December, 2007

Amidst the central topics of economic stability, its prongs of health and education spending, and our environmental challenges, many smaller but philosophically critical discussions will wind through the legislature this year.

Within health care, some of our biases are likely to be played out in a potentially intense debate over whether to expedite court orders to force persons with mental illnesses to be injected with controversial mind-altering drugs in the name of saving money on the state hospital “Futures” plan.

The debate will focus on the only Vermonters who can be locked up against their will without any court hearing for weeks, based upon a hypothetical risk of a harm to others (not a crime already committed) or to themselves.

If we did not have them on the public tab behind locked doors we would ask different questions than the ones that will surface for involuntary mental health care. Ironically, more than two thirds of the health care in Vermont is already on the public tab – actually, virtually all of it, since it comes out of either taxes or wages pooled together – but we look elsewhere than forced treatment compliance for cost and quality initiatives in other types of care.

How are some of the questions different?

* We have grown in the momentum for looking for alternatives to the most invasive health care treatments.

* We are moving to smarter care management through patient involvement in care and in decisions, recognizing that more collaboration and illness self-management is what brings greater consistency in treatment and thus better (and less expensive) outcomes.

* We have begun to learn that “overuse” – accessing unnecessary levels of intervention – is one of our cost drivers. Just “doing something” isn’t always best. Sometimes time heals.

* We have begun to recognize how much the pharmaceutical industry is driving medical decision-making, both through conscious marketing to us, and more subliminal impacts upon physicians. Those same companies provide substantial funding to national public advocacy groups as well as to political lobbyists.

* We are realizing that in the resulting demand for quick relief, we have exponentially expanded use of new and expensive drugs, many of them prescribed “off label,”and then have wrung our hands when our children look for “off label” drug relief or when “self-medication” leads to addiction.

How are we upending all of that in new proposals for treatment for those with serious mental illnesses?

Short term cost savings would be the primary driver.

Instead of spending the time to work towards mutual agreement on a treatment plan, many more Vermonters would be forcibly injected with risky drugs to get them out of a hospital faster. Some of those same drugs are now known for such side effects as diabetes, a chronic, debilitating and expensive illness – one of those facts that pharmaceutical companies knew and hid and for which they are now paying out billions in damages.

Instead of support for alternative healing strategies craved by many of these Vermonters, we would stress the temporary pharmaceutical quick fix – a response that accepts the sales pitch that drugs are the only and best course of treatment.

We are not focusing on the question, is this person capable of making medical decisions despite an illness? Or, how do we address any other situation of invasive medical treatment for a person who cannot make a decision fully on their own? What are the criteria for any of us in being allowed, or not being allowed, a medical decision that a physician disagrees with?

Are we prepared for the implications of the answers, or can we again just shunt this off as being somehow different if it involves psychiatric illness instead of other decision-making impairments such as unconsciousness, senility, stroke...or it involves visible public cost?

While we build new hospital wings for everything else – all on public dollars – we don’t want to have to spend capital money on modern alternative solutions to the decertified asylum in Waterbury.

After all, we do legitimately also have roads and schools and offices in urgent need of care. Perhaps those are just easier to understand how to address.

So we want to believe that if our community hospitals can just add a few more bolts to the doors and to forcibly inject medications into patients who don’t comply with a doctor’s treatment plan within a week, they will be able to “handle” such patients quickly and efficiently.

We are willing to build a new, cheaper non-hospital institution for those who don’t respond to medications, but we do not want to recognize that this component is primarily for our own self-interest, to allay our fears about the tiny number of those whose symptoms do include violence.

We don’t seem to be interested in understanding the need for providing both the kind of top-flight inpatient care that is needed for all highest-severity illness, and for the collaborative alternatives that we are trying to encourage among “willing” patients of every other kind.

Vermont is hailed as the most progressive state on many fronts, including in “parity” – the recognition that mental health is part of, not different from, the rest of our health.

Sadly for our country, even Vermont’s version of parity for insurance coverage still allows separate funnels of money to carve out mental health treatment from integrated care.

Sadly for our state, this year we will be looking to other, less progressive states to use as examples to address the issues of treatment for those who have been diagnosed with a serious mental illness and believe they need a difference response than drugs to succeed in life.

Instead of progressing on parity of treatment approaches and integration of care, we now look to divide further, and to conquer by force.

The new session begins on January 8, and I will be hearing then from our Human Services Committee Chair, Rep. Ann Pugh, how she will be prioritizing our work for the next several months. Since it is the second half of the biennium, we will be likely to be spending more time on the floor earlier as bills advance. Please stay in touch on your own needs and priorities. Despite the narrow scope of committee work, I can always find out what the status is on issues in other committees that you have questions about – that’s an important part of my job in serving you, and it’s a pleasure to do it. You can leave messages for me at 485-6431, counterp@tds.net, or directly at the statehouse via 828-2228.