Medicare for All

Usually on the Medicare for All Podcast, we talk about people who want healthcare but can’t get it, but today we’re talking about people getting healthcare they have specifically refused: folks who have been involuntarily committed. For plenty of our listeners, the idea of being held against your will at a psychiatric institution feels like a nightmare from another time – something out of gothic fiction or horror movies set far in the past. But for folks struggling with mental illness in 21st century America, the terrifying prospect of psychiatric commitment is alive and well. In fact, a 2020 UCLA study found that in the 25 states where they actually keep data on this, the numbers of involuntary psych detentions have been sharply rising in recent years. Today, we’re joined by two experts in this dark corner of our healthcare system to talk about why so many people are getting committed and who is reaping the benefits.

Show Notes

Originally from Massachusetts Jesse Mangan has experienced a few different psychiatric hospitalizations and has spent over two decades struggling with the impacts of those experiences, so now he produces a podcast about mental health laws called Committable.

Rob Wipond is a freelance journalist who writes frequently on the interfaces between psychiatry, civil rights, policing, surveillance and privacy, and social change. His articles have been nominated for seventeen magazine and journalism awards. He is also the author of the 2023 book Your Consent Is Not Required: The Rise in Psychiatric Detentions, Forced Treatment, and Abusive Guardianships.

Jesse shares how he came to have so much (unwanted) expertise in psychiatric commitments, and how he turned that experience into a podcast, Committable. He was involuntarily committed and held longer than the standard of care dictated, past the date his insurance ran out. He was finally discharged with no real discharge plan and a big bill.

Rob tells us he’s been writing about mental health for a couple of decades. He says that the media typically portrays people who have been committed as really out of touch with reality, but he’s found that they’re far more like the rest of us. He watched his dad – who had no history of mental illness – go through a catastrophic health crisis that led to a depressive episode. Rob tells us that his dad was held and treated against his will for months. This happened in Canada where healthcare is guaranteed, so it’s a more complex problem than just enacting the right financing system.

A lot of people tend to think of psychiatric commitment as a barbaric tactic from the bad old days – like Nurse Ratchet in One Flew Over the Cuckoo’s Nest – but this is obviously a practice that continues to this day. It’s more common now for people to be held for a few days, rather than months or years on end. We only have data on these commitments from 25 states, but they show that these kind of commitments are rising dramatically.

Jesse explains that due to disability rights activism and investigative journalism, a number of federal cases in the 1970s established some basic due process standards for patients. At the same time the mental health system became increasingly privatized and our understanding of mental health changed dramatically. The expense of due process became a factor – as soon as a case reaches a court hearing, private providers become more likely to release the patient because of cost. State mental health laws have given a lot of authority to law enforcement and providers to detain patients on an emergency basis without a due process check until the point the facility wants to hold the patient beyond the emergency period (in many states 72 hours). The justification for holding these patients are often very vague and broad, posing a risk to many Americans.

Mental healthcare in this country isn’t a clearly defined system. Providers are often driven to be more conservative about holding patients because of a fear of liability if they don’t. The profit motive is certainly involved, but there are other motives as well: it’s widely accepted that forced treatment helps and is good for the patient. There’s also a social tendency to isolate people we deem dangerous from the rest of society.

Jesse highlights that we spend a lot of public resources on the court process for outpatient commitment as well. There are some resources that are only available to people on a court order, which incentivizes family and clinicians to seek a court order to get those resources. Advocacy on behalf of people with mental illness tends to be dominated by families and groups with more “respectability” leading to a generally paternalistic approach to mental health laws.

Because the US doesn’t have a federal healthcare system of any kind, those of us in the Medicare for All movement tend to attribute a lot of failings to that patchwork of coverage. Rob tells us that the same critiques (“chaotic” and “patchwork”) happen in Canada because systems are run provincially. The real elephant in the room is that there’s no evidence to support involuntary mental health treatment. There’s nowhere in Canada or the US where outcomes of involuntary commitment are tracked. Money is thrown at whatever the advocates or healthcare corporations claim will work, without any scientific evidence informing a consistent standard of care across the country.

Jesse also notes that there are interactions between the mental health system and the criminal justice system that Medicare for All won’t solve. In many cases patients are committed in order to restore their competency to stand trial (rather than to restore them to wellness). As soon as they are restored to competency and relased from the mental health facility, they are returned to the criminal justice system where they won’t receive treatment and may deteriorate again. Financing won’t solve mass incarceration and perverse incentives for treatment.

While we continue to advocate for Medicare for All, in order to make mental healthcare truly equitable, our guests stress that we need to make sure the system covers more than just medicalized treatments, and we need to…

Q6: This seems like one of those problems with US healthcare that M4A can’t solve on its own – as we fight for universal healthcare, what other changes do we need to be fighting for to make mental healthcare truly equitable?

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