Prisons, Mental Health Policy and Incarceration Rates

At Lawyers, Guns and Money, we're reminded of this prison's extremely high incarceration rates and the resulting costs to states. The Detroit Free Press explains the cost to Michigan:

Before the nation hits two in 100 behind bars, which seems inevitable, it's time for a national debate on corrections and criminal justice policies that will lead to a more rational, humane and cost-effective system. The nation has gotten far too little for its enormous investment in locking people up. Violent crime rates are higher than they were more than three decades ago, when tough-on-crime policies, including mandatory sentencing laws, created a prison-building boom.

States can no longer afford to divert so many resources from education, health care and other pressing needs. Michigan, for example, with one of the nation's highest incarceration rates, spends $2 billion a year on corrections, or 20% of its general fund. It is one of four states spending more on corrections than higher education. In today's economy, spending more on prisons than college is a recipe for failure.

If you've been reading this weblog for a long time, you have a sense of my position on this - "... before we get "tough" on them by throwing away tens of thousands of taxpayer dollars on their repeated stints behind bars, perhaps we should take a long and hard look at what we are doing and, for those cases where it isn't working, what we can and should do differently." Our nation's legislators irresponsibly toss billions of dollars at prisons without any sense of whether incarceration works, or whether there are more effective or more cost-effective alternatives.

A while back, an interesting graph was put up at the Volokh Conspiracy, illustrating our nation's prison and mental institution incarceration rates. Short of saying "correlation is causation", the illustration makes it hard to miss a connection between the closing of state-funded mental hospitals and the exploding incarceration rates in jails and prisons. I'm not arguing for reopening state mental hospitals and mass "mental health" incarceration as an alternative to prisons. But I am saying this: We had a lousy mental health policy that was followed by a paradigm shift (community-based mental health, self-determination) that was not adequately funded and supported, followed by misguided budget-slashing in states like Michigan which closed many of the state's remaining mental health facilities, followed by a willful blind eye to the fact that jails and prisons were filling up with people who were mentally ill, and otherwise untreated or given a lot less community-based support than they need.

I'll renew my call for evidence-based public policy.

Opposing Universal Health Care On The Basis That It's A Service?

Over at MedRants, Dr. Centor has posted an essay suggesting that universal health care is wrong because it involves the provision of services as opposed to, for example, guaranteeing a freedom.

The essay first asserts that recognizing a right to services would be a "positive right", with a finite supply of service providers unable to fulfill an unlimited demand. I don't dispute that, but it is no different from any other service we expect from government. For example we expect the government to provide police and fire services, but nobody realistically expects those services to be without limit. The notion that we would not impose any limits whatsoever on health care is a red herring - no nation, no matter how broad their national health plan, provides unlimited health services, and I have yet to see a serious health care proposal which calls for unlimited services.

The essay next asserts that to recognize a right to health care services would depart from traditional notions of morality.

We acknowledge an obligation to help the needy, but that obligation is unconditional only in certain circumstances: with family-members, people we have previously agreed to help, or certain kinds of immediate need that appear in our presence—such as the child drowning in a puddle as we’re passing by. If we had more general obligations to aid strangers that were absolutely unconditional—if we HAD to give our money to the street-person asking for it once we confirmed that he needed it to gain something he had a right to—our own negative rights to choose what to do with what is ours would be nullified; a conclusion most of us could not accept.

This argument is again a red herring, given that we already extend significant benefits to the poor through a wide range of government programs. It also confuses legal duty with moral duty. While we may not have a legal duty to assist anybody with whom we do not have a status relationship, we traditionally have recognized broader moral duties. Consider, for example, the long tradition of provision for the poor as practiced through religious institutions, whether through food aid, shelter, counseling, legal assistance, or (yes) charitable hospitals. My grandparents took considerable pride in the fact that their church would provide food, clothing and shelter to any passing vagrant who made the request, without any further regard for whether that person was "deserving" of the charity.

At its heart, this argument is that the poor are undeserving of medical care - that if you can't get good health insurance coverage from work, and can't afford to pay out of pocket, you should suffer through whatever health consequence comes your way. That's not good public policy given the possibility of contagion, but also because of the fact that if you create a context in which the poor cannot get treatment for disabling, debilatating, degenerative, or disfiguring conditions, you all-but-guarantee that they and their families will remain impoverished.

The author does recognize a "a conditional and limited duty to help" the needy, but in such a way that service providers are unaffected. That is, his greatest fear seems to be that any national health plan "not to endanger production and nullify the negative rights of producers" - which I read as a somewhat nuanced way of saying, "If you do this, make sure my salary doesn't go down." And at its heart, that seems to be author's fear - that a national health care plan will result in lowered physician compensation as one of the mechanisms of broadening supply while containing cost. Our "private" system already does this, as do Medicare and Medicaid - most medical care is provided within the context of that false market, with the insurer negotiating or dictating rates paid for particular services, so apparently the concern is one of degree.

I note that this doctor is silent in regard to the common practice of billing uninsured patients significantly more for the same service than would be paid by an insurance company. Can anybody point me to a similar physician's lament of national health care, which also acknowledges the unfairness of a system in whcih the poor, uninsured and underinsured often pay more for health care than wealthy, insured people "pay" (through their insurance)?

The Government We Deserve?

On NPR yesterday I heard part of an interview with the new Senate Minority Leader, Mitch McConnell, which included an exchange to the effect of,

Q. Would you support ending subsidies for big oil?

A. I oppose any tax increase.

That exchange could inspire a lot of discussions... The compliance of the media, and why politicians aren't called on their deceptive and misleading answers, or their nonanswers to simple questions. Whether lying with a straight face is a talent politicians learn on the job, or if politics is a world of sociopathy. Or (perhaps) less cynically, why anybody would call for the Democratic Party to try to reduce the Bush deficit when his party cannot be honest about our situation or what we would have to do to correct it.

David Ignatius writes,

The Democrats have to decide whether on economics, they want to be (forgive the sexist term) the "Daddy Party" of fiscal responsibility. Unless politicians find the courage to trim entitlement spending to what the country can afford, the projections are scary.

By Mitch McConnell's reasoning, isn't Ignatius calling for the balancing of the budget on the basis of a tax increase on the poor?

McConnell offers more words of wisdom....

Earlier on the Senate floor, McConnell said he'd fight attempts by Democrats to end the Bush administration's warrantless domestic-spying program and any attempts to roll back Medicare prescription-drug benefits.

Because, darn it all, the President needs to be above the law. And it's always the Democrats who want to scale back programs like Medicare.

Is McConnell actually saying that he will oppose any effort to bring common sense into the Medicare prescription benefit? That he will oppose efforts to eliminate the "donut hole" in prescription coverage, to allow Medicare to compete directly with private insurers to offer the benefit, or to permit Medicare to negotiate discounts with pharmaceutical companies? That he will misrepresent efforts to improve the benefit while lessening its costs as a "roll back"? Or is he simply delusional?

This represents the Republican concept of "a restoration of civility and common purpose"?

I would rather have my daughter die of cancer than....

I hear what they're saying, but I'm still puzzled by what, exactly, opponents of HPV vaccination are thinking....

Is This Waste?

Let's say you are insured through one health insurance company, but for one reason or another (a change of employer; a decision to change plans during "open enrollment", expiration of COBRA eligibility, etc.) switch to another plan. You have commenced treatment for a medical condition with the first plan, which requires that they invest in medical equipment. You buy the equipment, or "rent to buy" over a relatively short period of months, with the insurance company paying the significant majority of its cost.

The new insurer requires that you switch doctors, which means that you also need a new evaluation, perhaps new testing, and at the end of the day a prescription for new medical equipment which is slightly (but significantly) different from that you (and your former insurance company) recently bought.

Or perhaps you're under treatment for a condition which, although generously covered under your former plan, is covered more stingily under your new plan. That may not be immediately apparent - that is, the coverage may look the same on paper, but each insurer interprets the terms of the policy and bounds of medical necessity differently. So instead of getting continuous coverage you spend hours on the phone with the new insurance company, and bounce between doctors who are included in the plan trying to get authorization for treatments they don't normally cover, for doctors who don't participate in the plan but who offer a treatment unavailable from doctors "in the network", or both.

Meanwhile, behind the scenes, there's a mad scramble to try to get medical records transmitted from the old doctors to the new, with an alarming frequency of medical records being somehow lost in transmission. A doctor may apologetically tell you that although he is not certain that the records were transmitted to his clinic, they may have been misplaced, and thus you need to again try to secure copies.

Does all of this count toward the 20% of U.S. health care dollars lost to waste?

Restaurant Innovation and the Health Code

It sounds like New York has very stringent requirements for restaurant hygiene, and, as one would expect, that can interfere with innovative cooking techniques and the quality of food produced. A chef comments,

While the inspector is mandated to have a single-minded focus on the Department of Health's taste-killing rules, a good chef is driven by many concerns — the health and well-being of her customer paramount among them — and it is in her hands that I would rather entrust my eating experiences.

While I agree with the chef that "serious chefs are compulsively clean by nature" and Not one of us would serve a customer something that we ourselves would not relish to eat, and also with his observation that sanitarians would regulate a range of delicacies and specialty foods out of existence, the health code is not just about what happens inside the restaurant. No matter how carefully food is selected, there is a chance that it will have been contaminated prior to its introduction to the restaurant kitchen.

The temperature requirements imposed across this nation ensure that most bacteria are killed in the cooking process, and that hot food is maintained at a high enough temperature that it does not become a breeding ground for bacteria. It also prevents certain innovative food preparation techniques, and limits the ability of restaurants to preserve hot food in a palatable form. Under a heat lamp or on a warming tray, even the best of food is quickly reduced to cafeteria fare.

That said, I think that professional chefs should be able to experiment with innovations such as sous vide - but they should first propose a set of health regulations to govern the innovation and have them passed by the health department. The consumer should also be made aware of any additional danger posed by the food preparation technique. Warnings about raw and undercooked food haven't scared customers away from the sushi bar. After all, the greatest danger is not so much that the best chefs in the best restaurants, working with the highest quality and most carefully selected ingredients, will put their patrons at undue risk. The greatest danger is that the same cooking techniques will be applied by chefs and restaurants which don't act with such care. There's a reason that health regulations are aimed at the lowest common denominator.

Fixing Health Care... the Wal-Mart Way?

Wal-Mart, perhaps most famous in relation to the subject for offering little health coverage to its employees and their families, is apparently offering to apply its genius to fixing the nation's health care system.

Wal-Mart Stores Inc., at the center of debate over corporate responsibility for health care, said on Tuesday that it wants to use its cost-cutting expertise to help make the U.S. health care system more efficient.

* * *

Wal-Mart said health care is a national problem and required a joint effort from government, corporations and workers to find ways to make the system more efficient.

* * *

The retailer said the key is to figure out what is driving up health care costs -- just as Wal-Mart does with its vaunted supply chain network -- and then wring inefficiencies out of the system.

Wal-Mart tracks expenses so closely that cardboard boxes at its distribution centers bear a message reminding employees that each box costs the company 75 cents.

The retailer offered up its information technology expertise to help develop a system for keeping electronic medical records as another means of reducing costs.

Wal-Mart also said that lessons could be learned from health clinics it is opening in dozens of stores around the country, many of which serve uninsured patients who would otherwise go to the emergency room -- a major drain on health care resources.

Funny, I don't recall Wal-Mart suggesting that it needed help from the nation's workers, the government, or other coprorations to figure out how to run its own operations. Proposing electronic medical records, also, is far from an innovation.

Perhaps this is just a fancy press release for its planned in-store medical clinics (which presumably will also be the primary provider of medical care for its workers and their families under the next generation of Wal-Mart's employee health insurance plans).