In the Pennsylvania town hall on April 25, Hillary Clinton was asked about what it means to her to be a feminist, and she delivered a masterful response that disavowed people of the “women’s issue” nature of that which gets lumped in to “feminism.” She spoke of pay equity, which is not always particularly (if at all) egregious early in careers – after all, women are better represented in college and graduate school than men now – but which becomes all too obvious as people stay in their professions and women find themselves earning considerably less than their male counterparts for the same work. And this is not even an issue of income in the current period, as she noted in the context of Lily Ledbetter (side note: my first time attending a congressional hearing was for the Ledbetter Act at the Senate Judiciary Committee… not too shabby). Not only was she being paid less annually, but that had implications for her retirement and 401K, because less money was being put away. This is not an issue easily remedied with a pay raise, given the long-term ramifications of this inequity. This is not a women’s issue. This is an economic issue.
 
What was more noteworthy about Hillary’s response was the fact that she discussed further that beyond being a women’s issue, beyond being an economic issue, it is a human issue. When a woman is being paid less, not only are her retirement prospects down the line more grim, but that also impacts her family. It impacts whether she can afford out-of-pocket medical expenses, and thus her health and welfare. It impacts the financial security of her family. Consider a single, working mother. I was raised by such a person. If she is underpaid for her work, this impacts the neighborhood in which they can afford to live, and in turn likely the quality of the school to which she can send her child, with education quality highly correlated with ability to go on to higher education and to be economically secure. And when the issue of pay equity is hitting on equal rights, education, health care, and economic security, it is no longer a “women’s issue,” but rather speaking to the bread and butter of the Democratic Party platform.
 
For obvious reasons, gender has played heavily into this election cycle. Abortion has been under attack across the nation and pay equity has been discussed frequently, but many issues are dismissed as “women’s issues,” relegated to a niche rather than applying broadly, and many voters dismissed as supporting Clinton on the basis of her gender rather than accepting the fact that her policy proposals are well-reasoned, progressive, and achievable. After all, they couldn't possibly be voting for the candidate who was declared by the New York Times as one of the most broadly and deeply qualified candidates in modern American history. And they couldn't possibly be voting for the candidate who built her career around fighting for women, families, health care, and the economic security of the working class. 
 
We saw this in 2008 as well. People must have been voting for President Obama because of his race. It is an easier argument to make than accepting the fact that one might actually be losing on the grounds of policy substance. But it isn’t simply inaccurate to characterize minorities as voting for Obama on the grounds of race, or women voting for Clinton on the grounds of gender. It is patently offensive, dismissing as women incapable of making reasoned political analysis as opposed to letting their anatomy decide their vote. The Democratic Party (and Sanders supporters in particular) can and should be better than that. 

Following a 16-point loss in New York, a growing number of commentators have noted that Sanders' prospects for the Democratic nomination have gone from "if everything goes right for Sanders, he might have a chance" to "it's not going to be possible for Sanders to overcome Clinton's lead." The question remains, then, Why stay in the race? And perhaps more pertinently for the Democratic Party's November prospects, if staying in the race until the convention as he and his campaign's surrogates have said vociferously that they plan to do, why continue to be on the attack as opposed to shifting the campaign to just be about the (positive) message of combating income inequality?

Politico framed the issue as one of Sanders being in the political trap of being too successful to want to concede months ahead of the convention, and yet not successful enough to win. But the failure to concede or even change strategy has ramifications that extend well beyond his own candidacy for the presidency: "Choosing to back off too soon would anger or disappoint Sanders' millions of loyal supporters, his team worries. But deciding to continue fighting could risk damaging the likely Democratic nominee ahead of the general election, though that’s not a concern that weighs heavily on their thinking."

Such a stubbornness to continue to the convention evokes memories of the 2000 election, with Nader's 4% of the vote ultimately serving as a spoiler in key states, most notably Florida given the historic closeness of the race and its resolution in the Supreme Court. Of course, one can make a number of arguments on the Nader front: the race didn't need to be that narrow if the Democratic Party had a stronger candidate, and we don't know with absolute certainty how (or if) Nader voters would have otherwise voted. But the point is that in a very close election, even just a couple percent of the voting population can make enough of a difference as to swing an election outcome from the Democratic to the Republican Party. And while Sanders is not threatening to run as an independent candidate, his willingness to remain on the attack with respect to Clinton provides enough ammunition for the Republicans to use in the general election, and arguments for Democrats and independents not to trust her leadership, that he risks empowering the interests that he purports to so oppose.So while this is not a wholly analogous case -- we are still talking about the Democratic nomination and not the general -- there is reason to question his motives (policy as he suggests, or ego as his actions imply) and to discuss the potential for his campaign strategy as promoting a spoiler outcome moving forward. 

It is no secret that I am an avid fan of John Oliver (some might say obsessed). I look forward to his show every Sunday, not just because it is hilarious, but because he truly is one of the only people doing true investigative, gutsy journalism these days. As a consequence, I was quite surprised to come across this news story: a New Jersey high school teacher was temporarily forced to resign for showing his students the John Oliver clip on "Make Donald "Drumpf Again." 

There is not a secret as to Oliver's politics. There is an ideological bent to the show, which viewers can take into consideration when evaluating its content and trusting its message. But it also reports a number of stories that are highly salient and deserving of greater public attention, for example:

* Pharmaceutical companies' marketing of drugs to doctors
* Mandatory minimums in sentencing
* Voter suppression tactics and other constraints on voting rights
* DC voting rights
* The limited resources of public defenders
* The "revolving door" in government regulation with the FCC chairman appointee
* Abstinence-only education
* Paid and unpaid family leave
* Televangelists' seed-faith practices
* Sweat shop labor in the fashion industry

I, for one, have shown the clip on the FCC and interest group capture when teaching on the relationship between bureaucracies and interest groups. It is a crisp and recent example of the relationship between the communications industry and the federal government and the implications for effective and responsible regulation of monopolies (and of course, with a healthy dose of humor thrown into the mix).

The teacher's resignation provoked a marked response from the school community and led to him rescinding his resignation and ultimately reclaiming his position. But the broader point is that provided that instructors do not present the show as being an unbiased source of information (indeed, as with any op-ed, it should be a starting point for more, important investigation and discourse), one should hardly be justifiably fired or otherwise pressured to resign for using its political commentary as an instructive tool. 

On Tuesday, April 19, the Supreme Court heard oral arguments on Universal Health Services v. United States, ex rel Escobar, in which Universal Health Services, Inc. made the argument that providers ought not be held liable for fraud for failing to comply with particular regulations. The outcome of the case will have important implications for the number of False Claims Act suits that are brought against a number of industries but healthcare providers in particular, with two-thirds of whistleblower suits targeting healthcare entities. 

At the heart of the case is the False Claims Act, legislation enacted amid the Civil War and awarding treble damages against government contractors that "knowingly presen[t] . . . false or fraudulent claim[s] for payment.” The majority of cases brought under the Act are by whistleblowers, who can then recover 15-30% of the government's overall recovery. 

Supporting UHS are a number of healthcare groups such as the American Medical Association and the American Hospital Association, which wrote briefs for the case in support of the petitioner's argument that imperfect compliance with the law does not constitute fraud and that the Court should not open the door to meritless lawsuits. Opposing this position are whistleblower groups and mental health advocates, holding that the law is in place to protect patients against being subjected to substandard care, of which Universal Health Services has been frequently accused, with a number of their facilities under Department of Justice investigation, Departments of Children and Family Services refusing to send children to some of their units due to patient conditions (see my previous post on UHS maltreatment), and the Commonwealth of Massachusetts recently requiring that four UHS-managed facilities submit correction plans given patient care and life safety violations. UHS is no stranger to False Claims Act suits across the country, with the company and two subsidiaries settling in 2011 for $6.9 million claims that they had provided substandard psychiatric care to adolescents and had engaged in Medicaid fraud, and with 25 of its behavioral health facilities under federal civil investigation under over alleged violations of the False Claims Act. 

Justices Kagan and Sotomayor appeared during the oral argument to be skeptical of the argument made by UHS, with Justice Sotomayor asking early on, "I always thought that when you asked for payment, you're making a promise: I did what I agreed to do. Pay me, please. That's, to me, what's sort of understood. If I hired you to provide me with doctor services, you ask me for money, I'm assuming you provided me with doctor services. And you know you didn't. Why isn't that a fraud?" Justice Kagan noting that the issue at hand was quite analogous to the type of fraud that the False Claims Act had been meant to address -- namely, contractors' selling to the government non-functioning guns and other materials to the United States during the Civil War -- and she noted, “I would think that this is the exact same --that the contract was for a doctor's medical care, and a doctor's medical care was not provided." Chief Justice Roberts, however, was more sympathetic to UHS's arguments about the harshness of applying the False Claims Act given the complexity and extensiveness of the applicable (thousands of pages of) regulations in challenging cases. Justice Breyer sought to distinguish between garden variety breaches of contract and those violations that could accurately be construed to be outright fraudulent under the FCA. 

How the Court ultimately will come down on the case is ultimately unclear, apart from the quite vocal and pointed Justices Sotomayor (pro-relator) and Roberts (pro-contractor). Should the Court be split 4-4 along party lines with the ninth seat not yet filled, the 1st Circuit's 2015 holding will stand (though it is worth noting that this is an issue of inter-circuit conflict, with the 7th Circuit rejecting the 1st Circuit's argument in a separate case). The 1st Circuit had validated the notion of "implied fraud" -- that is, that even absent actual misrepresentation, claims can be misleading because demands for payment contain an implicit misrepresentation (e.g., the provision of certain medical services that were ultimately deemed substandard). 

While a case of fraudulent claims, at first blush, does not appear the stuff of front page headlines, the implications of the case are vast, with Universal Health Services being the largest provider of inpatient behavioral health services in the United States -- boasting facilities in 37 states, Washington DC, Puerto Rico, the U.S. Virgin Islands, as well as the United Kingdom -- and managing approximately 25% of inpatient care. Touching on so many lives across the country, the company is highly influential in the lives of its patients and their families, but with that power comes the responsibility to adhere to certain standards of care, standards that a number of suits and reports have suggested that they have failed to make. Chances are, we will not know until June how the Supreme Court ultimately will rule on the matter. 

The New York Times ran an op-ed on April 18 highlighting Sen. Sanders' dismissal of the outcomes of southern states, and the role that they play in the primary race, bringing to light for example the following quotes:

“Secretary Clinton cleaned our clock in the Deep South. No question about it. We got murdered there. That is the most conservative part of this great country. That’s the fact. But you know what? We’re out of the Deep South now. And we’re moving up.” -- Sanders on CNN

“Well, one can argue — people say, Why does Iowa go first? Why does New Hampshire go first? — but I think that having so many Southern states go first kind of distorts reality as well.” -- Sanders on The Nightly Show

There are a couple of problems with this logic, which the author Charles Blow brought to light. For starters, three of these southern states that he lost -- North Carolina, Virginia, and Florida -- are key states in which the Democrats hope to be strong contenders (North Carolina being the most conservative of the three and plagued by voter ID problems, and the other two voting for Obama in both 2008 and 2012). Secondly, in southern states, a large share of the Democratic primary voters are African American, a demographic group with which Sanders continues to struggle. 

Sanders and his supporters have made (especially in the context of discussions about superdelegates) rhetorical flourishes about Sanders' successes in caucus states such as Wisconsin and elsewhere have reflected a surge in support and the "will of the people." It is undeniable that Sanders has vastly outperformed what many expected of him, and for that he should certainly be proud. But given the demographics of the states in which he has been successful (e.g., Wisconsin, New Hampshire, Alaska, Idaho, etc., as opposed to the more diverse states in which Clinton has been successful such as Virginia, Florida, North Carolina, Texas, etc.), it is nevertheless difficult to accurately characterize such outcomes as the will of the people, much less the will of the Democratic Party overall, which relies on the support of the African American community. Moreover, while Sanders touts his average campaign contribution of $27 -- and indeed it is admirable and impressive to have garnered such financial support from so many small contributions -- he has sharply criticized Clinton for taking larger contributions and for benefiting from large fundraisers from such people as George Clooney, despite much of the money going toward not Clinton herself, but to the Democratic Party and down-ticket races, suggesting potentially a broader engagement in the Party and its supporters. 

Part of the reason why we should take Sanders' support with a grain of salt comes down to the nature of the primary system. Much of Sanders' support has come from caucus states, which many have characterized as undemocratic given, for example, the logistical challenges posed for lower-income workers, families without child care, students, and seniors (all demographic groups that he argues that he represents), in addition to the generally haphazard nature in which votes often are cast and counted. Further, and applying to both Clinton and Sanders, not only are primary elections low turnout relative to the general election, but political scientists have noted that primary voters tend to be more ideological than are general election voters. Thus, there is for all states a problem of representativeness. 

With this caveat of less-than-representative subsets of the American electorate determining the Democratic nominee for president, Nate Silver notes that Clinton is doing far stronger in states that more closely resemble the national Democratic Party. Not only do the states in which Clinton boasted victories have large populations of African American and Hispanic voters, both central to the Democratic Party if it will be successful, but Silver argues that North Carolina, Virginia, Florida, and Texas (all supporting Clinton) "are among the most demographically representative of the diverse Obama coalition that Clinton or Sanders will have to rely on in November."

There are demographics in which Sanders has been more successful than Clinton -- notably, young voters and in particular, 18-29 year-old women -- and Clinton will need to ensure that they turn out in November given that young voters tend to be less reliable voters. Sanders has also scored well with independents, which may prove important in an election in which there is so much uncertainty with respect to the Republican Party nominee. However, for Sanders and his supporters to argue that his recent successes represent the "will of the people" or a tidal wave of support that should be noted moving forward to the convention is indeed misleading. Sanders may indeed prove valuable in working to bring new people into the party. But if key demographic groups for the Democrats continue not to "feel the Bern," and if he fails to address this limitation in his mobilization, he will continue to face an uphill battle.

 Much of the debate over Clinton versus Sanders has centered around the question of ideals versus experience. The idea of what should be versus what can be, particularly given the realities of persistent divided government and thus limitations on what the president can himself or herself achieve. Clinton called attention to this in the recent debate in New York, holding that "it's easy to diagnose a problem, it's harder to do something about it," with Sanders' policies being discussed far more in broad strokes than in achievable policy particulars.

But one day ahead of the New York primary, it is also important to consider whether, in the unlikely scenario that he becomes the Democratic nominee, and in the even less likely scenario that his policies are carried into effect as he wishes, would it be good for the country? A number of economists have said no, but I wanted to dig deeper.  

I have not been one to vote my pocketbook. I believe that taxes are an important contribution that we as citizens need to make in order to invest in public schools (from which I benefited, both in secondary school education and in higher education, go bears), roads and public transportation (which I use daily), environmental protection (a global imperative), and the like. But efficiency in those allocations of funds is important (as is one's ability to pay for rent and groceries), and looking between the Democratic candidates, both of whom support those policies, with whom would a middle class person such as myself benefit? 

The focal point of Sanders' campaign has been income inequality. Make the people on Wall Street accountable and protect those on Main Street. Prevent the rich from getting richer, the poor from getting poorer. That's all well and good. This tool can help one to calculate their change in tax liability under the four frontrunners for their party nominations (Trump and Cruz on the right, Clinton and Sanders on the left), given income level, marital status, and number of children. I am single, have no children, and have a current income of $45,000. According to those numbers, I would benefit from a tax perspective under the Republicans, I would pay $40 more with Clinton, but I would pay $4,880 more under Sanders. This is with an income that is incontrovertibly middle class. 

I then looked to see whether the benefits under Sanders would kick in if I were at or around the poverty line, so I entered an income of $15,000 (holding constant marital status and children). Still, I would be paying more under Sanders, with an increase in tax liability of $20 under Clinton and $1,630 under Sanders. Even if earning $15,000 per year with two or more dependents, I would be paying $990 more under Sanders while breaking even with Clinton. Even more absurdly, with a marital status of married and with two or more dependents, one would need to make under $5,000 to benefit under Sanders' tax plan (under $10,000 year if single with two or more dependents). And while it is true that his policies absolutely hold millionaires and billionaires accountable at a higher rate, the fact that those on the middle and lower ends of the income distribution are feeling such a pinch -- in some cases to a debilitating extent --is inconsistent with his rhetoric of concern about the middle class disappearing and the desire to combat income inequality that benefits the wealthy at the expense of the poor. In fact, a recent poll revealed that Sanders supporters are willing to spend only an additional $1,000 more on taxes, vastly exceeding that which his policies would require of them.

It is consistent with the challenge that the Sanders campaign has faced throughout, which is that talking about policies and problems is an easier task than is implementation. Short of careful, deep thought about how to combat these economic and political struggles, he has devised an economic plan whose specifics appear to go against the positions for which he purports to stand. I do not in any way believe that this is the result of any nefarious work on the part of the Sanders economic advisors, but it should give New Yorkers and Americans across the country pause before endorsing these policies. ​

​ 
For many Democrats, one of the more cringe-worthy moments of the 2004 election cycle is John Kerry’s notorious “I was for the war because I was against it,” which led to ample attacks from the right with respect to his supposed “waffling” on the issues. That said, sticking stubbornly to unpopular policies carries a number of costs as well, particularly within the domain of issues deemed important in the eyes of voters.
 
The April 14 debate reminded us of this tension that candidates face when public opinion shifts with respect to issues on which one has voted or made public statements, or when new information comes to light which might have informed that behavior. In particular, the issue that appears to repeatedly haunt Sen. Sanders is that of gun control, on which he has voted more consistently with his home state of Vermont, which is more pro-guns than is the national Democratic Party.
 
Sanders has voted to give gun manufacturers immunity from liability when those guns are used toward illegal ends, an issue that has been particularly heated in the context of such events as Sandy Hook. He has shifted a bit on the matter, indicating that Sandy Hook victims should be entitled to sue, though overall he has stuck by his record and its purported consistency, touting his adverse record by the National Rifle Association despite Clinton’s attacks on Sanders for not working to hold gun manufacturers accountable (particularly given his emphasis on corporate accountability), and despite the fact that the NRA had backed his candidacy in 1990. Admitting that he may have been wrong on the issue of guns is not a statement that we have seen from the Sanders campaign.
 
Admitting to being wrong – whether on guns, on war, or even on a narrower issue – does not come easily, in particular given the spotlight under which the candidates are operating in presidential election season. However, the cost-benefit analysis leaves a lot of questions as to why Sanders would not back away from his (prior?) positions on gun control, if for no other reason than strategy.
 
A number of southern states (e.g., Georgia, Texas, and Virginia) whose elections were held earlier this year rated gun control as important (sometimes even more important than the economy and ISIS) and an issue on which they must agree with the Democratic candidate for whom they vote. These are all states in which Hillary dominated. They are also all states in which the Democratic base is more notably minority, communities in which gun violence is a prevalent concern and communities in which Sanders is struggling to gain ground relative to white voters.
 
A recent survey of Americans on gun ownership reveals not only a widening partisan division in gun ownership and support for gun restrictions, but also a notable disparity between whites' and non-whites' rates of gun ownership, with 40 percent of whites owning guns compared with 14 percent of non-whites, and notable racial division in support for gun restrictions as well. In fact, these divisions over gun ownership are at their highest since 1977. Moreover, deaths from gun violence vary dramatically by race, both in number and by type, with whites more likely to die by suicide and African Americans more likely to die by homicide. 
The African American community has been a reliably Democratic voting demographic, indeed being characterized often by political scientists as “captured.” However, it is not news that despite progressive politics, black voters have not been feeling the Bern. Part of this is attributable to Clinton’s solid record in challenging racial discrimination and issues disproportionately affecting minority communities (e.g., poverty, crime control). But part of it has to do with Sanders. For starters, while reliably Democratic, black voters are not always as socially liberal as are many of the white voters who Sanders has mobilized under his self-described “democratic socialist” policy agenda. And second, in a time in which mass shootings and other incidents of devastating crime, the issue of gun control remains all the more salient, leaving Sanders vulnerable when the issue comes up in debates and other campaign settings (which Clinton would be right to continue to address). With recent investigations into the institutional racism within the Chicago police force, we can reasonably expect the issue of crime and guns, and the relationship to racial tensions, to remain at the forefront for many voters.   
 
Sanders has the misfortune of representing a state to the right of the country where gun control is concerned, and as a sitting Senator running for president, he is caught between the multiple constituencies that he seeks to represent. (And indeed, it is relatively easy to be pro-guns in Vermont, a state in which there is very little crime). The fact of the matter is, Clinton’s position on gun control in this period of racial tension and mass shootings is more in line with the national Democratic Party’s mainstream, and it is evidenced by the large states that she as won, Clinton voters’ priorities as indicated in exit polls, and the demographic groups that she continues to win over. While there are certain liabilities in shifting a public position, admitting to a more pro-gun control stance than he has supported in the past – whether out of growth as a politician or as a result of reflecting a broader set of public preferences and seeking to be responsive in turn – would likely serve him well moving forward. 

​As a political scientist who has spent prior time working on voter protection and campaign mobilization, I am occasionally asked about the tactics that we can expect to see play out in the upcoming presidential election given its status as the first presidential election in the aftermath of the Supreme Court’s decision regarding the Supreme Court’s 2013 invalidation of a key portion of the Voting Rights Act of 1965. To be sure, it was a holding that is specific to states covered by the preclearance provision of Section 5 of the Voting Rights Act, which had relied on earlier data to determine which states and locations were covered by the Act. These states covered by Section 5 are those that have historically been faced with problems of racial discrimination, in this case in the form of voter suppression, whether in the form of poll taxes or literacy tests or arbitrary questions such as “how many jelly beans are in this jar?” or else outright intimidation or violence. However, in addition to the deep South (e.g., Mississippi, Alabama, and Georgia), there are a nontrivial number of states and counties in politically pivotal regions such as North Carolina, Florida, and Virginia, for example, that for the first time since 1965 will be exposed to racially discriminatory tactics aimed at suppressing the votes of minorities, typically a Democrat voting bloc.
 
There are a number of strategies that have been employed historically and that are no doubt on the table in the upcoming elections. I wrote in a previous piece the trials through which North Carolina voters are going with the implementation of the photo ID requirements of citizens in order to vote. 218,000 registered voters in the state lack government-issued photo identification in order to cast their votes such as if they are non-drivers and are unable to navigate the labyrinthian system that is the acquisition of a government ID card, which itself requires a passport or a birth certificate and accompanies a cost that amounts to a poll tax.
 
There is an additional measure that can be exploited, and to which relatively few have paid as much attention: time off on Election Day to vote. An increasing number of states allow voting by mail or have other early voting or absentee voting procedures in place, which have the benefit of flexibility with respect to voting scheduling as well as reducing the length of lines on Election Day. Other states have various different procedures to permit employees to leave work for some period of time in order to vote. Some states require that employers provide employees with two hours of paid leave to vote, others three hours of paid leave, and others do not require that the leave be paid but do require that there not be retribution as a consequence of taking that time off.
 
The State of Missouri allocates three hours for employees, who with prior permission from their employer are entitled to paid leave for that period of voting time. Needless to say, such laws disproportionately impact non-exempt employees (that is, those working for an hourly wage), which in many cases garner less income than do salaried positions, and thus having a disproportionate impact on those who are less wealthy or economically stable.
 
On April 5, 2016, local elections and bond measures were voted on in Missouri, with this type of election admittedly already low in turnout given that the state’s presidential primary was held just weeks earlier on March 14. Despite Missouri’s election laws, there was confusion among the hospital staff at SSM Saint Mary’s as to their ability to take time off to vote and with what degree of notice it would be required. Compounding the confusion was the fact that election times had to be extended due to precincts running out of ballots, in turn requiring an adjustment in allotted time off from work, with some voters ultimately unable to make it to their polling places. The election was not widely publicized and thus many were uninformed of its presence, let alone the intricacies of Election Day voting laws (especially when working 7am to 7pm shifts that cover virtually the entire time that the polls are open), and this case was merely anecdotal evidence.
 
However isolated this incident of inability to vote was and however ripe the conditions were for voters to lack the tools with which to assert their voting rights at work, it may well be a more pervasive challenge that goes undocumented if workers themselves are not cognizant of the hours to which they are in fact entitled to vote in their state, and thus know neither their ability to challenge their employer’s behavior nor to report that behavior to election monitors. The lack of information regarding election laws among the American electorate (made all the more complicated by the extensive state-level variation in rights and protections) makes these sorts of malpractices (e.g., a company making it difficult for their employees to vote on Election Day and not allowing for added time in the more densely populated regions that can accrue several-hour long lines) all the more likely, or at a minimum all the more possible.
 
One solution is to make Election Day a federal holiday or on a weekend (as is the case in some countries abroad such as France, Germany, and New Zealand), which would not solve the photo ID challenges, but which would preclude voters from facing the undemocratic trade-off of political participation versus needed income. The setback to such a remedy is, of course, the political reality that the present and increasing constraints on voting disproportionately benefit one political party, that which controls Congress currently. However, this is not an issue – or should not be an issue of partisanship but rather of process. Republican Representative Jim Sensenbrenner wrote recently that he would rather lose an election than suppress votes in order to win. I call upon members of both parties to promote further transparency with respect to voting rights and eligibility, and greater accountability with respect to those individuals and entities that are not compliant. Maximizing access to the ballot box and helping voters to avoid fearing being penalized for taking time to participate in the democratic process – arduous though we make it at times – is truly the least that we can do while calling ourselves a great democracy. 

​On January 26, 2016, the U.S. Preventive Services Task Force issued a report advising that primary care doctors screen all adults for depression. They advised that such screenings can raise awareness of the common and treatable nature of many mental illnesses. This is particularly important given the potentially fatal consequences of untreated depression (with 41,000 Americans committing suicide each year, 90% of which are associated with mental illness according to the Centers for Disease Control and Prevention) as well as the economic impact of costing the United States $210 billion per year (40% of which are related directly to depression specifically, as well as indirect costs such as losses of productivity).
 
Such advisement was in keeping with an already noted trend of primary care doctors – trained as internists – treating many patients for mental illness, with more than a third of patients relying solely on their PCPs for mental health treatment given limited accessibility of care in many regions as well as concerns about stigma.
 
Given both the prevalence of mental illness and the high degree to which physicians outside of psychiatry are treating mental illness directly or incidentally to other medical conditions, it is important to evaluate the ways in which non-psychiatrists treat patients with psychiatric histories. Do they treat medical conditions equally for patients with or without histories of mental illness, or are there intentional or inadvertent practices that discriminate in the management of health conditions?
 
A firsthand account of this was taken up in a 2013 New York Times op-ed, with the author Juliann Garey noting the numerous occasions in which her medical conditions were not treated seriously once the treating physicians noticed her history of bipolar disorder and her medications to treat it. From being given only Tylenol for an ear infection that soon resulted in a ruptured eardrum and permanent hearing loss, to being scolded by her gastroenterologist because of co-existing psychological and stomach problems, she found that the nature of treatment was noticeably poorer once it was revealed to her provider that bipolar disorder was in the mix, a phenomenon referred to as “diagnostic overshadowing.”
 
The term was coined in 1982 to characterize physicians’ potential propensity to attribute physical symptoms to mental disorders, yielding bias in diagnosis in treatment. Thus, if a patient with a depression history is having digestive symptoms, they might be more quickly attributed to stress as opposed to leading to a GI workup. Mild chest pain might be more quickly attributed to anxiety than a cardiac arrhythmia. While the initial instincts may well be accurate in the end, the disparity in treatment quality may be problematic.
 
By and large, I have been immensely fortunate in that despite a history of depression and a complex medical history, both have been treated seriously, with my physicians highly invested in my recovery in both domains and treating my health conditions with dignity and professionalism, often going above and beyond the call of duty. I cannot say enough good things about my primary care provider and the specialists I have had over the years. However, a recent and quite severe experience with this at SSM St. Mary’s Hospital in St. Louis, MO necessitates some further discussion on this matter of discrimination on the basis of mental health from those in whom we trust for our care.
 
Having entered their hospital care by ambulance after severe complications involving psychotropic medications, it was revealed that my previously diagnosed endocrine conditions were acting up at dangerous levels, with electrolyte abnormalities that were worse than in any of my medical workups to date and such electrolyte abnormalities associated with a significant potential for cardiac complications.
 
Despite my having had prior discharge paperwork from only three weeks earlier to attest to their knowledge of my medication list and dosages to manage chronic parathyroid and stomach conditions, they neglected to provide me with my normal medication regimen, even with the increasingly severe electrolyte abnormalities with which I had presented in their emergency department. Multiple conversations with multiple nurses and the attending physician failed to result in their correcting the numerous deficiencies in this regard: one medication would be approved but another not, another medication prescribed for four times daily (calcium carbonate, hardly carrying any addictive properties) authorized for only once daily. What’s more, the attending psychiatrist ordered the discontinuation of all psychotropic medication without ever once informing me of the decision, let alone explaining the rationale. (It is worth nothing that cold turkey discontinuation of one of these medications, Klonopin, is considered to be medically dangerous).
 
To fail to so much as inform a patient as to the medications that they are being prescribed, or from which they are now barred, is an act of unprofessionalism. To justify it on the grounds that the patient has a history of severe depression adds a further dimension to this maltreatment, which is discrimination on the grounds of mental illness (covered by the Americans with Disabilities Act of 1990) not only from primary care medicine but also from psychiatry, the very subspecialty of medicine designed to treat these illnesses. It should thus come as little surprise that I left the hospital with declining electrolytes and more noticeable symptoms given their lackadaisical mode of treatment and diagnostic overshadowing that, if in a patient more critical than I, could have resulted in much more significant complications.
 
While it is perhaps understandable to take with a grain of salt a medical report from a psychiatric patient, particularly one whose condition contains psychotic features or delusional thinking (neither of which typically applies to unipolar depression), prior medical records and prescription records from pharmacies, and the ability to consult with one’s primary care physician should assuage concerns in this regard and should not result in the failure to adequately treat the medical needs of those who have co-occurring medical and psychiatric disorders and move beyond these discriminatory treatment practices.
 
In a perfect world, such a change would be in the interest of all parties – certainly patients, but also for physicians seeking to do their best jobs in treating their patients, depressed or not (though such an approach may admittedly result in more insurance claims). More realistically, practices will be adjusted strategically on the basis of risk aversion with respect to medical malpractice litigation. With any luck, with more primary care physicians involving themselves to some degree in the mental health care of their patients through routine screenings and such, so too will there be increased understanding of mental health among PCPs whose work had not previously focused on such conditions, and with that greater knowledge in treatment, also greater compassion and thoroughness in treating other conditions in those same patients. 

Reported on April 9, 2016, the Commonwealth of Massachusetts ordered that 4 Arbour mental health facilities -- those in Pembroke, Quincy, Westwood and Jamaica Plain, with a combined 363 psychiatric beds -- all owned by Universal Health Services, “urgent patient care and life safety violations.” This is only further and growing evidence of the lack of care with which Universal Health Services continues to provide mental health treatment in its monopoly of care around the nation.  

The Massachusetts Department of Health and Safety is reportedly empowered to halt new admissions to these facilities on the grounds of these egregious safety violations revealed through recent inspections are corrected:

"The state agency did not specify the violations uncovered at the facilities, but Pembroke Hospital has come under fire by state and federal regulators since late August when a 20-year-old patient, Amber Mace, was found dead in her room at the hospital. Mace had been dead for at least two hours and her body was already in “full rigor mortis” before any staffer at the 120-bed hospital took action, according to state investigative reports obtained by The Patriot Ledger from the woman’s family. Pembroke Hospital staff was supposed to check on patients’ well-being and verify signs of life at 15-minute intervals through the night, but the safety checks were done improperly because staff did not actually enter Mace’s room and watch for signs of Mace breathing, according to state reports. The state determined that Pembroke Hospital created a 'dangerous and inhumane' condition for Mace and said the policy and treatment failures could have prevented the young woman from receiving meaningful treatment."

The pervasiveness of such substandard are provided by this organization is becoming increasingly clear, and should not be tolerated by state agencies or by the organization itself.