The Status of Mental Health and Health Insurance in Nebraska
My name is Robert C. Bowman, M.D. I am a family physician and an advocate for underserved and rural communities. I practice half time at the University of Nebraska Medical Center Family Practice Clinic. I have been there for over 9 years. I have had a chance to see the ebb and flow of situations in some of my patients for many years, particularly the impacts of the tar pit we call poverty and how we actually tend to prevent people from escape from this situation. Education and health care are the ways out of poverty. This page deals with how state policies and practices actually return people to poverty, even when they desire to leave. These are true stories from people that I know personally. The names have been changed:
Oh, I forgot to add some perspective, unfortunately Nebraska is dead last in governmental spending on health care.
http://www.unmc.edu/nebraska/publications/files/vol2num5.pdf
This means that Nebraska has attempted to put off health care costs into the future, unfortunately the future has become the present.
Failure of Workers Compensation: Studies demonstrate that workers that are injured on the job and that do not return to work within six months are unlikely to return, foverever after a burden on the insurance program. Unfortunately workers comp fails and this pushes the costs into Medicaid and other state and county programs. It is hard to understand why the state does not beef up workers compensation and speed it up to avoid this important source of increasing state health care costs. Helen and Larry – When I first met Helen and Larry, they were doing pretty well. They had two cars and were about to put money down on a house. Helen was working at a local grocery store. A big strapping country girl, she prided herself on being able to life and move as much as any man. Many of the employees took advantage of this and asked her to help, which she was only happy to do. She suffered a back injury at work and had a prolonged recovery period. There was no contest whether the injury was related to work or not. Her condition did not improve despite medications and therapy. Workers comp initially sent evaluators to the office who attempted to coordinate efforts, but their promises for therapy and arrangements were not kept. She settled into a deep depression. Her boss changed from supportive to quiet and then stopped communicating with her. The workers comp told the boss about her situation, a questionable practice. The insurance company arranged consultation with a consultant of their choice. They even biased the consultant with edited information. After a questionable report Meanwhile Helen and Larry struggled. Eventually she recovered enough to resume some work, but was out 2 years of wages. Instead of workers comp paying the bill. Medicaid had to pay. Medicaid also had to pay for the delivery of her child, which would have been paid by private insurance. When her workers compensation case came to trial, she was advised by her lawyer to take the $3000 offered the day before trial. Desperate for money and deeply dependent on her parents, she did so. End result, minus Helen and Larry deep in debt and back where they were 5 years ago, the state out over $20,000 in Medicaid charges that should have been provided by workers compensation and health insurance. Helen and Larry’s family lost out on several thousand that they can ill afford.
Premature Loss of Medicaid and Health Insurance Often states try to convince citizens that there are people that make a lot of money and still get benefits for poor people. However some of these people have illnesses that are the real reason for their problems. Cuts in such programs will turn these people from devoted workers into dependent martyrs, at least until states realize that the must have universal health care coverage. Marlene first came to Nebraska from Arizona. It is likely that she was escaping legal or criminal issues. She entered a half way house in Omaha and worked her way out of drugs and depression, with the help of housing, Medicaid, and state support. Her son, age 6 at the time, had no respect for her and was out of control. His asthma was severe, requiring many ER and clinic visits and a few hospitalizations. As she improved and their living conditions improved, his asthma improved. Having seen what he was like before, it brought tears to my eyes to see him respect his mother again at a clinic visit. Depression and drugs returned again, and then another recovery. This time the recovery was prolonged by the onset of breast cancer. Again with the help of Medicaid and state assistance, she was able to do well. She returned to the work force and found a series of employers who were fairly flexible, so that she could meet her needs for treatment and her son’s need for assistance with asthma and school problems. For some reason, the state tired of supporting her. She was not able to get health insurance due to pre-existing conditions. She could not even consider paying $500 or more for continued health insurance. Other patients laid off have quoted $800 a month figures to continue coverage. Few even attempt to do this. For Marlene this was not a consideration as she had no income, rising bills, eviction notices, and utility cutoffs. One previous time the utilities were cut off, she was immobilized with depression, and the state took her children for a time, adding to her stress and depression. Recently the family disappeared from my care. I thought that they had gone to another state as per my last conversation, but in the past week I have heard from them again. Now they depend on the Salvation Army. Basically she is back where she was 5 years ago, except that her son is more bitter and in worse health. The status of her breast cancer is unknown, but her prognosis without continued care is bad. With little support, it is actually worse. If she does deteriorate and die, she has no real family to care for her 2 kids. Now that she is off Medicaid, our clinic is still caring for her, but mostly by phone and by medication samples. Her risk of suicide is very high except that her mother checked out that way and she does not want to do that to her kids. Her son has significant risks from asthma, particularly since they have little control over his housing environment.
Health related Poverty Can Strike High Level Managers Bills continue even when patients are trying to recover. Disability income is low and patients can lose their job and benefits. Stephanie – When I first saw Stephanie she was a mess. She had problems with her esophagus and skin and arthritis. She had severe allergies and sinus problems. Eventually she was diagnosed with multiple chemical sensitivity syndrome. Having a good educational background and some experience in a grocery store, she was able to move up to an accounting and then assistant manager position. This allowed her body to heal up but increased her stress levels. She eventually moved back to the accounting position. A string of illnesses and surgeries on her knees and back depleted her sick leave, but did not constitute enough of a problem give her disability income. Her boss, fearful of her falling at work, asked her to stay home a little longer. Her savings depleted, she turned to family assistance but there is little there. She stood in line for 3 hours to get $10 in food stamps. Her boss called around and found $35 dollars worth of food at a church. She gets regular calls from creditors and notices from utility and eviction notices. Next week she will have to risk a return to work on crutches. She depends on samples at our clinic for 5 major medicines, but suffers when she runs short. If she can avoid a fall and continue to repair, she will be able to restore her finances and her health. One slip and she is in total poverty and homelessness, despite her education, training, and experience. She is actually worse off than she was 5 years ago.
People With Multiple Injuries Can Never Resolve the Problem Health insurance comes from workers comp, auto insurance, health insurance, disability, and other sources. It is not uncommon for patients to have overlapping injuries and claims. In a universal system, the focus is on taking care of the patient and problem. In our system of confusion and conflicts, it is impossible to resolve responsibility. This usually means no payments for months or years and little care, with poverty and dependence on the state. Ellen has been a caregiver for others most of her life. She cared for her husband in his final days before cancer took him. Ellen has been hit from behind on multiple occasions. She has had injuries involving 2 auto insurance companies and workers compensation. She has constant pain in her foot, knee, hip, and back. It is nearly impossible to tell where one injury starts and another leaves off. She is allergic to just about every medicine. Her husband died a few years back. She cared for an elderly lady for some time, until this lady became too ill to care for at home. Now Ellen scrambles to keep her home in repair and meet monthly bills. She needs care in other areas but cannot afford it. There is little hope of resolving her insurance claims. Fortunately two insurance companies were involved so they seem content to wait and pay some doctor’s visits and not much else. More extensive health care is out of her reach. Perhaps the insurance companies are waiting for her to die so that their responsibility will end. Her situation has not improved in 5 years and she may no longer be able to work.
Mental Illness Impacts Everyone Mental health coverage is the key not only to the current generation, but generations before and after. Multiple generations of depressed, alcoholic, or addicted families can be healed. More commonly lack of coverage pushes these costs (health, legal, education, and more) onto future generations. Mollie has been close to death from depression and drugs on many occasions. She managed to recover and seeks care regularly. Painfully her teen daughters have chosen a similar path. She has continued to get them care, even across many miles in state institutions. Since she cannot afford private placements, she is dependent on the state for mental health. Since Nebraska is near last in the nation in mental health resources, especially for drug and alcohol problems, she has few options. Recently her child returned home from a facility. Initially she was doing well, but recently has come under the influence of an older teen and it appears that she is falling into old habits. In her last visit, it seems that she is attempting to get pregnant so that she can a) get independence from her mom and b) stop taking her psych medicines. In this instance Medicaid and state support are a weapon she is using so that she does not have to be accountable to her mom or the state. Mollie struggles against recurrent depression herself. Her situation is worse now than 5 years ago. Better health and mental health care would help her and her daughters. Better mental health would have likely prevented significant legal and prison costs for her children. Mental Health Gets No Respect
Even the Legal Profession Is Powerless Insurance companies are powerful, well organized, and practice a winning game plan of delays, investments on the proceeds, and preying on the desperation of patients months to years later. Even patients with access to legal help cannot get proper care. The next patient I will call Erin because she reminds me of Erin Brockovich from the movie of the same name with Julia Roberts. Like Erin she also works for several lawyers and is trying to improve her family situation. She suffered a rollover auto injury and has constant neck and arm pain. Like Erin, she was not able to get help from the auto insurance people. They refuse to pay for her medicines or treatments. This is sad considering that she works for lawyers. Like Erin, she has kids to care for and a job and it is difficult for her to get care or pay for medications. She also depends on samples when we have them. She is much worse off in the past 3 years and could well be unemployed soon if her condition worsens. Delays will cloud her claims and make it more difficult for her to make her case.
Some People Would Be Dead If We Allowed Insurance Companies to Decide Care. John is a physician and a state employee in a state with Blue Cross insurance. His daughter Elie has attachment disorder and depression. She has attempted suicide and been admitted to inpatient care twice for care. John and his wife stayed home more and more. They provided supervision in the mornings with daily tutors, they took Elie to psychiatrists monthly and therapists two visits a week. They also divided the night shift to supervise their daughter to attempt to keep her safe during her troubles. Despite these efforts, their daughter used drugs to the point of unconsciousness on at least two occasions. When she again risked her life with drugs, suicide, and running away, John and his wife sought care for her at a mental facility. The initial week of care had preapproval. During this time Elie did not improve. Her behavior continued to be a problem even in maximal supervision. She wrote notes intending suicide and expressed such thoughts even as late at two months into hospitalization. She had drug flashbacks with death thoughts and severe anxiety for over a year. In the mean time much of her care was paid by an out of state Blue Cross affiliate. They were obviously happy with her care. Blue Cross Nebraska, however, was not. They ambushed the hospital with a one day notice to provide records and a summary of her past 6 weeks of care. They began proceedings to get refunds from the facility. They stages a review and an appeal. Elie's parents appeared at the appeal and provided the above information and more. Blue Cross insisted that Elie needed minimal supervision, despite multiple hospitalizations, suicide attempts, cutting on herself, failures of medications, flashbacks, and the documentation of multiple doctors and therapists. John appealed to state officials, who refused to help. Some were former Blue Cross employees and might have been hoping to get a future job at Blue Cross. This was not the first time for John to have blues regarding the Blues. Blue Cross delayed processing mental health claims for psychiatric care for over a year from the previous residential treatments, delaying payment of thousands of dollars. Blue Cross lost a $6000 claim for intensive outpatient care for Elie taken in June of 2001. Only a later communication with the facility noted that Blue Cross had attempted to process the claim at all. Despite a combined income of well over $100000, the take home pay for John and his wife is about $1500 a month, not enough to cover regular bills. In another state with better mental health coverage, John and his family would be doing much better financially. In Nebraska he is refinancing his home and running up incredible credit card balances. Elie is so far doing well in long term residential treatment in Utah. John has little hope of recovering any of this $4000 a month. Mental health has cost him one year of the past 3 years salary and will cost him over $70,000 in 12 months time. Payments will come to mental health providers, but they will be delayed. John is much worse off over the past 5 years in Nebraska. John wonders how mental health facilities can continue to function with such delays and excess paperwork and erroneous decision-making.
My observations over years of continuity with these situations:
1. There is little help for those in need of mental health.
2. The impact involves a great variety of people across a wide socioeconomic strata.
3. Those who are nearly off state aid, become deeply dependent again, instead of continued help with health coverage and making it off dependency.
4. There are unchecked abuses by insurance companies
5. We are mortgaging our future in costs, increased costs to patients, trauma and poor health for their kids, increased costs for schools, increased likelihood that their kids will not graduate and will cycle into poverty, increased costs to the state as those in poor health are dumped onto state budgets
6. Medicaid policies can encourage future dependency, particularly regarding coverage of teens and their new pregnancies.
7. Safety net clinics will not be able to continue to function, as they will soon face increased need and decreased reimbursement.
8. Cuts in Medicaid only mean that payment will decrease, not health needs. Crisis care will likely cost more than regular care also.
9. The stories make a strong case for single payer or universal health care
P.S. added 12/2002 Now that I have learned even more about mental health, drugs, meth, and community resources, we are far worse than I ever thought.
Robert C. Bowman, M.D., Co-Chairman
Email: rcbowman@atsu.edu
http://www.ruralmedicaleducation.org
Underserved - Overview and Models
The following attachment was handed out to staffers and state senators at today's meetings. Also to Dick Raymond and Denny Behrens.
There was very little discussed in these areas, mental especially. There was almost no discussion from the patient perspective. This was not a surprise.
There were good leads during the meeting and discussion toward generalized reform, examining accreditation in nursing and perhaps other areas, and working at the local level more.
I truly believe that the lack of support and inefficiency of putting the support together well virtually assures that even people attempting to rise out of poverty with good faith efforts, will get kicked back into the pit so quickly and carelessly that it hardly seems worth the effort to their friends, families, neighbors, and kids.
By the way, the last patient example, the one with John as the example, John is Bob Bowman and the child involved is my child Tracy. Because of her problems, I can write and understand a bit more than I would otherwise.
Isn't it time for a 5 year plan for health care in Nebraska. If it is even half as successful as the 5 year rural health plans you guys put together and implemented....
Further evidence of widening gap
Main web site www.ruralmedicaleducation.org