the public trough
I recently attended a rally protesting cuts to health care for the mentally ill here in Sacramento. The Sacramento Bee covered
the rally, and one of the first user comments on the web page accused the protesters of "feeding at the public trough." At first I was indignant but, you know, I can understand the reader's anger and frustration. Looking through the short article, several interesting facts emerge. Please try to bear with me as I attempt some arithmetic:
- The department responsible for providing health care to this population has, according to its director, a budget of $203,000,000.
- Two hundred million dollars. Remember that number. The mental health "public trough" is huge!
- The Department of Behavioral Health Services (DBHS) currently provides services to fewer than 10,000 adults with mental illness. They spend over twenty thousand dollars per patient per year to provide mental health care. As a provider in that system, I can tell you that, for $20,000, the majority of those patients get 3 twenty-minute visits with a psychiatrist per year.
- The DBHS director says they are expecting a shortfall of "as much as" twenty million dollars this coming year. In response to that 10% cut in revenue, they are eliminating services for half the patients. That means that the new, leaner DBHS will now be spending $180,000,000 on 5,000 patients. Instead of $20,000 per patient per year, they will be spending $36,000 per patient per year.
- They have to cut services to 5,000 patients to make up for a $20,000,000 shortfall. That means that each patient they eliminate only saves the taxpayers $4,000 -- still a lot, but within range of national averages. It also means that $4,000 per patient per year is the actual incremental cost to DBHS of providing services.
So, even with administrative bloat, it will cost DBHS $20,000,000/year to provide mental health services. Those same services end up costing the taxpayers $180,000,000/year. The comment writer on the SacBee web site was right to be incredulous: an astonishing 89% of the budget -- $160,000,000/year -- is going to fill that public trough. Consider that DBHS, at a time when it is unable to meet its obligations to our family members and neighbors, is rebranding itself from "The Division of Mental Health of the Department of Health and Human Services" to "The Department of Behavioral Health Services." Stationery, signs, press releases for this critical renaming -- but no money for health care? Peanuts, of course, when you have a two hundred million dollar budget. But even peanuts add up.
Now I have to get defensive, and perhaps a bit bitter. As a shrink in that system, I should be thrilled at this lush overspending. But here is what a day is like at one of the County-contracted facilities:
I park on the street and walk into a shabby building carrying two large satchels. I walk through a dingy, overcrowded waiting room filled with nervous and frustrated patients, some of whom have waited six months or more for an appointment. I have to get the attention of someone at the reception desk, behind a window, so they can push the button that will unlock the door. I walk down a narrow hall with scuffed paint and threadbare indoor-outdoor carpet. My office is dark, but the lights don't work so I have to fumble around until I get the table lamp turned on. The table lamp was brought in by the doc who uses the office when I am not there (thanks, Ted! you've saved me a third satchel). When I get the lights turned on, I behold my office. I am privileged to be able to use one of the largest offices in the facility, and it has nice windows. Truly a luxury, even though they look out on a treeless, cracked asphalt parking lot and a block wall. With the light on, I can behold the same threadbare indoor-outdoor carpet, stained by over a decade of use. I can see the smoke-blackened light fixtures that presumably once illuminated the space. I can push the bent, tattered, and non-functional mini-blinds back into place. Now it's time to open the satchels.
First, the box of tissues. I have to bring them from home because two hundred million dollars doesn't cover the cost of a box of Kleenex for patients who might cry. Ditto the stapler and staples I have to bring from home. Leave these basic office supplies there, and some other employee, desperate to provide amenities for their
clients, might borrow them. I cannot reliably log in to the supplied ancient computers with their cathode-ray displays, so I bring my own laptop and pray that it doesn't sprout legs. I connect my own wireless networking equipment to the antique printer and the 10baseT LAN so that I can access the software I developed at my own expense
(hundreds of thousands of dollars) to help keep the County's paperwork burden from eating in to the precious few minutes I'm given to actually spend with each patient. I get out my t-shirt for when the office temperature gets over 90 degrees and the sweater and jacket for when it dips below 60 degrees. These temperature variations are independent of the season or the temperature outdoors. Portable heater, you say? That's what caused the fire that took out the light fixtures.
Did I mention the smell? The bathrooms?
The overburdened clerical staff struggles to find bloated charts crammed into a minuscule file room. They try to keep track of my appointments on a computer system that would have been pathetic even back in the 1980's. They try calling me on my phone when a patient arrives, but my phone only works about a third of the time.
I am paid a good salary, but it's only about half of what I get paid when I do the same work in private-sector jobs (with better smelling offices). Like everyone there, I do the work because the patients are so wonderful and so deserving of humane care.
The public trough might be huge, but my patients and I are at the wrong end.
- 12 Apr 2009