“It don’t matter how many men you shot in Memphis,” the saying goes, “if your name is Sierra or Sequoia, you can’t sing the blues”. In a sense, this adage reworks an older, more bitter joke from the civil rights era, the one that begins “some of my best friends are …” and ends with “but you wouldn’t want your sister to marry one.” Both statements embody stigma, the social effects of being someone who violates others’ expectations or fails to fit into an assigned social niche.
Stigma attached to illness has a long, ignoble history. The most classic example, the devalued social role of lepers, illustrates its classic elements: fear and avoidance. Deformities elicit basic revulsion in many, while infections also trigger fear of contagion. Historically, some of the positive stigma that doctors enjoy reflects our ability to transcend our fears and provide care to those whom society would consign to the desert beyond the pale of a socially integrated life.
In modern times, patients with psychiatric disorders (including addictions) experience stigma in painful and damaging ways. The American Journal of Public Health devoted its entire May edition to the consequences of the stigma that plagues those with mental illness and the disordered behaviors that it often causes. The bottom line of the Journal’s complex assessment across many articles: stigma kilIs. According to Hautzenbuehler et al, increased health care costs, poorer health outcomes and, most tellingly, premature death are all consequences of having a psychiatric disorder of any kind. While we all intuitively “get” why people with schizophrenia or addictions might face stigma based on their disruptive, non conforming behavior and the frustration caused by the intractability of their conditions, the negative consequences of having a psychiatric disorder also extend to otherwise normal appearing people with depression and anxiety, and, most tragically, to children.
The journal appropriately parses stigma into its component elements, which are prejudice (beliefs about undesirable others) and discrimination (behavior towards the undesired group). Discrimination in its most damaging form is utterly impersonal: the social policies that discriminate by denying insurance coverage and setting insurmountable barriers to employment, housing and other social goods mean that however enlightened, broad minded and compassionate we are, we cannot help but compound the stigma that gradually impoverishes the lives of our afflicted friends, neighbors, family members and others who comprise the population of the mentally ill.
The cure for prejudice is education and engagement with the stigmatized group. The cure for discrimination is policy reform. The Patient Protection and Affordable Care Act builds on the principles underlying three earlier federal laws that were passed to reduce discrimination: the Mental Health Parity and Addiction Equity Act of 2008 (which supplanted the Mental Health Parity Act of 1996), the Education for all Handicapped Children Act of 1975 and the Americans with Disabilities Act of 1990. The PPACA mandates that essential benefits packages offered by insurance plans include mental health and substance abuse coverage and that the benefits offered fulfill the requirements of the MHPAEA. While this is a laudable development with the potential to save both money and lives, it does not go far enough.
The mass shootings in Newtown and elsewhere have shined an intense spotlight on the deficiencies of the mental health care system in this country. Although many have called for reforms, there has been little recognition that insurance companies are still allowed to delegate the management of benefits for mental health and substance abuse care to specialized firms, socalled “carveouts” . These firms continue to violate the spirit of mental health parity legislation with impunity. In Washington, DC, where I practice, for example, psychiatric hospital stays are ludicrously short. Outpatient visits may be reimbursed LESS if the doctor codes both psychopharmacology and psychotherapy services for the same visit (as it now permitted under new CPT codes) than if the doctor bills for psychopharmacology alone. As a result of persist discrimination, few psychiatrists accept direct insurance payment, which leaves patients who cannot pay out of pocket for care unable to find anyone to treat them.
All the major carriers, including Blue Cross and Blue Shield, participate in this endless effort to avoid paying fairly for mental health care. Perhaps it is no longer necessary for Sierra or Sequoia to shoot someone in Memphis—if they happen to have a serious mental illness, maybe they are in fact entitled to sing the blues.