
As Suicides Rise, Insurers Find Ways to Deny Mental Health Coverage - pseudolus
https://www.bloomberg.com/news/features/2019-05-16/insurance-covers-mental-health-but-good-luck-using-it
======
hedora
Even before the insurance denies, it is basically impossible to get someone
that is delusional/psychotic mental health care in the US, unless they go in
voluntarily, which they won’t, by the nature of the illness.

A friend that has been certified mentally ill stopped taking his meds and was
fantasizing about killing himself, a family member and shooting up religious
organizations. His doctor, family, employer and friends all called the police,
talked to lawyers, mental health professionals, etc.

The end result was that he was facing sleeping in a car that was about to
repossessed, and eating in homeless shelters. At that point he decided to
accept free housing in exchange for seeking help.

His family’s only other recourse would have been to pay tens of thousands of
dollars in legal fees to petition the court to force the police to uphold the
law. This would have had a medium to low chance of succeeding.

Of course, during the months this dragged on, he missed an insurance payment
or two (he had also been fired, divorced and evicted), so it lapsed.

There is a 12 (6?) month wait to get government disability insurance to kick
in for this sort of thing, and the clock starts after the mentally ill person
goes in for scary interviews with the government to establish they’re actually
crazy.

The law used to handle this sort of thing properly in California, but Regan
repealed the lions share of it as governor, and loopholes that accidentally
allowed people like my friend to get health care have been progressively
closed since them.

Nurses at the intake office of the appropriate mental health facility in Santa
Cruz told me that most of the homeless people in the Boardwalk area there are
in exactly the same situation as my friend was in, except they’ve been trapped
in it for years.

~~~
sokoloff
> it is basically impossible to get someone that is delusional/psychotic
> mental health care in the US, unless they go in voluntarily

I'm not sure I see a better solution to this that doesn't come with its own
set of risks and downsides (involuntary commitment or counseling of someone
against their will is not something to be taken lightly in any event, even if
their reality diverges from your own).

~~~
dsr_
Things which would have helped here:

\- healthcare not linked to employment

\- a housing-first homeless policy

\- a compassionate aid policy that presumes that people who are asking for
help need help, and starts providing help as soon as it is asked for rather
than after a year or more.

Those don't seem like they have any major risks other than monetary.

~~~
hedora
I strongly disagree with the housing first policy. I tried paying for
temporary housing for my friend, and things spiraled. The housing has to be
conditioned on some sort of recovery plan.

Threat of homelessness is basically the only remaining lever the law allows in
these situations.

The other two points are spot on.

~~~
Frondo
I don't know your circumstances, and first of all that is a great and generous
thing you did for your friend.

The one place I know of where a housing-first policy has been implemented,
Salt Lake City (or maybe all of Utah?), doesn't just give homeless people a
set of keys. They do assign everyone a social worker at the same time. The
goal is to minimize the risk of what happened to your friend; that isn't good
for anyone, including the person spiraling.

It's key, though, to start with a home (and a social worker). The wealthiest
country in the world can do that for its people -- and it shouldn't be on
private citizens, though that was generous of you.

~~~
dv_dt
A big advantage of institutions is to collect the long term learning and
lessons into more effective actions. Trying to handle it individually is
admirable, but it's at a huge disadvantage and without experience with
multiple cases to know what might work better or worse for various people.

------
vinbreau
I've lost three friends over the years to psychotic episodes or schizophrenic
breakdowns so I've seen several examples of what happens to people and it all
comes down to financial means. The friend born to a wealthy family had a
safety net to fall back on. Same for the friend born to a very religious
family.

As for the friend from a poor family, it was horrible to watch what everyone
involved had to go through. He was a happily married man in his mid 20's.
Decided to go off his meds and not tell anyone. It didn't help that he had
never told us about his mental illness, but that was his choice. He snapped,
left his wife and vanished for a while. When he was brought home his parents
could not keep him in their house as he was prone to threaten violence. He
even threatened me once during this period. Since they had no insurance they
could not house him at a facility. The only thing they could do was pay for
him to live in a motel, one within their abilities which meant the cheapest
motel they could find, one known for drug users. My friend had previously had
a problem with drugs, had to go to court mandated Narcotics Anonymous, even
had a mentor to help him. Despite having cleaned up for over 10 years, here he
was in a motel full of drug dealers and users while in the midst of a
psychotic breakdown.

The last time I ever saw him he was having a fit in a field near a mall. I
stopped to help him, he was in a fugue state thinking he was in World War 3.
he smelled of urine and his clothes were a mess. I drove him to a local YMCA
because I had no idea what else to do. They told me there was nothing they
could do, but agreed to take him in for the day and see if they could clean
him up. Knowing he was prone to violent behavior I figured that wouldn't work
out.

I never saw him again. A friend of five years just evaporated. But what I saw
is that if you are poor and have a mental breakdown, and your family has no
means to help you, you are screwed and have no choice but to live on the
street.

~~~
skinnymuch
That’s heart breaking. When was that last time you saw him?

~~~
vinbreau
It's been about 20 years now. No idea what ever happened to him sadly.

------
macinjosh
In my experience a related obstacle to obtaining mental health services is
that the insurance companies require that the records from therapy must be
available to the insurance company so they can verify the services they are
paying for. Meaning, the notes from deeply personal discussions with your
therapist and any resulting diagnosis can end up in the hands of your
insurance company. Once this information has left your therapist's office it
can end up any number of places. While that might be a risk I am willing to
take with my social security number or other personal information the deeply
personal topics discussed in therapy are not worth risking.

I don't see how this gets any better with single-payer/government funded
funding routes. I don't want anyone to know what I discuss with my therapist
much less a soulless corporation or the government. The avenues this could
open up for oppression from corporations and/or the government sends a shiver
down my spine.

~~~
dsfyu404ed
>The avenues this could open up for oppression from corporations and/or the
government sends a shiver down my spine.

Tons of vets already avoid mental health services because it's a black mark on
their career and can hinder their ability to bear arms in civilian life.

~~~
LyndsySimon
It’s a huge problem in the firearms community - most of us are scared to seek
even minimal mental health assistance because of the stigma associated with
it.

I faced my own issues with depression in my late teens and early twenties. Gun
rights are very important to me, and I was extremely hesitant to speak to any
mental health professional due to the potential future restrictions it might
place on me. I did see someone, and over the course of a few years recovered
to the point that I was able to get my life back on track - but even then, it
was difficult to find a therapist that wouldn’t immediately demand that I
dispose of all of my firearms. I ended up asking around and basically
“interviewing” several providers before I chose one. I wasn’t suicidal and
didn’t have anything resembling an urge to harm myself or others, for what
it’s worth.

I still believe that seeking help may come back to haunt me one day. It’s
something I’ve come to terms with and I believe I made the right decision, but
I think my ability to introspect and make a rational decision in the face of
my illness is... atypical.

I think it’s a consequence of the “do you have firearms in your home”
questions during routine checkups. The current push for so-called “red flag”
laws seems to validate the concern.

~~~
HarryHirsch
On the other hand, in the US it happens that a disaffected fellow has a
dissociative episode and shoots up his former workplace or school. It's a
culture-bound syndrome. You need to defend society against it.

When you taught at college and had to deal with a deranged individual who
eventually got himself expelled for stalking and attempted rape your opinion
about gun rights changes.

~~~
dsfyu404ed
Your first and second sentences seem to strongly contradict each other.

------
conanbatt
The core problem of mental health and insurance is:

1) resource utilization 2) long term cost-effective value

A therapist can induce infinite demand on a patient, by just doing follow-up
sessions ad-infinitum. In argentina for example, people go to the same
therapist for decades!!

This means that the insurance model doesn't work well, because you can't do
actuarial analysis on how much therapy someone might need and how to
distribute that in the population.

The second part is that as a patient, if the insurance covers your cost, you
might as well go to the most expensive therapist you can find, and consume the
infinitely. Also, you know more than the insurance company if you plan on
using or needing this care, thus you have a very strong adverse-selection
situation going on with any plan that is generous on mental health.

Economically speaking, mental health should not be part of an insurance
scheme. It should be cash pay. To help people that could not afford mental
health and they need it, you would do better to provide state-run service,
that is low-cost high-effective-value and cover the lower side of the
population.

~~~
arcticbull
> A therapist can induce infinite demand on a patient, by just doing follow-up
> sessions ad-infinitum. In argentina for example, people go to the same
> therapist for decades!!

You know people who take insulin are on it for the rest of their lives, but
that doesn't make it the fault of their doctors.

Therapy actually works. "Hundreds of studies have found that psychotherapy is
an effective way to help people make positive changes in their lives," Nordal
says. "Compared with medication, psychotherapy has fewer side effects and
lower instances of relapse when discontinued." [1]

> The second part is that as a patient, if the insurance covers your cost, you
> might as well go to the most expensive therapist you can find, and consume
> the infinitely. Also, you know more than the insurance company if you plan
> on using or needing this care, thus you have a very strong adverse-selection
> situation going on with any plan that is generous on mental health.

This is a very strange American perspective on health care. If it was suddenly
available to everyone, there's a perception that we'd all be like kids in the
candy store getting 1 of everything at the doctors office. That's just not how
it works. Nobody in Canada goes to their GP and asks for the immunotherapy and
a few casts. People go to doctors because they're sick, and they need
treatment and would rather be literally anywhere else.

It's not as though we're socializing the electronics section at Best Buy.

> Economically speaking, mental health should not be part of an insurance
> scheme. It should be cash pay. To help people that could not afford mental
> health and they need it, you would do better to provide state-run service,
> that is low-cost high-effective-value and cover the lower side of the
> population.

Sold, but it should cover everyone.

[1]
[https://www.apa.org/monitor/2013/02/therapist](https://www.apa.org/monitor/2013/02/therapist)

~~~
conanbatt
> You know people who take insulin are on it for the rest of their lives, but
> that doesn't make it the fault of their doctors.

The bet on diabetes has to happen before it is diagnosed to make actuarial
analysis. If you want to guarantee that all diabetes patients get access to
insulin, what you want is charity, not insurance.

Insurance is risk pooling.

> This is a very strange American perspective on health care. If it was
> suddenly available to everyone, there's a perception that we'd all be like
> kids in the candy store getting 1 of everything at the doctors office

The science has already shown that is true. Over and underutilization of
healthcare are studied effects, ones insurance companies pay very close
attention to because if they don't, they will go bust. That is also why
countries with free healthcare also have copays.

> People go to doctors because they're sick, and they need treatment and would
> rather be literally anywhere else.

I think you are have an outsider's view on how healthcare provision works. No
doctor i met would ever agree with this statement.

~~~
arcticbull
> The bet on diabetes has to happen before it is diagnosed to make actuarial
> analysis. If you want to guarantee that all diabetes patients get access to
> insulin, what you want is charity, not insurance. Insurance is risk pooling.

Yep! That's why health _insurance_ is a misnomer. There's no guarantee my
house will catch fire, so I insure against it. There is a 100% chance each and
every human will catch a terminal illness. That makes it at best a structured
payout program. The amount of the payout can be reduced through preventative
care, and yes, maintenance drugs like insulin. That's the best case for why it
should be socialized.

It's not insurance, and it's not charity, it's a service in the public
interest. And of course people should have access to the medication they need
to live, we're not savages.

> The science has already shown that is true. Over and underutilization of
> healthcare are studied effects, ones insurance companies pay very close
> attention to because if they don't, they will go bust. That is also why
> countries with free healthcare also have copays.

Insurance companies get paid in advance, and their goal is not to provide the
best care but to return the largest amount possible to their shareholders. Co-
pays keep people out of hospital, especially lower-income folks, which allows
insurance companies to make more money. Same with high deductibles. Their goal
is not care, it's profit.

The UK and Canada (the systems I know best) don't really have co-payments,
certainly not like in the US. The vast majority of services are co-payment
free [1] (UK: "Out-of-pocket payments for general practice are limited to some
services, such as examinations for employment or insurance purposes and the
provision of certificates for travel or insurance", in Ontario going to the
hospital you only pay for parking or 'upgrades' like private rooms - [2], [3]
is the entire fee schedule). Same with Australia [4] who in 2015 rebelled over
an AU$7 co-pay. You get sick, you go to the doctor, they take care of it.

Think about it, if you could access any procedure right now, what would you
get done? Nothing, because it's not fun, it's not rewarding. If it's medically
necessary, you'll get it done one way or the other, if it's not, literally why
are you at the hospital? Yes, use goes up a bit. IMO, that can be offset by
creating clinics and guiding people to them for minor ailments as in the UK.

> I think you are have an outsider's view on how healthcare provision works.
> No doctor i met would ever agree with this statement.

Respectfully disagree. Both my parents are doctors, and I grew up in numerous
medical systems all over the world. I've benefitted hugely from socialized
medical systems and not having one right now is downright terrifying even
though I'm well 'insured'.

My dad refused to work in the US because he felt the healthcare system here
was inhumane. He wanted to provide people care based on their needs not what
they could afford. It took me until I lived here to understand he was exactly
right. There's a lot of this apologist: "there must be _some_ reason the
American system is better" \-- sorry, it's just not better.

[1]
[https://international.commonwealthfund.org/countries/england...](https://international.commonwealthfund.org/countries/england/)

[2]
[https://www.qch.on.ca/hospitalcharges](https://www.qch.on.ca/hospitalcharges)

[3]
[https://www.qch.on.ca/uploads/Finance/Hospital%20fees%20Webs...](https://www.qch.on.ca/uploads/Finance/Hospital%20fees%20Website%20version%20for%20Insured%20Res%20April%201%202019%20NewLogo.pdf)

[4] [https://transferwise.com/au/blog/healthcare-system-in-
austra...](https://transferwise.com/au/blog/healthcare-system-in-australia)

~~~
conanbatt
> That makes it at best a structured payout program.

This is what prepay's are, and HMO's. You have 2 opinions on HMO: they love it
because pricing is transparent, they dislike it because they ration service.
An example of that with Kaiser: they put severe barriers on their own mental
health services. An industry gossip for you: one of the biggest consumer of
mental health services at Kaiser is Kaiser doctors.

> Insurance companies get paid in advance, and their goal is not to provide
> the best care but to return the largest amount possible to their
> shareholders...

At the same time, insurance has an interest in controlling how much the
insurance is used, something governments can fail at pretty hard. Remember
Medicare insurance already costs 1k per person per month. That's the
socialized system america has now, and it won't be more efficient by being
bigger.

> Think about it, if you could access any procedure right now, what would you
> get done? Nothing, because it's not fun, it's not rewarding.

This is just not the reality. It's a well studied effect, denying it is
depriving the science behind policy analysis from any legitimacy.

> Respectfully disagree. Both my parents are doctors, and I grew up in
> numerous medical systems all over the world. I've benefitted hugely from
> socialized medical systems and not having one right now is downright
> terrifying even though I'm well 'insured'.

They told you that patients never go to the doctor for superfluous reasons? I
won't believe it. I am in the industry and I can see every case imaginable.

We have had this argument before. The U.S. socializing healthcare will not
bring out-of-us healthcare results. It will get something else, because what
makes healthcare suck is not private vs public, it's the regulatory framework.

~~~
arcticbull
> This is just not the reality. It's a well studied effect, denying it is
> depriving the science behind policy analysis from any legitimacy.

You are correct. People do go more often, and to counter it programs exist in
the UK which drive people with less severe issues to local centers where they
can get looked at without taxing the hospital system to the same extent. [1]
It's not that big an issue. All that and they still deliver better health
outcomes for a much lower price.

FWIW the NHS actually offers free mental health services with no co-pays too
[2]. It looks like it's managed via GP which is a good middle ground IMO
between co-pays and unlimited fee-free access. Canada does not as a rule,
though it's an active conversation [3] and has been for years -- and it enjoys
a (razor thin) majority of support with 51% in favor. Psychiatry is covered
today, therapy is not.

> They told you that patients never go to the doctor for superfluous reasons?
> I won't believe it. I am in the industry and I can see every case
> imaginable.

No, they told me the US healthcare system is inhumane. I may have misread your
post if I wasn't replying to the right section :)

> We have had this argument before. The U.S. socializing healthcare will not
> bring out-of-us healthcare results. It will get something else, because what
> makes healthcare suck is not private vs public, it's the regulatory
> framework.

The US is already at the bottom of the OECD, do you have reason to believe
it'll get worse? We've got a lot of models that show it'll be better and
really nothing to point to that shows it'll get worse. Socialized systems are
cheaper and control costs better, even here.

[1]
[https://www.newdevonccg.nhs.uk/file/?rid=109734](https://www.newdevonccg.nhs.uk/file/?rid=109734)

[2] [https://www.nhs.uk/using-the-nhs/nhs-services/mental-
health-...](https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-
services/how-to-access-mental-health-services/)

[3] [https://globalnews.ca/news/5276022/canadians-mental-
health-s...](https://globalnews.ca/news/5276022/canadians-mental-health-
services-provincial-health-plans-ipsos-poll/)

------
mnm1
That's the business though. Kill, maim, and let people suffer to make more
money. That's the core of every single health insurance company with every
single patient for every single problem. To claim otherwise is lunacy. So why
don't we have nationalized, single-payer health care? People are still
claiming that they don't think the government can do a good job despite the
existence of Medicare and Medicaid. People are worried about government "death
squads" when private insurance "death squads" have been killing people for
decades. Frankly it's fucking ridiculous at this time. Can one even call the
US a "developed" country anymore with this kind of healthcare? Certainly not
in my mind.

------
MarkMMullin
Having seems the guts of a lot of different insurance technology stacks, it's
possible to see how the nature of the commercial business biases the behavior
of the systems. In the simplest cases, health care providers have systems that
take enough time to just get going that someone who becomes very sick and
after a small amount of expensive intervention dies doesn't become a cost,
because that system operates as if they had recovered....leading to the sad
mantra at one 'Death is proof of recovery' . Same case here effectively. If it
isn't treated it can kill, if it isn't treated then costs don't accrue, if it
isn't treated then other potential costs don't materialize. I have never met
anyone in the technology side of insurance evil enough to do that, but have
met plenty horrified by the fact that it is what their systems keep evolving
to do. The goal of profit is inversely related to the goal of care, plain and
simple.

~~~
apacheCamel
I guess why have it at all then? If their goal is profit and profit means to
skip care, which is the main reason of healthcare, why even go about trying to
pretend then? Skip right to the fact, take my money and leave me to die. I
know this isn't a real answer and isn't how it truly works but the system just
seems to defy the whole idea behind healthcare.

Edit: missed a word.

------
chiefalchemist
While this might shooting from the hip...If health care insurance came bundled
with life insurance, perhaps the providers would have an incentive that would
be good for everyone?

Again, this is simply a "what if", please don't go all HN on me. tia

------
SolaceQuantum
_"...Some practitioners who want to join networks are turned away. Melissa
Davies, a psychologist in Defiance County, Ohio, was part of Anthem’s network
for years when she worked in a larger medical group. But the insurer refused
to contract with her after she started a solo practice in 2012, saying the
area was saturated, even though Davies is one of only three psychologists in
the county. When Davies examined Anthem’s directory, “I found a great number
of their providers were no longer practicing, or were dead,” she says..."_

This is damning.

~~~
e40
It's really, really hard to find a good therapist. I've heard so many stories
from friends and have direct experience with employees who've had trouble.
Kaiser completely screwed over an employee of mine, which led to him being
homeless for more than 6 months and abandoning his job. It took him more than
a year to get back on track.

IMO, it's criminal what these insurers are doing.

Also, there was a post here, I believe, about a successful therapist (in
Australia, I believe) that was quitting because of the BS he was putting up
with from the insurers. It was a youtube video where he laid out all the
reasons. It was just heartbreaking to watch.

~~~
orky56
If you're comfortable, I would like to hear more about the Kaiser-related
incident.

------
samirillian
This is what I don't get about the Stephen Pinker argument that "everything's
getting better." To a country experiencing something like a collective mental
breakdown, how does the claim that the bad parts are "all in your head" help
anything at all?

Mental health is getting worse because the economy is getting worse, simply.

~~~
Analemma_
I don't normally go for Marxist or populist analyses of the world, and indeed
spend a lot of effort arguing against them, but Stephen Pinker made a lot more
sense when someone pointed out that he's basically a shill for globalism, or
neoliberalism, or whatever your word for "that thing" is. His whole shtick is
going, "Everything's fine! Getting better in fact! No need to examine the
current system and all the ways it might be flawed, or change it at all!",
since that kind of thinking could hurt entrenched interests immensely.

~~~
jlavine
Your characterization better fits someone like Thomas Friedman, not Pinker.
Pinker absolutely acknowledges the many problems of the current system and the
need to devise solutions to these problems. His argument is that things have,
on the whole, been improving, we've solved big problems in the past, and we
can solve current problems so long as we hold with Enlightenment and humanist
/ liberal values and put the effort in. He's arguing against those who want to
throw away liberalism and replace it with some form of mystical
authoritarianism, whether that be socialist, fascist, or whatever. And there
are many such people, who take the benefits brought from liberalism for
granted and would throw them all away for some romantic wishful thinking. His
argument reminds me of essays written by Albert Camus defending liberalism
against fascism during WWII and against the communism that was en vogue in
France after the war among Sartre and others that Stalin referred to as his
"useful idiots".

By liberalism here, I mean the original (and only sensible) meaning of a
system of individual freedom in social, religious, and economic spheres,
equality before the law, and democratic representation, not the New Left's
utter misappropriation of the term to represent tribal resentment and mob
justice.

------
gumby
Fundamentally the actuaries have figured out that the cost of treating someone
with mental illness is greater than the value of the premiums.

~~~
conanbatt
Correct. Mental health does not really fit insurance models.

To be fair, most healthcare doesn't. Primary care being part of insurance is
ridicolous.

~~~
gumby
> Primary care being part of insurance is ridicolous.

It’s the cheapest to provide and saves a lot of “downstream” costs

~~~
conanbatt
Not related to cost itself, but how the utilization is decided. You can go to
the primary doctor for a cold it's just a pure waste of resources.

It is also bad for the pcp to be so transactional with insurance: it should be
a relationship, which is proven to give better medical outcomes..

------
throwaway55554
Of course they are. They're incentivized to make money, not pay it out. I'm
completely baffled that people would rather this system than a universal
healthcare system simply because they don't want a poor person to have
insurance because they're "not pulling their weight". And that's the reason.
"Hard working, red blooded Amerikans don't need anything taken away from them
by them poor folk that don't wanna work!". ugh.

~~~
z9e
Yeah, this system needs to be refactored for sure. But the counter argument to
universal healthcare isn't as basic as you outline. It really comes down to
how do we pay for it. Healthcare costs are ridiculous, and so is our deficit.
The counter argument is more in that realm, and you painting it as "they don't
want a poor person to have insurance" is not helping the discussion.

~~~
throwaway55554
>... and you painting it as "they don't want a poor person to have insurance"
is not helping the discussion.

Then I sure wish people didn't say that if they don't mean it.

------
olivermarks
I'd imagine the 'customer service' people at insurances companies would also
need mental health care after breaking the news to their clients...must take a
toll

------
LorenPechtel
What we need to do is turn the procedures on their head--you can demand the
insurance company find you an appointment with <any specialty>, they have say
30 days (to the appointment, not to respond). If they don't come up with one
you can go out of network and pay no more than you would in network.
Exception: If you're in a smaller place and there's only one such doc in town
you're expected to go to the bigger city instead. (So you can't have one
specialist setting up in an area without any such and charging an arm and a
leg.) It's not the insurance company's fault if there are no providers, it is
their fault if there are no in-network providers.

------
unittest
Hasn't suicide rates increased along with mental health coverage/therapist
usage?

It seems like everyone is seeing a therapist nowadays. Why are suicide rates
still increasing?

Is there any real scientific proof that therapy or mental health coverage does
anything?

Why was suicide lower when nobody was using therapist? Why is it increasing
now that so many people see therapist?

What's with the neverending drive to get people to take more drugs, spend more
on counseling, etc? Every week there is an article about how depressed we are
or how lonely we are and all the pharmaceutical or therapy that can help.

------
hestipod
I am suicidal and have been off and on for years due to disability/pain from
medical mistakes that cut my life short at 30. I am 45 now. That led to
immediate loss of quality of life, career, financial security...and a slow
painful loss of relationships and self worth. I was told to "get help", and
did when I could afford it, but the problem is the root issues were never
addressed. All mental health care has for most people is superficial bandaids.
You cannot live an entire and healthy life drugged while things fester. You
cannot cope every minute of every day. Life also isn't static or always
improving and we have to deal with new issues like added health problems,
aging, financial pressure weighing us down further. Bail one bucket of water
out, two more pour in.

I had to ask family for help and one by one after a time they began to resent
me and abandon me. I was denied SSDI. I was denied nearly everything I applied
for and buried in bureacracy. I lived abroad for a time and had a much better
quality of life and access to healthcare, but I couldn't legitimize
permanently (still a fantasy at times) and had to come back to the USA. I now
live, and who knows for how long they will allow it, with resentful family,
isolated in rural Murica with no transport or access without much more expense
and effort. No insurance. Limited income based medical care. Living on 600
dollars a month from a partial pension I was fortunate to have. Hearing every
day how it simply has to be my fault and treated as if I am a loser who chose
and continues to choose this. I am the same person I was when I was a public
servant and seen as doing good in the world, but now that I have lost my
autonomy I am lower class and shamed.

There was a time when my root issues would have been addressable and I could
have had a decent life, but there was no help and things got worse. There was
a time I though if I could just find someone to give me the "right" job that
would work around my issues I could have a survivable life, and finally a kind
and caring soul did that after years of nothing, but those two buckets I
mentioned above poured in and things got worse and I wasn't able to do it. Now
I have no idea what if anything can save me. How is one supposed to survive
since "suicide is never the answer" when you have a miserable, painful life
and no realistic way to dig yourself out? I cannot magically become a citizen
of a nation with social support and healthcare. I don't have the bootstraps to
pull on and rebuild. I cannot endure decades more of this yet anytime I
discuss it I hear "seek help" or other shallow pearls of wisdom. Hotlines and
calling the police seems the default response if someone brings up the topic.
Everyone feels good like they did something and pats themselves on the back.
The patient might get sent to hospital and that results in tens of thousands
in medical debt and a worse problem. So it goes. No real solutions happening.

In cases like mine, which are a majority of suicidal people in my experience
professionally and personally, it's rooted, situational stuff (often from
multiple angles) and not some primary mental illness that Prozac and CBT
mitigates. It's not simply about insurance (or the lackthereof) and what it
will and will not pay for. I have been to a lot of doctors in my day and not a
single one has improved my quality of life, most in fact the opposite. It's
about there being no willingness to solve root causes and the eventual
response being victim blaming and turning a blind eye when the bandaids don't
work. Until society addresses the fact that many people end up in bad
situations through no fault of their own (and honestly even those to blame
somehow are still human beings who deserve help and not some abstract
calculations on a moral or financial ledger) and provides a safety net and
path to rebuild as much life as possible (something friends have accomplished
in nations with such support), you will find more and more people choosing to
quit living. We don't want to...we have no options...most especially not in
America where all the things we need to stabilize and rebuild are even more
costly and unattainable...where the only places we can afford are isolated
with no services...where we are further and further cut off. Everything that
would give me a chance is the opposite to where and what I am living now.
Can't win.

~~~
thesagan
I’ve heard variants of your story from so many people here in the midwest.
There’s an entire nation of people in the US hurting, and many who could
return as first class citizens if we had some more empathy paired with grit.

Godspeed.

------
angel_j
How is mental illness not a pre-existing condition?

~~~
NikkiA
It certainly was when it was the norm for insurers to deny pre-existing
condition coverage.

------
Trisell
Mental health problems are seen as a weakness in this country. It's very anti
the American way to:

1\. Have a mental health problem

2\. Seek help for a mental health problem

This leads to insures being able to deny this, and it not seen as a negative,
because it's denying something that's weak. And weakness in the USA is the
ultimate sin. Homelessness/Joblessness also fall under this same belief
system.

~~~
diegoperini
I'm not from US but I believe this is incorrect. Everytime I visit there, I am
always amazed to see how caring the people are. This is a sample size of one
though.

~~~
rectang
It's uneven. There are many who are kind just like you say. But if you have
ever seen the savagery in the comments on any HN-linked story on homelessness,
that perspective is also well-represented in the US.

~~~
FireBeyond
> But if you have ever seen the savagery in the comments on any HN-linked
> story on homelessness

And frankly, compared to Facebook posts from Fox News or indeed any other news
outlet, the "savagery" on HN is downright pleasant.

------
andbberger
It's all around you folks. Count your good fortunes if such a situation is
foreign to you.

There's no one to catch you if you fall.

It could happen to you, or your loved ones next.

Try to have some empathy, and fucking VOTE

~~~
ben_jones
Vote for what? Here in San Francisco we just voted to raise hundreds of
millions of dollars in additional funds for homeless and related services.
Most of this will be funneled to over 40 NGOs/non-profits by our city
officials, the same 40+ organizations that have ineffectively applied nearly
$500m a year for the past decade. My hope is that some of this money TRICKLES
DOWN, but my hope for change is pretty much gone. Simply raising/spending the
money gives incumbent politicians plausible deniability that they are "fixing
the problem" even though they aren't. It's an homeless-industrial-complex at
this point where major players are motivated to sustain it because it gets
them paid well.

We could vote to build more housing. Oh wait, SB50 just got rejected by the
appropriations committee - which is full of non-elected government officials.

I know, we could completely re-elect all of our local government officials to
shake everything up, oh wait that's the promise of our last N mayors who
haven't done anything.

I'm disgruntled, if any of these points are incorrect please let me know -
it's very frustrating and I feel helpless as a voter (in SF).

~~~
dv_dt
Vote for Medicare for All to build a more solid foundation for healthcare and
health services instead of each of our single cities having to patchwork with
yet more bandaids.

~~~
vonmoltke
That only works when there is an effective provider network exists and the
main problems are expanding it and removing cost as a barrier to access.

The problem with mental health care is that such providers either don't exist
or are very rare, meaning there is little to no effective care to be had for
any amount of money. Simply throwing more money at this problem will not do
anything to solve it.

~~~
closeparen
Providers presumably respond to economic incentives; if there are not enough
therapists in your area, enticing more people to become therapists really will
help. It's a better problem to have.

~~~
vonmoltke
I don't think my point was clear. I'm arguing that most of the extant
providers are at best worthless. Too much of mental health "care" is focused
on treating the symptoms, rather than the underlying cause. More money isn't
going to fix ineffective treatment; it's just going to multiply the number of
practitioners of it.

------
hello_friendos
Why do Americans continue to accept this terribly flawed systems for their
'healthcare'.

~~~
mmanfrin
None of the responses to your question seem to hit at what I believe the
source: racism. Single payer has met resistance from the right because people
have this misguided notion that they will have to pay for "other peoples
mistakes", which is just dogwhistle.

~~~
betenoire
There are plenty of reasonable "mistakes" people make; smoking, diet,
exercise, alcohol, idiocy, stunts, etc, without having play the racist card.

Lots of people don't want to pay for problems they don't have control or
influence over. You don't have to be racist, just a bit myopic.

~~~
asdff
The whole insurance system is that your monthly premium is paying for someone
else's treatment. Universal healthcare is just a larger insurance pool that
brings costs down for everyone in it.

~~~
betenoire
Oh, I agree 100%.

I just get tired of bad faith racism interpretations.

------
minikites
Anyone who thinks we have a good healthcare system in the USA would learn a
lot by reading the replies to to this tweet:

[https://twitter.com/AllOnMedicare/status/1124042436345569286](https://twitter.com/AllOnMedicare/status/1124042436345569286)

Moneyed interests are pulling the levers:

[https://twitter.com/mattb/status/1015270406754713600](https://twitter.com/mattb/status/1015270406754713600)

------
JohnAtCC
I'm not sure how this all plays out in policy, but outside of the criticism of
the gun community and it relates to deaths by firearms - we have half the
suicide rate in the United States as Japan - which has almost no access to
firearms by its general population.

It's worth noting in relevance, because the politics in Healthcare reflect the
policy of public opinion as well as legislation around other tangent issues
our country is trying to reconcile what it wants to do (if anything) about it.

~~~
DanBC
> we have half the suicide rate in the United States as Japan

What definition for suicide does the US use?

What definition for suicide does Japan use?

EDIT: and you don't have anything like half the rate. Comparing across
countries is hard, but Japan has a rate of about 17 per 100,000 while the US
has a rate of about 14 per 100,000.

