For those who don't know, April is Sexual Assault Awareness Month, part of a campaign to end sexual violence.

​ This is an issue that continues to affect far too many individuals,- with approximately 1 in 6 women experiencing rape or attempted rape, and while we often (and rightly so) see discussions of sexual assault in the context of college campuses and fraternity culture, 44% of survivors are under the age of 18 and 15% are under the age of 12. What's more, such assaults occur approximately 293,000 times a year. 

Despite the prevalence of these crimes, they remain one of the two least reported crimes in the United States (along with household theft), with 68% of sexual assaults not reported to the police and only 2% of rapists ever spending a day in jail. That is, for every 100 rapes, 32 will be reported to the police, 7 of which will lead to an arrest, 3 of which are referred to prosecutors, and 2 of which will lead to conviction and in turn serving time.  This is compared with only a 1/3 chance that a homicide will go unresolved. 

It is not difficult to understand why, even with the anger and hurt and violation that accompanies this experience, individuals would not want to endure the arduous and trying experience of a criminal prosecution (exams, questioning, etc.), especially if there are accompanying feelings of shame, guilt, or confusion. (Indeed, when I inquired of a medical professional at what point I should get tested, I was asked whether I had been drinking that night). It is perpetuated further by the fact that most incidents (approximately 4/5) are committed by someone known to the individual, making the reporting process more complicated. And there is some inclination to try to simply erase the memory and evidence, as I did the morning after in one of the longest showers of my life (despite my otherwise eco-friendly tendencies).

The National Sexual Violence Resource Center has compiled valuable resources on sexual violence for its 2016 campaign on college campuses and beyond. Prevention is possible.  

Today, former congressman Patrick Kennedy delivered a speech at the Healthy Minds Conference, consistent with his long track record of advocacy on mental health issues: 

"Mental illness need not to be an alien to our affection... Those with mental illness and addiction should not be precluded at any level of care based upon the severity of their illness. If their illness was cancer and was that severe, would they be garnering the same services? Or whether it was diabetes in need of that care, would they be expected to receive those services? That's a revolutionary concept. I guarantee you most people in this country do not know that there is a federal law that mandates that insurance companies not discriminate against people simply because their illness in on the brain as opposed to any other organ of the body. We need, essentially, an NAACP of mental health. We had the 1964 Civil Rights Act, but that didn't guarantee anything. Then you needed to get the Voting Rights Act. Then  you needed to get the Fair Housing Act. Then the Fair Employment Act. My point is, the fight has to continue. What we need to do is make sure that the laws that are written are actually enforced."

​I’m going to do something unusual now: I’m going to defend a Republican. Not on policy, mind you, but because of the personal nature of one of Trump’s recent attacks, in this case targeting Heidi Cruz for her history of depression.  
 
The gendered nature of this election cycle has not escaped anyone, from the obvious point that the leading Democratic contender is a woman, to Trump’s notoriety for sexist remarks on the campaign trail. Most recently, he tweeted to his opponent Ted Cruz regarding Cruz’s bout of depression approximately ten years ago.
 
Despite ongoing (and increasing) attention to mental health issues, along with discussion of the remarkable prevalence of mental illness (approximately 1 in 5), there remains persistent stigma attached to these diseases. Part of the reason is that it is difficult for those on the outside to understand. Though scientists are developing better diagnostic criteria, there is not an easy blood test, not everyone is responsive to medication, the symptoms are not as visibly physical (relative to, example, bleeding or breaking bones), and powering through the symptoms of depression is not nearly as easy a feat as one might believe. Celebrities’ “coming out” about their own struggles (or more sadly, their suicides) arguably promotes more open conversation about these challenges, and in turn facilitates people viewing it as more acceptable to seek out help. Patrick Kennedy and Tipper Gore notwithstanding, however, we see little firsthand discussion of this in the political sphere, making the Cruz case noteworthy.
 
Heidi Cruz said, “When I came out of Washington and the White House, I didn't feel that there was really a glass ceiling in the administration ... and Texas was very different,” with the “traditional culture” and social environment less hospitable and perpetuating her feelings of depression. She was reportedly found in 2005 by an Austin police officer, appearing to be a danger to herself. Her transparency on the matter is noteworthy. A Cruz advisor responded to the Trump attack by saying, “About a decade ago, when Mrs. Cruz returned from D.C. to Texas and faced a significant professional transition, she experienced a brief bout of depression. Like millions of Americans, she came through that struggle with prayer, Christian counseling, and the love and support of her husband and family.”
 
Apart from the question of whether candidates’ spouses should be fair game for attacks, in particular of such a personal nature, there is the fact that it frames the issue of depression as something to which one must “confess” and can be “accused of,” rather than a medical condition for which she appropriately sought treatment. Such a characterization of depression only further reinforces people’s sense of shame, reticence about symptoms, reluctance to reach out for help, which can be dangerous and even fatal depending on the severity of the condition.
 
There are many grounds on which to criticize the political extremism of Ted Cruz or even Heidi’s political influence in his campaigns. However, reinforcing the closeting of depression by attacking Heidi on these grounds is a major (and dangerous) setback in the treatment of mental health conditions. 

In case there were questions as to the potentially anecdotal nature of my previous post on the poor quality of patient care by Universal Health Services, the nation's largest provider of psychiatric care, this article may lay those fears to rest:

"In Sherman, workers at a psychiatric ward dropped a suicidal patient off at a bus stop; a day later he was found dead after jumping from a Dallas bridge. In San Angelo, hospital employees created infection risks by leaving an observation room covered in vomit and a kitchen black with grease and dead bugs. And in Austin, male nurses stripped a teenage sex-abuse victim and shut her in solitary confinement, naked... Across Texas and around the country, government inspectors investigating patient complaints cited 44 of the company’s hospitals for dangerously poor care or unsafe conditions between 2012 and mid-2015, according to data from the federal Department of Health and Human Services... Inspectors found safety breaches at 13 of the company’s 26 such facilities in Texas, the hospital company’s largest market."

UHS company officials continue to characterize their record as excellent.

In 2008, I had the privilege of working on the presidential campaign staff in the oh-so-scenic terrain that is Winston Salem, NC, which at least at the time smelled exactly as it sounds like it would. Turning out the majority minority housing projects and over impoverished areas, I spoke with individuals who well into their thirties, forties, even fifties, had never voted, let alone had campaign workers on their doorsteps. After all, the perk of having such a well-resourced campaign is being able to touch the less reliable voters who would reliably be allies, and turn them out to the polls. By a margin of only approximately 25,000 votes, Obama won the state. 

In the 2012 campaign, I spent the home stretch in State College, Pennsylvania, a region notoriously low in turnout due to electoral institutions that systematically depress turnout (e.g., no early voting, excuse required for absentee voting). While the courts had put a stop on the photo ID  law, confusion was rampant, with signs throughout the region claiming that voters had to present photo ID (their response to challenges was that they were "preparing voters for the next election") and voters not being clear on the fact that while poll workers were entitled to request photo ID, they were not entitled to require it. Some erroneously walked away from their polling places due to photo ID confusion. Others, seeing long lines due to the absence of early voting and the like, opted out of the extensive wait time. Such conditions should be anomalous, but sadly are not.

Florida 2000 notwithstanding, the chances of one's own vote determining the election outcome is indeed infinitesimal. That said, with many reasonably narrow election outcomes we can see easily how shifts in the laws can powerfully impact the likelihood of one being able to vote (and certainly of being likely to vote), with constraints on voting rights disproportionately hurting the poor and minorities, demographic groups that typically vote Democratic. 

A number of tactics -- from felon disenfranchisement to constraining early voting to photo ID laws -- have been employed across the country to supposedly crack down on voter fraud, though in effect disenfranchising voters unlikely to be in the Republican camp. Only Maine and Vermont allow prisoners to retain their voting rights while incarcerated, with other states demonstrating a range of constraints. 19 states now require that one present photo ID in order to vote, with an additional 14 states requiring non-photo ID. Obtaining a photo ID is not costless. I, for one, do not have a driver's license. Obtaining my California state ID came with a fee, which if required to vote could constitute a poll tax. This does not even account for the time needed to obtain that ID during business hours, or the forms of other identification needed to obtain a state ID or driver's license (e.g., passport or birth certificate).

North Carolina is the latest controversy with respect to voting rights, with the implementation of a photo ID requirement and 218,000 registered voters, disproportionately African American, lacking the necessary government identification in order to cast their votes.  Such an effect is particularly stark when considering an investigation into voter fraud revealing only 31 credible instances out of one billion votes cast, calling into question the validity of the justifications for this legislation. 

The Nation detailed this recent struggle of a North Carolina voter: " In September 2012, Douglas’s niece, Clara Quick, took her to the DMV in Laurinburg, North Carolina, to get a state photo ID. Douglas was told she needed a copy of her birth certificate to get an ID. So they traveled across the state line to Dillon, South Carolina, where Douglas was born, to find her birth certificate. But the government office there said she needed a photo ID to get a birth certificate, and Douglas was caught in a seemingly unresolvable catch-22...  Her niece called the South Carolina’s Vital Records office, paid $17 for an expedited birth certificate, but still couldn’t get one. Instead, she was told to find her aunt’s marriage certificate, which was in Bennettsville, South Carolina. After getting that, they made a second trip to the North Carolina DMV, but were once again told Douglas couldn’t get a photo ID because she didn’t have a birth certificate.  They were so frustrated that they gave up trying for a time. In the fall of 2013, after North Carolina passed the voter ID law, they made a third trip to the DMV. An employee told Quick to get a census report to confirm her aunt’s identify, which she purchased for $69. Quick brought her aunt’s census report, marriage certificate, Social Security card, and utility bill during a fourth trip to the DMV in September 2014 and was finally able to get her the photo ID needed to vote." There is little ambiguity as to the motive, and the effect, of such laws being in place.

The Supreme Court's holding on the Voting Rights Act paved the way toward greater constraints on voting rights in southern states with histories of discriminatory practices. Moreover, the xenophobia by which some of the current primary debates (ahem...Trump) could aptly be characterized only further perpetuates the racial tensions underlying these voting constraints. Indeed, North Carolina's photo ID law (along with cuts to same-day registration and early voting, which can have the effect of producing long Election Day wait times and in turn suppressing turnout) was passed oh-so-subtly a mere month after the Supreme Court's VRA decision. Consider this statistic: in recent elections in North Carolina, African Americans were twice as likely as whites to utilize same-day registration, early voting, and vote out of their precinct. 

Rather than simply seeking to outperform their opponents, coalitions have turned increasingly to such suppressive tactics to limit the pool of eligible voters in ways that disadvantage minorities and the poor, thus being both anti-Democratic and undemocratic. In addition to calling attention to the pervasive racism that still remains in much of our nation, it highlights the striking impact of Supreme Court holdings on key civil rights (and other) issues. Clinton has begun to make the Court a central issue in her campaign as she addresses voters about the dangers of the extremism and racism promoted -- or at least motivated -- by Trump. We won't have long to wait to see whether the Senate is responsive to public support hearings for Garland, the prospective replacement for the late Justice Scalia and a game-changer with respect to Supreme Court politics and the preservation of basic voting rights for the American electorate. 

The pharmaceutical industry has come under marked scrutiny in recent years, with critiques of payments directly to physicians and direct marketing to consumers while spending relatively little of their funds toward the actual drug research. I addressed some of this in a previous post, John Oliver brought out a pointed critique in the Season 2 opener of Last Week Tonight, and most recently Congress has introduced legislation to impose a ban on direct-to-consumer (DTC) drug ads (though it is not clear how likely it is to pass). Concerns regard DTC ads are not new, though to be sure the increased availability of data at such places as https://openpaymentsdata.cms.gov and https://projects.propublica.org/checkup/ have promoted more transparency and open discussion as to the merits of increasing checks on their influence over consumers’ medical care. And to be clear, the use of DTC bands would not address the concerns as to influence over physicians, though it would theoretically help to curb what might be seen as an over-encouragement of taking certain drugs, particularly those that are brand name. (DTC advertising has been heavily criticized also by the American Medical Association, which called for its outright ban, and by consumer groups and physicians viewing such advertising as encouraging patients to unnecessarily seek out medications).
 
When we think about our medical care, there is a certain normative desirability that many of us have that it be based solely on medical judgment and not the business aspects of who is influencing whom or the politics (as opposed to evidence-based health benefits or potential benefits) of prescribing X rather than Y, and hearing about the potentially undue power of pharmaceutical companies, for lack of better description, rubs us the wrong way. We would expect that if pharmaceutical companies are continuing to spend money on such marketing, they are getting a payoff in return, but we still need to look carefully at the nature and extent of this industry’s influence on care provision. So let’s begin…
 
Journalists at ProPublica revealed recently that doctors taking money from pharmaceutical companies are markedly more likely to prescribe brand-name drugs as opposed to the generic versions. The financial impact for consumers of brand-name versus generic prescriptions is marked, given that on average, generic versions of drugs are 80-85% lower cost than their brand-name equivalents, which adds up considerably given that 34% of American adults take at least one prescription drug and over 11% take 3 more more. In Washington, for example, brand-name prescription rates were 18% among those who had not received any payments from pharma, 20% among those who had received at least one payment, but 27% among those who had received $5,000 or more. Thus, from these data it does not appear to be the initial treatment effect of interacting with pharma, but receiving some threshold level of support from them that is associated with brand-name prescription rates. The concern is that those who are receiving larger sums of money may be more inclined to be responsive to the drug companies by prescribing brand-name drugs, even though generic versions typically work as well and pose less of a financial burden to consumers. (To be clear, these data show only correlation – we do not know from this the rate at which doctors were prescribing brand-name drugs pre- and post-treatment of the contribution(s), and thus cannot rule out that pharmaceutical companies are selecting into certain contributions, that is, rewarding doctors who are already prescribing their brand and hoping to ensure continued loyalty).
 
Within the ProPublica database, one can look at state-level data on total claims, brand name drug claims, low income subsidy claims, percentage of claims that are brand name drugs, and the percentage that are low income subsidy, for primary-care specialties among doctors writing 50 or more prescriptions for at least one medication in Medicare Part D in 2013. The top ten states for rates of brand-name prescribing are New Jersey (28%), New York (27%), Washington DC (25%), Connecticut (25%), and Texas (24%), Hawaii (24%), Delaware (24%), Alaska (24%), and North Carolina (23%) is tied with Maryland (23%), Louisiana (23%), and California (23%). Those at the bottom are Washington (19%), Rhode Island (19%), Oregon (19%), Nevada (19%), Massachusetts (19%), Alabama (19%), Puerto Rico (18%), and Minnesota (18%). So, while there appears to be a particular influence in the tri-state area and the DC metro (little surprise on either front given the amount of political influence in both regions), and somewhat less influence in the western states, we do see representation here in states of varied size, region, and partisan bent.
 
Receipt of payments from pharmaceutical companies is very commonplace – 9 in 10 cardiologists who wrote at least 1,000 prescriptions for Medicare patients received such contributions in 2014, as did 7 in 10 internal medicine and family physicians. What gets interesting is when you dig in to the state data and can see the number of providers in the database and their claims data by specialty and physician name, along with the top drugs by state. For example, following family medicine and internal medicine, the third most common type of prescriber in California is psychiatrists, and one can see that among psychiatrists, as many as 70% of prescriptions are brand, though with an average of 19% and thus a huge variance. The top three specialties are the same in New York, with similar rates of brand-name prescriptions. The number one prescribed drug in California is Hydrocodone-Acetaminophen (otherwise known as Vicodin), manufactured by Abbott Laboratories, followed by the cholesterol-lowering drug Simvastatin, manufactured by Merck, followed by the blood pressure drug Amlodipine Besylate (manufactured by Pfizer). The number one prescribed drug in New York is Simvastatin, followed by Amlodipine Besylate and the heartburn medication Omeprazole (manufactured by Novartis). These medications, Amlodipine Besylate, Simvastatin, and Omeprazole in particular, occupy top spots in many of the states, and similar patterns persist with respect to the specialties prescribing at the highest rates according to this database (some other commonly prescribed drugs were the Abbott Laboratories-manufactured Levothyroxide Sodium, the Merck-manufactured Lisinopril, and the Pfizer-manufactured Atorvastatin Calcium). So we see some trends in the common prescriptions, though these are also associated with common medical conditions and represent a number of different companies. Individual doctors may be dominated a given company, which raises normative concerns for many, but there does appear to be market diversity among the top sellers.  
 
But let’s now take a look at the companies that appear more than once on those lists: Merck, Pfizer, and Abbott Laboratories. In 2014, Merck made $26,620,095.98 in general payments across 316,707 general transactions, averaging just over $84 per general transaction (which could be education, food and beverage, consulting, etc.). It additionally made $98,674,829.90 in research payments from 6,541 research transactions, averaging $15,086 per research transaction. Not exactly a trivial sum of money. But the numbers get even bigger when we turn to Pfizer, which made $53,486,322.64 in general payments from 562,178 general transactions (average of just over $95 per general transaction) and $234,173,044.01 in research payments from 134,792 research transactions (average of just over $1,737 per research transaction). So here we see a greater aggregate financial influence, with modestly higher average general payments though smaller-scale research payments. Abbott Laboratories gave the comparatively lower $11,882,832.80 in general payments from 39,814 general transactions and $9,902,201.57 in research payments from 1,588 research transactions, though the average payments from them are higher at $298.46 and $6,235.64 respectively.
 
Having looked at the aggregate level, let’s take a look at some individual-level data, omitting individual doctors’ names so as not to single people out (though it is all public information that can be checked among the databases cited here). Doctor A (Cardiology) in New York City received in 2014 approximately $1,050 in general payments and over $9,000 in research funding. A large share of the general payments received by the doctor are from E.R. Squibb & Sons, LLC, which manufactures one of the three most common medications that Doctor A prescribes (Clopidogrel). Doctor B (Internal Medicine) in Saint Louis received in 2014 over $8,000 in general payments, with a number of such payments coming from Pfizer, which manufactures the drug that they prescribe the second most often. To be clear, such trends are far from universal, though they are not anomalous either. And granted, most doctors receiving payments are receiving many small contributions (often in the form of the notorious “food and beverage” gifts) and are receiving such contributions from a number of different companies, which might at least give some comfort that there is not necessarily (from this glance, at least) systematic evidence in favor of many doctors being in the pocket of just one company to which it maintains loyalty. However, the influence itself – particularly in the aggregate – might reasonably make one feel ill at ease (but don’t worry, there are pills for that too).
 
There’s little denying that this collectively indicates an immense amount of money to be allocating toward marketing to (or at least interacting with) doctors in a given fiscal year. It is also clear that the most commonly-prescribed drugs, though in part commonly-prescribed due to the frequency of the conditions that they work to treat (e.g., high blood pressure, high cholesterol, heartburn, pain), are manufactured by those who are spending lots of money toward such marketing. The thing is, they’re also (not surprisingly) also among the top political spenders (already in an industry know for marked political contributions. In the 2015-16 election cycle alone, Pfizer has contributed $928,256 (#1 among pharmaceutical companies), with Merck also in the top 5 at $503,772, and Abbott Laboratories coming in 8th at $484,924. In the 2010, 2012, and 2014 election cycles, these three companies also all came in the top 6 pharmaceutical company contributors. Thus, what we find here is consistently high levels of financial investment in both the political and the private spheres over several election cycles, with the deregulation of campaign spending only further empowering such spending to continue.
 
So is there a solution? The catch with respect to legislative solutions is that those on whom we would rely to monitor the influence of these companies are also stakeholders themselves. Not only do these companies make contributions to candidates and parties themselves, but many members are also shareholders. For example, 40 members of Congress owned Pfizer, Inc. shares, 26 own Merck & Co. shares, 27 hold Abbott Laboratories shares, 23 hold Bristol-Meyers Squibb shares, and so on and so forth. If there’s a theme to this admittedly too-long piece, it’s probably the obvious point that there appears to be, not surprisingly, a marked degree of conflict of interest across many domains – from physicians to pharmaceutical companies to the government itself. We do not know the counterfactuals that we would need to make clean causal claims about industry influence on medical practices – that is, we don’t know that they wouldn’t prescribe those medications anyway based on their professional opinion – but there is at minimum suggestive evidence that pharmaceutical companies are strategically targeting doctors in making financial contributions and that there is some responsiveness with respect to prescribing in ways that impose higher costs on consumers and financial gains for the corporations.
 
Absent monetary or political incentive to impose greater constraints on the revolving door between the pharmaceutical industry and the government, it is unclear how realistic it is to expect major changes. However, with greater transparency through these public data, and hopefully an honest conversation about pharmaceutical marketing with the consideration of Rosa DeLauro’s (D-CT) proposed Responsibility in Drug Advertising Act (whether or not it passes), we can continue this conversation and work toward reducing their degree of influence.     

​​Inside the lobby of Hartgrove Psychiatric Hospital in Chicago, IL, one finds glossy floors and an open lobby, the greatest expanse of freedom that patient here will experience between admission and discharge. While premier hospitals such as Northwestern Memorial and Rush University hospitals often refer patients to the facility when they themselves do not have beds for patients in their networks and cannot locate beds elsewhere, there is either ill-information or denial among the care-givers thinking that they are facilitating care as opposed to outright regression in psychiatric progress, an instance sadly emblematic of the state of mental health in America. Hartgrove, however, is notorious for its malfunctioning, with the markedly high rate of violent attacks on the units leading the Department of Family and Children Services in 2011 to decide to no longer place children in the facility. 
            Upon admission to this facility, one finds conditions of care more akin to those of a prison rather than a provider of key and needed mental health services. Indeed, prisons provide valuable access to mental health care relative to the labyrinthian system that the general public is forced to navigate, often when they are at their worst. While it is common practice in psychiatric facilities to do a body map of a patient’s scars, bruises, tattoos, and other markings so as to be able to identify the appearance of new such markings and injuries over the course of one’s hospitalization, at Hartgrove they conduct it far more like a prison strip search, having patients remove all clothes, squat, and cough, a particularly high level of invasiveness (and particularly stressful for those with trauma histories, as many of their patients, especially among the women, do). 
Next, patients are asked to pick their poison if they get out of control, ranking from 1st to 4th choice medication, isolation, physical hold, or restraints (note that no options are technically off-limits). Patients then find themselves surrounded by often rude caretakers more intent on constraining rights rather than expanding horizons. Individuals are refused access to their relatives (even their children) during hours outside of regular phone call times, at times following being on hold for as much as half an hour. Ironically, one fairly standard rule that the facility does not impose is a prohibition against patients touching one another, though one might imagine such a rule might be warranted here. The conditions of the searches and potential restraints strike at something particularly crucial, which is that depression eats at one’s sense of self-worth, and the treatment at these stages only validate those cognitive distortions of low esteem, potentially even “deserving it.”
            One young woman, 18 years old, just old enough to be separated from her friend and ex-boyfriend of 17, who thus is in the adolescent unit – stares wistfully out of her semi-private bedroom window, watching as women in the salon across the street get their hair and nails done, looking happily at their done-up complexions as she herself covers the scars and scratches that she has inflicted upon herself when the voices in her head become more vocal. Another patient asks for the fourth time for his legally-provided paperwork entitling him to discharge on his fifth day of stay provided that he is not a danger to himself or others, and after repeated denials of this request within his legal rights, is granted the form only after threatening publicly to call the patient advocacy line with which patients are all equipped  but that too few of them actually use, perhaps because they have come to believe that they do not deserve better, or perhaps because they have not yet had the chance to know better, to be treated with human dignity. Another woman enters her fifth day of requesting her book of phone numbers from her purse being held in security, so that she can notify her family and dog-sitter of her location and status. A nurse who could aptly be characterized as a modern-day Nurse Ratchett flatly denies the request on account of “being busy” while openly discussing details of a patient’s case in the nursing station in a loud tone, with other staffers and patients well within earshot.
“She was in the ICU and intubated,” she calls out to a fellow staffer managing a new patient’s intake as a handful of patients congregate near the nurse’s station awaiting their receipt of medications. There are many other such “confidentialish” discussions about patient information, raising questions as to their understanding of compliance with HIPAA patient protections and a need for a private room in which to discuss case information that is away from patient access. The same patient seeking her family members’ phone numbers had a neurologist-approved medication withheld from her without discussion with her psychiatrist or social worker, with subsequent refusal to engage in discussion with the patient regarding the matter.
            “Is it always this acrimonious?” the new admit asks.
            “The desk manager unabashedly answers “yes,” which is a rare piece of truth that one finds among those running the unit. Some are seasoned and dedicated but overworked and understaffed and thus unable to maintain what might have been a prior sense of competence. Others are clearly of the view that with this patient community, one must impose the most restrictive rights, draw the brightest lines, impose the strictest of terms, allow the least freedom. For example, only two incoming and two outgoing calls per person are allowed (typically not consecutively and only within narrow time windows), there are no doors but rather curtains in front of the bathrooms (again, with bedroom doors not permitted to be closed, thus leaving virtually no privacy), patients may not stand in front of the red line approximately six feet in front of the nursing station without express permission, patients are not allowed to walk the halls for the most marginal degree of exercise to burn off some of their all fried foods (deemed “worse than prison food,” according to an ex-offender), between 9pm curfew and 8am breakfast patients are required to be in their rooms, occasionally scolded for getting up in the middle of the night to obtain more pain or sleep medication. Checks throughout the night are often conducted by way of holding flashlights in front of the faces of patients, purportedly to check that they are in bed and breathing, but also maintaining the dictatorial attitude according to which this “mellower” unit is run. And while patients in the "mellower" unit 2 South are no doubt glad not to be in the acute care unit of 2 North, the judgment with which the staff speak of the "crazy" patients in 2 North is stark. 
            Other staffers are young and perhaps well-meaning, but appear more intent on bonding with the patients than facilitating patients’ recovery and have yet to build the skill set necessary to be effective purveyors of care with respect to simple request such as retrieving phone numbers from personal belongings. The latter request is particularly ironic for a field of health build so centrally on the value of including a support system and making them integral to a patient’s recovery. Hartgrove has missed that memo, and perhaps instead taken a trip “back to the future” of dismal conditions that prey upon the often vulnerable mentally ill populations unable to advocate adequately for themselves. Such populations should truly get the most care (and in context of civil rights and the Equal Protection Clause, vulnerable populations are afforded higher levels of judicial scrutiny in the evaluation of constitutional rights) and yet sadly from an administrative standpoint, the red tape looms large and patients fall through the cracks, a phenomenon seen quite ubiquitously in this particular context.
            This is not to say that the staff and psychiatric care is universally sub-par. There are exceptions, to be sure, with some quite dedicated and highly competent. But the fact that there is such a wide variance in degree of care when it makes such an immense difference in length of stay, medication management, and after-care is an issue of grave concern. Whether you are cared for well and released in 5 days versus ignored and left for 10 days should be determined not by assignment to a particular doctor but by the patient’s individual condition and progress. Consistently, adherence to rules regarding things such as phone calls is left to the discretion of individual staff members, some of whom are accommodating and many of whom are not. Moreover, not all staffers appear to be well-versed in the nature of psychiatric illness, with one seemingly well-meaning staff member asking an academically accomplished patient, “Damn, girl, what you got to be depressed about?” The comment, though made in jest, marginalizes the real struggles, both biological and circumstantial that land patients in such facilities. When the patient acknowledges that her admission followed a suicide attempt by way of overdose, the staffer asks whether it was because of a boyfriend. Such was the inquiry of the patient by multiple (male) staffers at Hartgrove, another of whom mocked a patient about the effectiveness of her method of suicide attempt.
            A common standard of care, at least in top hospitals, is to meet daily with members of the treatment team (a psychiatrist and social worker), often both but in some cases alternate days with respect to the psychiatrist, with more limited care available on weekends except with respect to new admissions or an acute issue requiring immediate treatment. Hartgrove is notoriously understaffed and overcrowded, leading to what the DCFS to consider the facility to be dangerous conditions for children in this 150-bed facility. Such was the decision rendered at affiliated hospitals owned by Universal Health Services, including Garfield Park Hospital, an 88-bed facility where patients reported being injured during restraints by staff members and assaults on the units were frequent occurrences. Investigations into Hartgrove revealed approximately 100 incidents of violence and abuse between December 2010 and summer 2011, including the breaking of a child's arm during an improper restraint by staff members and the failure to to provide the child with medical treatment until the next day. One patient at Hartgrove had to wait 72 hours before being seen by her psychiatrist for the first time, and in six days had only seen the psychiatrist twice and her social worker once. Multiple requests to meet with social workers were rebuffed with “we’ll see,” or “we’ll track her down eventually,” but needless to say, eventually never came for a day or two, leaving patients with often poorly-organized groups (some better suited to prisoner re-entry than mental health treatment) that according to one staffer “sometimes meet, sometimes don’t,” and sometimes consist of little other than games such as Pictionary or sharing stories (technically anonymously) about prior patients. To the extent that an individual therapy session might have been afforded, it was held sitting on the floor of the hallway within earshot of other patients and staff, and thus not at all protective of patient privacy under HIPAA.
The staff are keen on using profanity among one another and with patients, which reflects a general casualness rather than level of professionalism that one should reasonably be able to expect, and many activities on the schedule do not ultimately occur (for example, exercise). Despite having a dietitian with whom patients meet, accommodations are rarely if ever made, even for religious reasons (e.g., kosher) and thus bringing Free Exercise Clause issues into play. If individual therapy sessions are able to be obtained, it is not uncommon for them to be held sitting on the hallway floor, in the presence of others staffers, as opposed to a private consultation room, again bringing into question issues of patients’ health privacy.
            There are no secrets as to the shortage of mental health services in most of the country, but the casual acceptance of their own laxness in care provision is stark. There are no books available to patients, nor information on psychiatric disorders or medications, only two board games, limited art supplies, only one puzzle with a third of the pieces missing. In turn, there are limited ways other than watching TV to occupy time before 9 p.m. curfew, at which point patients are not allowed out of their rooms, scolded at times for even looking into the hallway from their doorways, and must keep their doors open (though at least one staff member was found having fallen asleep during his night shift). Thus, the provision of patient care at this facility, where staffers go by Mister or Miss to further reinforce the hierarchy vis-à-vis the patients, appears to deemphasize constantly the operative word “care.”
            There are mixed findings as to the systematic effectiveness of psychotropic medications, and the consensus is that treatment in this domain is at least as much about art as it is about science when it comes to treating a particular patient. The findings of the beneficial effects of therapy – whether psychodynamic or cognitive behavioral – are more widely substantiated (despite obvious limitations of publication biases toward positive findings). While inpatient facilities are meant primarily for crisis stabilization in acute states, surely more group-based programs such as those at New York Presbyterian and Johns Hopkins and others should be encouraged if not required so as to ensure patients with some basic equipment (e.g., dialectical behavioral therapy) with valuable coping mechanisms before returning to the outside world with varied access to patient care (and thus reducing mental health recidivism, or “frequent flyers”). It would not be hard to envision a study of the patients whose particularly bad experiences in psychiatric facilities had not simply null effects on their progress but actually had induced setbacks in therapy progress.
Hartgrove Psychiatric Hospital is owned by Universal Health Services (UHS), the provider of 20% of all inpatient behavioral health care in the United States, and which is emblematic of poor cookie cutter solutions to mental health that may ultimately do more harm than good. Founded in 1983, UHS is the largest provider of facility-based behavioral health care in the nation, operating 216 centers in 37 states, Washington DC, and Puerto Rico, the US Virgin Islands, as well as the United Kingdom. Over the years, UHS has been caught in a number of scandals, from Medicare and Medicaid fraud to poor patient care. In March 2012, the organization and two of its subsidiaries paid $6.85 million to settle allegations that they were providing sub-standard care in Virginia and engaging in false claims under the False Claims Act. In August 2012, it settled for $4.25 a suit by parents alleging that they falsely billed for instruction of inpatient children and adolescents while actually just warehousing them. The institution has been alleged to have terminated whistleblowers across the nation, with employees raising issues such as patient neglect and sexual assaults against patients. Safety violations were found in 13 of the 26 UHS facilities in Texas, where among other violations, male nurses were held to have stripped naked a sex abuse victim and left her in solitary confinement, and elsewhere to have dropped off at a bus stop a suicidal patient who committed suicide the next day. Most recently, UHS lost in its False Claims Act case at the Supreme Court in Universal Health Services v. United States ex rel Escobar (2016) with respect to the UHS facility Arbour Counseling Services in Massachusetts.
The UHS-owned behavioral health centers of Chicago have been caught in a number of scandals over the recent yeas, with the Illinois Department of Children and Family Services not only deciding in 2011 to no longer send children and adolescents to Hartrgrove Psychiatric Hospital but also in 2013 opting not to send them to Garfield Park Hospital due to hundreds of alleged violent attacks and sexual assaults against patients. Riveredge Hospital, also now barred from receiving patients through DCFS, has also had allegations of sexual assaults of patients, and in 2013 a patient there committed suicide by hanging herself on the unit. It is not difficult to conceive of how experiencing, or even witnessing, such events while seeking acute psychiatric care would be traumatizing (or re-traumatizing) to a patient already in a vulnerable state. These are not isolated incidents, but rather systemic problems that deserve not just piecemeal Department of Justice investigations into specific patient complaints, but rather a large-scale evaluation of the institution’s mismanagement of such a huge share of the nation’s mental health care services.
            One solution is better funding, allowing for more staffing and thus more flexibility with respect to patient requests and meeting patients’ basic needs. Currently, Hartgrove staff receive only approximately 6 paid holidays per year, which is below most employment standards (and not surprisingly, the staff are not unionized).  However, it is unclear whether the culture itself needs a cleansing independent of the degree of staffing that they might hope to obtain.
We speak at times of the “prison industrial complex,” with some corporations reaping marked financial profits from prison overcrowding amid the expansion of the inmate populations in private prisons. That UHS manages approximately 20% of inpatient care is a figure that actually exceeds the numbers with respect to private prisons, which manage the incarceration of 6% of state prisoners and 16% of federal prisoners. The company overall, which manages an immense share of the national mental health care, reports large profit margins despite the struggles of many non-profit hospitals, though given the number of Department of Justice investigations that their facilities are undergoing for alleged fraud and patient abuse, it does not appear to be driven by the quality of patient care.
UHS declares that in 2015, they treated 2.5 million patients, with a citation of 400,000 patients per year within the domain of behavioral health. While UHS v. United States Ex Rel Escobar (2016) emphasized the False Claims Act, inherent in the determination of whether fraudulent claims were made was a discussion of the nature of patient care, and the substandard nature with which the hospital was going about its business. The federal government has a financial interest in Medicare and Medicaid claims being submitted in good faith with respect to patient care delivered as promised. But it also has an interest in the health and welfare of its citizens. Absent effective and safe care, they are more likely to face hospital readmission, disability or otherwise have reduced productivity, and poverty in future years. Hartgrove Psychiatric Hospital in Illinois and Arbour Counseling Services in Massachusetts are but two examples of the substandard care to which Universal Health Services patients are being subjected. The federal and state governments both have social, financial, and moral obligations to take action with respect to the risks to which UHS is subjecting its patients, and the deleterious health and economic impact of this substandard care being implemented across the United States upon patients’ admission to their facilities.

​Many commentators and scholars have called attention to the importance of filling the Supreme Court vacancy left by the death of Justice Antonin Scalia given the lack of precedent for Senate inaction on the Court within a certain time frame. On principle, President Obama is still the president and thus is entitled to nominate justices to the Supreme Court, as he did with his nomination of Judge Garland, and the nominee should be entitled to confirmation hearings.  
 
There are also pragmatic concerns. On Wednesday, the Supreme Court heard oral arguments for a case regarding religious accommodations to the contraceptive mandate under the Affordable Care Act (ACA). Justice Anthony Kennedy typically serves as the swing vote siding more often than not with the conservative wing of the Court. In oral arguments, Kennedy appeared sympathetic to the substantial burdens of those working to opt out of contraception coverage in health plans under the ACA, though he posed questions in both directions of the issue. If Kennedy votes with the liberal wing of the Court, Scalia’s death will not be consequential for the case, but if Kennedy aligns with conservatives, we will have a 4-4 split. In the event that the Supreme Court is indeed evenly split, as appears fairly likely the case, lower court rulings rejecting the Christian organizations’ challenges would stand.
 
Kennedy’s record on reproductive rights is mixed. He voted with the majority in Planned Parenthood v. Casey, which reaffirmed Roe v. Wade but nevertheless allowed states to impose a number of constraints on abortion access provided that such laws do not pose an “undue burden.”  However, he also authored the majority opinion in Gonzales v. Carhart, which upheld the Partial-Birth Abortion Ban Act of 2003. And in 2014, he authored a concurrence in Burwell v. Hobby Lobby, in which the Supreme Court held 5-4 that the Religious Freedom Restoration Act (RFRA) allows a for-profit company to deny employees contraceptive coverage given the religious objections of the company owners. So which Anthony Kennedy will we see in the resolution of this case? Time will tell… 

​Across the nation, approximately 1 in 5 Americans experiences some type of mental illness. Approximately 40% of those with schizophrenia and 51% of those with severe bipolar disorder go untreated. The consequences of non-treatment of mental illness are drastic and wide, ranging, from homelessness to incarceration to suicide. Treating these diseases is not easy – indeed, an estimate put the cost of schizophrenia treatment at $33 billion per year, on par with the $38 billion per year estimate of arthritis costs – but it is necessary.
 
While we have a growing public discourse as to the severity of mental illness and the importance of obtaining treatment, particularly amid the presidential election season and promises of changes to the American health care system, the consequences of non-treatment, we see precious little attention to the consequences of bad treatment. This is ironic given that physicians work to abide by the central principle of “do no harm.” And if it s true that there is no health without mental health, we must pay close attention to finding not simply cheap fixes and band-aid solutions, but constructive progress toward mental health stability and ultimately, thriving.
 
Universal Health Services (UHS), the provider of 20% of all inpatient behavioral health care in the United States, is emblematic of poor cookie cutter solutions to mental health that may ultimately do more harm than good. Founded in 1983, UHS is the largest provider of facility-based behavioral health care in the nation, operating 216 centers in 37 states, Washington DC, and Puerto Rico, the US Virgin Islands, as well as the United Kingdom. They claim to treat over 400,000 patients per year through a comprehensive range of inpatient and outpatient behavioral health services. Sounds great, right? Well, not quite.
 
Over the years, UHS has been caught in a number of scandals, from Medicare and Medicaid fraud to poor patient care. In March 2012, the organization and two of its subsidiaries paid $6.85 million to settle allegations that they were providing sub-standard care in Virginia and engaging in false claims under the False Claims Act. In August 2012, it settled for $4.25 a suit by parents alleging that they falsely billed for instruction of inpatient children and adolescents while actually just warehousing them. The institution has been alleged to have terminated whistleblowers across the nation, with employees raising issues such as patient neglect and sexual assaults against patients.
 
The UHS-owned behavioral health centers of Chicago have been caught in a number of scandals over the recent yeas, with the Illinois Department of Children and Family Services deciding in 2011 to no longer send children and adolescents to Hartrgrove Psychiatric Hospital and in 2013 not to send them to Garfield Park Hospital, due to hundreds of alleged violent attacks and sexual assaults against patients. Riveredge Hospital, also now barred from receiving patients through DCFS, has also had allegations of sexual assaults of patients, and in 2013 a patient there committed suicide by hanging herself on the unit. It is not difficult to conceive of how experiencing, or even witnessing, such events while seeking acute psychiatric care would be traumatizing (or re-traumatizing) to a patient already in a vulnerable state. These are not isolated incidents, but rather systemic problems that deserve not just piecemeal Department of Justice investigations into specific patient complaints, but rather a large-scale evaluation of the institution’s mismanagement of such a huge share of the nation’s mental health care services.
 
The Chicago metro area is hardly the only region in which UHS hospitals have come under heavy scrutiny and been found to gravely endanger patients. UHS's Timberlawn Mental Health System in Texas was determined to have practices that posed immediate jeopardy to the health and safety of its patients and failed to monitor adequately those who were suicidal. The Meadows Psychiatric Center in Pennsylvania was cited for failing to report a sexual assault on the unit. Fort Lauderdale Hospital in Florida failed to investigate numerous charges of patient abuse. The Hughes Center for Exceptional Children in Danville, Virginia has experienced numerous allegations of racial discrimination against staff members, hardly making for a therapeutic environment to which to send patients. The list goes on. Despite the national aspect of UHS's provision of mental health services, investigations into mental health care tend to be individualized, looking at state and not national reputations -- rare is the national review of mental health care provision. And what is perhaps most egregious about this patient mistreatment is that depression strikes at the very core of individuals' sense of self-worth and deservingness of human dignity, and the level of care (or lack thereof) afforded by this set of behavioral health centers only reinforces this cognitive distortion. 

In a field of medicine known widely for being underfunded such that too few have access to needed services, Arbour Massachusetts Hospitals, affiliated with UHS, reported profits ranging from 15 to 32 percent, compared to single-digit profit margins by the nearby and top-ranked McLean Hospital. This is but one of many red flags that have been raised by this set of hospitals, also noted for having undertrained therapists, too few nurses given the number of patients, and fraudulently billing Medicaid for services provided by unqualified workers. 

Many of those who are in the position of requiring inpatient psychiatric treatment have histories of assault and rape, the traumatic symptoms of which many of these centers purport to work to treat. Some research has been carried out to illustrate the dangers of retraumatization of prison inmates, many of whom already have histories of violence and/or sexual assault. Therapists working with victims of trauma work closely with patients to manage triggers and flashbacks given the risk that such patients face of retraumatization – and that is in a safe, clinical setting, not coming close to the levels of abuse reported in the UHS behavioral health centers.
 
The need for a large-scale investigation into UHS (mis)management is clear. The onerous system of complaint processing and litigation overwhelmingly benefits the upper echelon and “repeat players” (in this case, UHS) to the detriment of the more vulnerable populations (whether the children, the elderly, the homeless, or the mentally ill) who are ill-equipped to be effective advocates for themselves and who Galanter (1974) would characterize as the “have nots” who, rather than being intimately familiar with the legal system that they are navigating in order to assert their rights, are in stead “one-shotters” with greater stakes in the individual case. In the civil rights context, we see that while individual cases of discrimination may be brought piecemeal, there are greater interventions when there is found to be a “pattern or practice” of discrimination. Here, we have unequivocally a pattern or practice of mistreatment, and it is time to act accordingly.
 
We have seen many frightening images of bad mental health care depicted in films such as “One Flew Over the Cuckoo’s Next,” which arguably did more harm than good in the way of encouraging people to seek needed help for their mental health. While research has investigated the problems formerly associated with ECT, which originally carried more dangers, there have been fewer large-scale evaluations of substandard care’s impact on patients over time. It is not difficult to imagine that while a highly depressed person not in the care of a mental health professional might face a steady decline in functioning, their condition might spiral more rapidly out of control (and less predictably so) if on the wrong course of medication or subjected to traumatic experiences that stir up past traumas or grief, leading to outright regression.
 
There are a number of obstacles to obtaining good scientific research on “bad” psychiatric care. For starters, effectiveness of therapeutic treatments varies by patient, even with objectively good standards of care (responsible monitoring of symptoms, medication management, therapy). With good reason, Institutional Review Boards (IRBs) will not permit subjecting patients to poor psychiatric treatment conditions and measuring degrees of depression and anxiety pre- and post-treatment. However, finding mechanisms to longitudinally monitor treatment progress (or regression) when subjected to sub-standard conditions at UHS centers and elsewhere will be essential in gauge the deleterious effects of maintaining the operation of so-called patient care programs that may help some at the margins in a time of limited mental health care access, but appear to put many patients at risk. In the meantime, it is incumbent upon health care providers to think twice before referring patients for “care” in these hands. 

In  a recent visit to the emergency room (side note: one of its "frequent flyers" is a wanna-be singer, dabbling in opera it sounded like), it was brought to my attention that while most of the hospital was in-network, the particular division of doctors to which I needed access was not. It was a Saturday night. The insurance company was closed. And the dreaded phrase came up regarding transfer to another in-network hospital when it became clear that a hospital admission would be necessary: "insurance preauthorization required."

It turns out, despite the fact that peoples' propensity to get sick is not exclusive to insurance company business hours, insurance preauthorization often is required for the transfer to another hospital facility, or for certain procedures to take place. This can result in unnecessary delays in obtaining needed care, or being transferred to less reputable facilities that do not carry certain restrictions. 

The Department of Health and Human Services defines insurance preauthorization as follows: "A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost." Such requirements can in some cases lead to extensive persuasion by doctors to insurance companies (that is, those who are not medical professionals but on the business end of the deal) that certain procedures, tests, transfers, are medically necessary. Issues of preauthorizations absorbed in 2006 an average of 1.1 hours per week from primary care providers, 13.1 hours per week of primary care nursing staffs, and 5.6 hours per week of primary care clerical staff. While insurance companies are barred from imposing prior authorization rules in the context of emergency care, some issues regarding interfacility transfers still apply, and should it become clear that a battery of tests must be ordered in the near future, a patient nervous about an impending diagnosis and treatment may have a barrage of insurance inquiries awaiting them first. 

The fact is, this is just one of many ways in which we have nominally worked to expand health care insurance coverage while simultaneously making it profoundly difficult for people to actually utilize those benefits. Whether it is a large deductible that one must meet before benefits kick in, a large out-of-pocket maximum such that expenses can continue to aggregate, or a large coinsurance that can lead one to such conditions as asking their doctor to run fewer or less expensive tests, we often find ourselves crafting policies that perhaps work well enough for those wealthy enough to afford the out-of-pocket costs or poor enough to obtain government-sponsored insurance and credits, but with the middle class continuing to get squeezed. The matter of insurance preauthorization is in fact an equalizing force in that it is not about dollar amounts but rather red tape, navigating a complex system that is all the more challenging when medically compromised and potentially from a vulnerable population. And while parity laws are meant to ensure that medical and behavioral health are treated equally with respect to benefits, such laws are notoriously poorly enforced, with "medical necessity" looked upon with greater scrutiny in the behavioral health context, adding an additional barrier to a category of care already inaccessible to far too many Americans.   

There is little question who benefits from this bureaucratic maze: doctors and patients alike are frustrated if not maddened by the system, and insurance companies themselves are the lone stakeholders gaining from the system. In an election season filled already with so many surprises, one certainty is that health care will remain prominent on the agenda -- whether expanding but building more incrementally on the Affordable Care Act, moving to single-payer, or rolling back the ACA -- and one hope is that with this continued discussion, there should be greater emphasis on allowing questions of "medical necessity" and the timeliness with which those medical procedures be carried out be determined by those holding the medical credentials.