of my voice or the radius of the Internet to tell me how to solve this very real problem. But this isn't just an insurance question, either, so all you business owners, chief executive officers and heads of human relations departments chime in as well.
Here is the background: I have a teenage patient who intentionally cut herself to the point that she was taken to the emergency department of a local hospital to stop the bleeding. After being stitched up, she was transported by ambulance to an in-patient behavioral health unit for suicide prevention and nervous system stabilization. After more than a week she is now, for the next 10-12 months or longer, confined to a residential treatment facility.
The question for all you out there: Who will pay and how will they pay for this care?
Ah, yes, you all say it should be the family, its health insurance or maybe the state health insurance, Medicaid, because she could become a ward of the state from her acts. Well, it is not that easy. The parent is a single mom. The father is a deadbeat and a convicted child sex-offender. The woman has been unemployed for some months after losing her business and now is underemployed for her talents, smarts and education. She also has a second, younger child with a chromosomal defect requiring some ongoing medical interventions, although not much.
OK, obviously she will pay some, but every month her daughter is at risk of being kicked out of the residential facility if the thousands of dollars are not paid in advance. So then there is the family; the grandmother will loan her daughter some money. Great, we all say and return to our golf, "American Idol" reruns or our hard work and just cross ourselves praying that it won't happen to us and our children. Besides, it must have been something the mother did to push her child to such a desperate act.
Well, no, it is not that simple, either. As someone who has known this woman for some time and knowing her other children from a previous marriage, I would be hard pressed to side with you who vote in the column titled "It's your fault, Mom."
That leads us to ask about the U.S. system of employer-based health insurance ... Surely that will cover the costs. Isn't that why we all pay premiums? Isn't that what insurance is for? Of course, there would be parity between those health conditions that come from a germ or a cancer cell and those that come from some molecule or even genetic wiring problem in the brain? Wrong, again. This woman's plan, like so many around the country, discriminates between health problems originating in the brain and body below. The plan would probably pay bundles for a heart bypass surgery in someone who abused and neglected his body. I imagine it would also cover the medical costs for the bruises from a drunken brawl or if the girl were driving and texting and slammed into an oncoming truck. Not so for mental health; there is a lifetime cap that will barely cover some of the in-patient stay. That leaves the outpatient visits, ambulance, emergency care, meds costing hundreds of dollars a month the remaining residential treatment and who knows from there.So to my distinguished panel of experts and interested parties: What is the answer? Not in 20 more years, not in the next election cycle. Now. Right now. We have all contributed to the current health-care system in our own little or big way; now what do we do? Please tell me I need to know so I can tell this mother before she cuts her wrists.
Joseph Cramer, M.D., is a fellow of the American Academy of Pediatrics, practicing pediatrician for more than 25 years and an adjunct professor of pediatrics at the University of Utah. He can be reached at firstname.lastname@example.org.