08 December 2008

Uninsurance claims a life

This is as sad as anything else I have seen in a long time. A woman in her mid-thirties came in to my ER with a near-completion of a suicide attempt. Her husband reported to me that she had been diagnosed with bipolar disorder for a number of years, and had been doing extremely well on medications -- well enough to get married, start a career, and have a family.

Unfortunately, their family had hit some hard times and both she and her husband were temporarily out of work. He found a new job, but during the transition their health insurance lapsed. Her psychiatric medications, all brand-name, were terribly expensive, and money was tight around the house. So they made the decision that she would go off her meds, just for the couple of months until his new insurance kicked in. The risk seemed pretty small, since she had been doing so well for a very long time.

The first few weeks off the meds were not too bad, though she was moody and irritable. They had a fight a couple of weeks later, and then another. But other than that, there didn't seem to be any indication that she was slipping off the cliff. Then, after a fairly minor disagreement with her husband, she went and did something impulsive, with no warning.

And that's when she came in to see me.

After a short course in the hospital, she succumbed to her self-inflicted injury.

The sad thing, other than the terrible human tragedy, was how unnecessary this was. Why on earth did they think she could go off her meds? That was a bad decision on their part, but the consequence was an undeserved death sentence. Didn't they know they could apply for a free supply of meds from the manufacturers? Didn't they think of going to their church, or some other charity source for assistance? Couldn't they have gone back to her mental health provider to see if a cheaper prescription was available for the short-term?

But they were not sophisticated, medically, and didn't think of these options. They were self-reliant, figured this was their problem and they would figure out a way to get through it. They made the wrong choice, and now she is dead, and their children have no mother.

This is what makes me nuts about this whole universal health insurance debate. You have the folks on the right who deny reality and claim that those who are uninsured "choose" to be uninsured and that we shouldn't force people to pay for coverage they don't need or want. The conservative ideologues who theorize that the problem is that Americans have too much health insurance and what we really need is to let patients make rational decisions about where to allocate their health care dollars. The traditionalists who like their employer-funded health care plans who are afraid of severing the link between employment and health insurance.

This case, in a nutshell: a real, actual person whose life was lost due to our insane patchwork health care system. This case is an example of why we need fundamental reform of our health care system. One life is just an anecdote, I know, but writ large, how many times does this happen annually among the 60+million who are uninsured at some time in any given year? What is the gross morbidity and mortality that our insurance system exacts from our society?

Employer-based health care is great, so long as you are stably employed. If you lose your job, your health is at risk. Or you face the devil's choice of paying the mortgage or paying for your meds (or COBRA coverage). While I understand the general resistance of Americans to part with the known and understood health care which their employer pays for, a system which ties employees to a job for the insurance, which burdens employers relative to their foreign competitors, and which has no realistic provision for the newly unemployed to retain health care is both callous and stupid, from a policy perspective.

Despite the rhetoric regarding "patient directed health care," the truth is that patients do not always make rational decisions. Patients will, not in all cases but with a knowable statistical likelihood, forgo needed care, spend money on the wrong priorities, and generally lack the knowledge base to decide how best to spend their health care dollars. (Even if there was price transparency, which there is not.) This is not to say that patients are incapable of making these decisions, but that the consequences of shifting this burden onto patients does have a direct human cost.

It is fairly clear that, with the incoming Obama administration, the consensus is building towards a fundamental restructuring of the health care funding system. The designation of HHS Secretary Daschle, in addition to the Baucus white paper and the Kennedy committee are clear signals that the Democrats are serious about moving forward. The labor movement has found their strange bedfellow in the small business association, and even the medical lobbies are cautiously in favor. There's a lot that can go wrong, and a lot of heavy lifting to be done to transform the rhetoric into reality. I can only hope that they are successful, and that they do it right.

There are a lot of people whose lives may depend on it, even if they do not know it. It's too late for one patient and her family. Their children are eight, five, and two years old.

43 comments:

  1. Their problem wasn't lack of insurance, it was lack of JOBS to earn money to pay for medications. I'm sure they were eligible for COBRA, but they evidently chose not to purchase it. I doubt they could have paid for "government insurance" either, so their fellow citizens would be responsible. But what if the expensive brand name medications weren't on the government list (like how Medicaid doesn't cover Zofran).

    You sir, are a fear-mongering ideologue.

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  2. For the first time in my life I have found myself in the position of potentially being without health insurance. My husband and I are divorcing. The divorce is not final until January, so for now I am able to stay on his insurance. After that I will be forced to pay for COBRA for as long as I can manage it. I had hoped to get a benefited job with my employer, but due to the economic downturn my employer (a government agency) is about to institute a hiring freeze.

    We are lucky in California (as in most states I believe?) to have free health insurance for children, so my kids are covered by an HMO under Healthy Families (I make just a smidge too much money for them to have ordinary state insurance) for a mere $12 per month of my money. This is very lucky for us, especially since my oldest has cystic fibrosis and bipolar disorder and requires thousands of dollars in medication, and multiple doctor visits, each month.

    Unfortunately for me, making too much money (even though I am just over the poverty line and can't even afford to pay my rent) disqualifies me for state insurance for myself, and there is no Healthy Families available for moms unless they are pregnant. This state fundamentally fails parents... They'll cover my kids but make no guarantees that their mother will be able to have health insurance. What's wrong with this picture?

    I am very fortunate that I can hang onto my ex's insurance for myself, but once the COBRA term runs out (18 months I think?) I will be out of luck. Let's hope the economy will be better by then and I can get into a benefited position. (I'm not holding my breath!)

    It's true that many drug manufacturers offer savings programs. Also, many pharmacies offer prescription savings plans, but these usually only help substantially with generic medications. The fact is that people need not go without their medications even if they are uninsured, but the only reason I know these things is that I have a kid with multiple medical conditions and have educated myself about it. Many people, as illustrated in your example, are not knowledgeable about these programs, as imperfect as the programs are.

    Something needs to change in our health care system for sure. I have no idea what the perfect solution is, but what we are doing right now is not working.

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  3. All the resources you note -- "The sad thing, other than the terrible human tragedy, was how unnecessary this was. Why on earth did they think she could go off her meds? That was a bad decision on their part, but the consequence was an undeserved death sentence. Didn't they know they could apply for a free supply of meds from the manufacturers? Didn't they think of going to their church, or some other charity source for assistance? Couldn't they have gone back to her mental health provider to see if a cheaper prescription was available for the short-term?"

    So very sorry for the outcome, especially feel sorrow for her children.

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  4. "You sir, are a fear-mongering ideologue."

    From you, I take that as an compliment -- indeed, praise from Caesar!

    "their fellow citizens would be responsible."

    I see you have finally grasped the subtle intricacies of National health care! Congratulations!

    Rebakah,

    Sorry to hear about your troubles, and good luck to you in your own hard times.

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  5. Heh. Fear is the path to the dark side.

    If we ever have universal healthcare foist upon us, I eagerly await your "Rationing Claims Another Life" series.

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  6. What a gbreat blog so heartfelt. he comments are interesting too.

    Scalpel writes "they chose not to purchase it" meaning COBRA. This statement put the blame back on the family.
    Quite often a mother and or father will put their children's needs before their own. I have done it several times myself in the last year. Putting medication on hold until pay day. Because I believe feeding my kids, and having enough money for my son to bus to school is imperative.
    Pride, or independence can stop a person for asking for help. When a person already feels they have been a drain they don't want to be asking for more from their friends or family. In my case my father has recently died, I don't have a mother and my siblings live overseas.
    I had a close friend commit suicide leaving her 3 year old daughter behind. The night before she said to me she thought she was a bad Mum.
    She had not long been diagnosed with Depression and a few other things. She tried to get help, doors were closed on her for three months. She wasn't Bad enough, she had attempted suicide 3 times in this short period of time. So she hung herself. She hung herself because she believed she could no longer look after her daughter, it was a image I cannot get from my mind..

    I am not condoning any of her actions. We have "free" medical care here. Well the hospital is yet people still are dying.

    When people are in a desperate situation they don't always think rationally. In this poor woman's mind she may have thought her family may have been better off. I don't know. It's sad either way.

    I don't though agree with blaming statements. "They could have done this, or that", "She could have left him" "He is just attention seeking". If you place blame or labels on people do you think that they will rationalise what your saying, or will the opposite happen, where they feel even worse, hopeless, or useless, and either kill themselves, or stay in a bad situation.
    Society in general finds it hard to deal with a precarious situation. Instead of pulling together as a community and helping each other out we have developed a selfish, blaming, isolating attitude.
    My deepest empathy to the family involved.

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  8. Scapel, I'm glad that Marcia pointed out the cost of COBRA. I looked into it, last year when I nearly got laid off. COBRA would have cost me $450/month. It may not have been their choice to do without.

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  9. Yes, a tragedy--I've heard of others like this, a person who ended up diagnosed with metastatic lung CA, who had back and leg apin but did not go to the doctor until a spouse's insurance kicked in, by which time the person had been walking around with widespread bone mets and only some tylenol or aspirin for pain control. And a disease for which, now, no treatment options existed except comfort care. And, yes, COBRA and state-funded "high-risk" insurance coverage is extremely expensive, and there are tons of folks who can't qualify for Medicaid but can't afford these alternatives. No, doctors do not check cost of meds before prescribing, unless patients ask them to do so. I hope that we as a country can ask tough questions about health care, because there are too many tragic stories out there, of people who are trying to do their best.

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  10. "Couldn't they have gone back to her mental health provider to see if a cheaper prescription was available for the short-term?"

    We're talking about people who are tight on money and have lost their insurance, right? How are they supposed to afford another mental health provider visit?

    I think you're right that the problem is the insane patchwork that is our health care system. Even figuring out where to get help costs money and time and effort that a patient just might not have.

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  11. The real root cause of this issue is a lack of problem-solving skills on the part of the patient/husband (maybe mixed with too much pride) as well as a fundamental non-understanding of the basic cause and effect relationship of what happens when a bipolar person stops all of her medications, not a lack of insurance. As you said, there were numerous things that could have been done in this case that were not. Even a simple phone call to whomever prescribes the psych meds could have probably landed her a couple months' worth of samples.

    And as many have said, not paying for COBRA insurance was a choice, ergo, they really did choose to be uninsured. If you have any saleable items in your house or a savings account that could pay for the premiums, you're choosing those things over your insurance, health etc. Take out a loan on your 401K, pay for the premiums on a credit card...whatever.

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  12. COBRA is not always available after job loss. If the employer went bankrupt, there is no right to continue to participate in the plan because the plan itself vanishes. My brother had to find health insurance for his kids in a big fat hurry because of this once. He was fortunate enough to be able to pay for it, but not everyone can.

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  13. It's not as simple as choosing to keep your plasma,401k or whatever over Cobra.
    I am a nurse and have fallen on hard times,no job,no insurance etc.I also have a chronic health condition. I don't have a credit card with a balance on it,no 401 K and so on. Cobra costs about $500/month or more. I don't know what you have in your house but I don't have anything like that to sell to cover that kind of monthly bill. I'm having trouble paying the power bill,getting food on the table and paying for whatever generic meds I can here. I used to be in the middle class with a saving account,equity in a house,a credit line etc but all of that is gone now and I consider myself to be in better shape than a lot of people who have nothing at all. I don't have a cell phone,I have basic cable,we've already combined 3 families to try to make a go of it and are one mishap away from being out on the street.
    As a person who has suffered from depression in the past but has had about 8 decent years with no relapses I myself have gone off the medications for a short while(with not very good results). It really IS a choice between food,shelter and prescription meds.
    Many of those resources,those helpful assistance programs are long gone and will not be replaced due to extreme budgetary shortfalls but mostly because people who already feel powerless and shameful about their illness aren't going to speak up to try to get their return. It's like trying to run on paralyzed legs,the spirit is willing but it is impossible.
    And do you think we will EVER stop blaming the victims?

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  14. I don't think COBRA would have helped this patient anyway. I was on COBRA once, and I don't recall them covering medications. Nor would a universal healthcare plan likely cover expensive (new, brand-name) medications, nor would such a plan guarantee that someone could be seen by a psychiatrist (or even a primary care doc) promptly to discuss alternative medications. Many docs aren't taking new Medicare patients now; if we pass some sort of universal health plan, do you really think the new plan is going to pay more than Medicare rates? And cover expensive meds like Geodon, Abilify, or Keppra? People will have to settle for Lithium and Depakote, I suspect.

    Many docs will flee to a cash system unless the Socialists forbid free enterprise in this country, heaven forbid. So the combination of fewer doctors accepting the universal plan combined with the massive influx in patients seeking their entitled healthcare will ensure long waits for appointments and more rants from concerned liberals about the unfairness of it all.

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  15. "...as well as a fundamental non-understanding of the basic cause and effect relationship of what happens when a bipolar person stops all of her medications, not a lack of insurance."

    And do you think it's reasonable to expect Joe Public to have this kind of knowledge? Not just knowledge about what happens when a bipolar person stops taking their meds (which, from my point of view, is a difficult question -- I wouldn't be able to say if the reaction would be immediate or delayed, or severe or mild) but a general knowledge about the medical consequences of their actions.

    I mean, don't you people go to Very Expensive Medical School to learn this kind of stuff?

    The general problem is that the public (even the highly educated portion of the public) is unqualified to do an accurate cost/benefit analysis of a doctor's visit: they don't know the cost, they can't find out the cost (doctors don't know, or won't tell, and act like you're insulting them if you ask), and they don't know the benefit either. And even trying to find out the cost or the benefit is often out of the budget.

    And finally...

    "...will ensure long waits for appointments..."

    Yes, please. I would very much like to have a affordable medical appointments. I don't mind waiting.

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  16. Joe asks:

    And do you think it's reasonable to expect Joe Public to have this kind of knowledge?

    It is absolutely reasonable to expect patients to know the basics of their conditions. The lady wasn't a head trauma patient or developmentally disabled. She had a long-standing, chronic condition. I'd bet a testicle that somewhere along the way, a doc or a nurse sat down with her for ten minutes and explained the basics.

    Of course, not all patients bother to research on their own, ask questions, or retain the information, but that's not the medical establishment's fault - the blame for that lies squarely on the patient's shoulders.

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  17. I think they made the best choice available to them at the time. I don't blame them for making the wrong choice.

    Given the choice between trying to keep your head above water and buying meds for a condition that has been stable for years is a no brainer.... you keep your head above water.The only reason we're even second guessing this is because of this horrible outcome.

    My dad was recently laid off from an auto dealership, the dealership closed. No COBRA available. He and my step mom are pretty healthy so he's taking a risk, but one that he doesn't have a choice about taking. We were talking about his old insurance coverage. It sucked. He paid in a week (yes, one week) for coverage what I pay in three months in premiums. WHY? I do work for a bigger company with good benefits. Why is this OK?

    Most of us have to wait for care. The kind of care that's rationed in countries with universal coverage is the kind of care most of us will never need. Access to primary care is already an issue in this country. So with more people to be seen (because more will have insurance), there will be a longer wait. So what? I would rather have a longer wait than have 50 million people without health insurance.

    I live in a state that borders Canada. To have your knee replaced, you have to wait 8 weeks here at the larger hospitals in the state and 4 weeks at the smaller critical access type hospitals. In Quebec province you wait 10-12 weeks. I'm sorry, that kind of additional wait doesn't justify getting all up in arms about wait times. We're only talking an addition 2-4 week wait for a chronic condition that the person has had for years.

    Emergency issues are taken care of in an emergent fashion up in Canada, so the "wait times" that people talk about are for elective things, not emergency cardiac bypass surgery and the like.

    Honestly, if wait times are the only argument against universal coverage, it's a no brainer. Bring on universal coverage.

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  18. Care for every body12/09/2008 4:15 AM

    For many reasons, the approach of attaching health care to individuals' employment doesn't work.

    I'm sorry for this family.

    P.S. Is there an add-on that sifts out specific individuals' comments on other people's blogs? Kind of a three-strikes-you're-off-my-screen arrangement? I'd like to add on that add-on.

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  19. I really feel bad for this family. I have been in this kind of situatino before. I had a kidney stone once while waiting for my insurance benefits to kick in. As a matter of fact, I working for the company who was to become my healthcare provider when the stone hit. They put me in a wheelchair and rolled me over to urgent care, where I was told that they couldn't do anything for me because my insurance wasn't active yet, and sent me to the ER. A thousand dollars later I had a prescription for a few pain medications. It sucks. I hope we can find some way to patch these kinds of holes.

    That said, I think that this family has to share some of the blame in this scenario (or at least based on the few details I have of it). As pointed out in the original post, they did have a lot of options that they apparently did not try. Everybody should first try to rely on themselves, second try to get help from family, third turn to church or local community aid resources, and fourth seek help from government assistance. Having worked in a doctor's office, I know that many many times we gave free samples to patients to last them through a month or two's hardships. I also know that there are multiple resources out there to get assistance straight from the makers of many of these medications. www.pparx.org is a tremendous site and does most of the work for you.

    As has been mentioned by several people already, universal healthcare probably would not have paid for the medications that normalized her life in the first place, let alone keeping them afloat in a time of difficulty.

    With the abundance of charities and churches and resources out there designed to help people through tough times, I find it hard to believe that there was no way to get them the medications that they needed for a couple of months, and to the commenter that suggested that she had no way of knowing the result of stopping her medications, I say that if you do not have at least a basic understanding of your chronic medical conditions, then you are irresponsibly putting your life in danger. The Very Expensive Medical School gives the doctor the ability to understand the intricacies and interactions and pathophysiology of complex diseases. Anyone with a chronic condition needs to take responsibility to understand what the disease is, how it has and my affect them, and what the pros and cons of the available treatment options are. This is the same basic idea of research you would do before deciding what cable tv service to go with, why would you not do it with bipolar disorder or fibromyalgia or diabetes?

    Anyway, in the end my sympathies go out to this family who has suffered such a loss. Saying you should have and you could have will not bring this woman back, and I hope that friends and family and community resources are making themselves available for this man and his children to cope with the loss.

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  20. I too am a nurse, only I work OB. I see the opposite end of this problem. Women (girls) who know how to work the system. They know that an ambulance ride to the hospital will cost them nothing, and a free taxi ride home will be provided. They know they can get all the sonograms and "emergency" hospital visits they want. A spat with the boyfriend will result in an all expenses paid visit to my unit so she can get the attention she desires from him. And of course, she WON'T marry him, because that would end all the free medical care.

    It tickes me off to no end. Here was a family that NEEDED HELP. COBRA is NOT the answer. It probably would have been cheaper to pay out of pocket for the medication! I find myself more and more jaded about our healthcare system. I'm tired of paying for these 20 year olds who are on baby number 2 or 3, and so deep into the system that butts are permanently attached to the welfare system. Meanwhile, families that need it, families who have done the right thing, and paid into a system that then FAILS them.

    What is the answer America? It's not socialized medicine. We already have that (for those that know how), and it's not working.

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  21. Didn't they know they could apply for a free supply of meds from the manufacturers?
    I'm going to make a guess that there are severe restrictions on getting a free scrip from the mfr. Like, if you earn more than $10k per year, you don't get a free script. If you are on welfare, you will make more than $10k per year, so if you are on welfare, no script. The other catch, I'm guessing, is you get one month of free meds, per lifetime. That's it. One.

    Didn't they think of going to their church, or some other charity source for assistance?

    I'm guessing here again, but churches don't want to fund medicines due to liability issues. Just guessing.

    Couldn't they have gone back to her mental health provider to see if a cheaper prescription was available for the short-term?

    The new meds they are hawking these days run $500-$700 per month. I know this for a fact.

    I'd be interested what restrictions are involved with the "free meds" from the mfr, or church help.

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  22. Shadowfax,

    In my humble opinion your intentions are noble, your observations are keen, and it is obvious you are an extraordinarlily well educated and talented individual. However, I also sense condescension and a vainglorious tone to many of your blogs. I wonder if you have personally dealt with an individual with serious mental illness in your family. The answers are not always obvious. Again, with the utmost respect to you and your intentions, please continue with your informative and honest blog. However, beware of potential hubris.

    Sincerely,

    Goldberry

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  23. What a terribly sad story - I can only hope that the United States eventually starts something like Medicare in Australia, described here:

    http://www.medicareaustralia.gov.au/about/whatwedo/medicare.jsp

    In Australia, the Medicare Levy is only 1.5% of each person's *taxable* income (and there is an additional levy that high income earners if said high income earners choose not to purchase private hospital insurance). The additional high-income-no-private-insurance levy is fair enough, because *anybody* can use Medicare services if they so desire, no matter how much they earn. Nobody is barred as long as they are an Australian citizen or permanent resident.

    I travel regularly between Australia and the USA, and have dual Australian/Swiss citizenship. As a non-American I have always struggled to understand why the Government of the United States does not do more to take care of those citizens who need the greatest help.

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  24. You suggest in your own writing that the family should have looked into alternative methods of paying for the meds or cheaper meds, but then go on to blame it on lack of national healthcare. It was the risk they chose to take, not the lack of government intervention that is to blame. If you've worked the VA, you'll know government is stingy with medications. Maybe she would get them, maybe she wouldn't. Just depends on the button pushers up above.

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  25. And I'm sure you've met a few patients in your career who tell you they can't pay for their medications but they can afford the $4 a pack cigarettes they ask to go out and smoke or the EtOH that brings them in in the first place. I don't want to finance that sort of irrationality. And if you've worked in the VA, you'd realize the government is stingy because they have to pay for bureacracy. Button pushers from above tell you whether you can prescribe this medication even though they haven't seen the patient just so the VA can have enough money to pay button pushers to do said pushing. Maybe your patient would have gotten her medications, maybe she wouldn't.

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  26. Wow. I'm really impressed by the great understanding of mental illness expressed by the majority of medical posters on this blog. NOT.

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  27. Using a sob story to bash the status quo and force an unproven radical agenda in the name of the common good is a technique employed by the wild-eyed anti-vaccer crowd.

    You're not an anti-vaccer, are you SF? ;]

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  28. This is tragic. I only wish that the family had known about NAMI (National Alliance on Mental Illness). www.nami.org

    A family or an individual with a mental illness can call their local affiliate and the people there, who have the lived experience of dealing with mental illness and navigating the system, will do everything they can to help. They have knowledge of resources and places to try to get necessary meds, etc. that people who haven't had to deal with it all don't necessarily know about. There are also all sorts of free support groups.

    If you ever see a patient with a mental illness, please direct them to their local NAMI affiliate. They can go to www.nami.org and find the closest office.

    Our local affiliate is now partnering with the local hospitals, which are providing NAMI literature to their patients in an effort to get help to those who need it.

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  29. I'd like to point out a few things. I'm a college student, and luckily I have THE GREATEST mental health coverage I could ask for. All my visits are free, which is great when you're seeing a psychiatrist once or twice a month, and a therapist 4-6 times a month. I'm bipolar and while I spent 3 years treating depression, I'm just at the tail end of treating the ACTUAL problem. Getting stable has been a long and grueling process.

    But. To everyone who likes to point fingers and suggest that we should all just "give up" things in our life to pay for coverage like Cobra- which is $500 + a month, I'd like to know where you have that kind of money laying around. I know I don't. And if I was in a position where COBRA isn't available- I'm SCREWED. Why? Did you know it's pretty much impossible for anyone who actually NEEDS insurance (anyone with a mental illness, chronic problem, etc) to qualify for private insurance? I was denied private coverage by four insurance companies just because I had been (wrongly) dx'ed with irritable bowel. (This was before any psych dx, too.) It's not as simple as "Waltz on over to Target and pick up some health insurance, you lazy, selfish bastards!"

    My care is free (well, I pay $125/month for insurance), but my meds are not. I pay $195/month out of pocket for my meds. I'm a student with NO trust fund, NO parental help, NO spouse... it's just ME. And I pay it. My psych staff slip me as many samples as they can, which helps. But I go without A LOT as it is to afford those meds. If I suddenly lost my insurance, that med bill would balloon to over $600/month. I already have to forgo cable, movies, clothes, professional hair cuts, eating out (sometimes eating much of anything) just to make my current payment. If I were stuck in that boat- I don't know what I'd do either. Paper work for med assistance programs can take months to go through- and that can be the difference between life and death. And being out there, alone, in all of that- it's daunting.

    For everyone who wants to put the blame back on the patients, or who likes to think that it's a simple as you are making it out to be- I have a finger I'd like to show you. COBRA is not a feasible option for most people, and those of us who need our insurance are often not eligible unless they're under a group plan that can't say no.

    I'm so sick of self-righteous people in this country. It makes me sick.

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  30. Heather -- doctors and nurses make good money. You practice for a while and you forget what it's like to wonder whether you should pay your rent or your COBRA. :P Also, most medical facilities have great insurance. Among medical staff, it's mostly a case of "well I didn't need it when I was young..." & of course they had it when they got older.

    Most ER staff have no idea when it comes to psych stuff. Well, most medical staff in general. To them, a brand name med is mostly the same as a generic med.

    I was actually pleasantly surprised when I decided to switch to generics w/my psych. (In this economy...) You have many more choices than you did just a few years ago. Yet, I do best on SNRIs -- unfortunately Effexor (cheap) gives me heart problems and Cymbalta is $200 a month. You settle for second best, which is never the same...but it keeps you running.

    Frankly, if you can tolerate generics, ask for them. Your psych probably won't rx them at first but you have to demand it. If generics don't work, stock-pile samples. County has the sliding scale fees -- go through them, if you can.

    Obviously, the whole "she should have been edumacated!111" doesn't work. You spend /years/ stable on a med and you begin to wonder -- was it just a fluke? The worst part is that if you stop taking your meds, you don't notice shit right away. Nothing happens for a while. And then things happen but it's gradual. It's not like a diabetic who stops taking his meds suddenly. The stigma against mental illness doesn't help, certainly...

    ANd, no, you're not gonna get free meds from most places. Fact of life. Google walk-in mental health clinics. Hopefully you'll have one in your area.

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  31. Hannah-
    Thanks. Yeah, we have a decent free mental health clinic in my area, if I need it. Luckily I'm covered through school, and will be for quite a while, so I'm not concerned. But it's just that whole attitude that a few have thrown down making it seem like people are just choosing to go without like it's an easy decision. The irony of those who need insurance usually can't get it privately kills me.

    As for generics. I'm all for them, as long as they work. Lamictal just went generic, and I jumped on that. The transition was pretty rough, I won't lie. The dispersal rate is very different for me. But we tweaked the dose and it's better. Unfortunately, since it's the first major generic, it's not *that* much cheaper yet, but in 6 months it will be open to more companies and it will fall again. And my adderall, klonopin, ultram... they're all generic. My one killer is Seroquel. That stuff is EXPENSIVE. Not as bad as Abilify, but it's still rough. But it works like nothing else has. I can't take depakote (I have pcos, which it has been known to cause or worsen) and we have reservations about lithium. But Seroquel/Lamictal combo has been a lifesaver (quite literally) for me. Stability isn't something I want to mess with. I am blessed that I found something that works well (many never find a good combo, period). I will forgo as much as possible in order to stay with those meds.

    But I also have a pdoc that is more than willing to go generic first. It's a student clinic and our med coverage is lame, so they try to help people out as much as possible. I rode the med-go-round for a while with some generic ssris/snris before realizing they were making things worse. (Effexor made me go batshit, btw.)

    I guess I just get so pissed at smug, arrogant assholes who have never been there. It's so easy to look down on people who struggle and assume that they waste all their money on stupid stuff, I guess. Perhaps that's their way of sleeping at night: if they can make generalizations and explain it all away ("Oh, they would rather buy x-boxes and stuff, they have the money, they're just irresponsible") then they don't have to face the fact that people are hurting. Kids go to bed hungry. And people can't afford the medical care they need.

    I have a lot of "right" friends who bitched, and continue to bitch, endlessly about people who are leeches to the system, and how we need to abolish all of our gov't assistance programs. I told them all to pray on their lucky star that they never find themselves unemployed or burdened in some way they never expected or prepared for. No one sets out to fail or sets out to get in these terrible situations. And gov't programs don't work perfectly, but I'll tell you what- they can sure help a lot. So anyone who wants to bitch about it... Well, I hope you never need it, but if you do, I wish someone at the counter would just stamp a big "denied" on any request for help. Because, of course, when you go it will be different, right? It would be justified and special because you're better than everyone who went before you, right?

    I need to go to bed before I rant all night long...

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  32. We already have rationed health care in the US. It's rationed, in some cases, by your ability to pay and in other cases, by your inability to pay. I agree with Heather (I'm also bipolar). Generic lamotrigine is absurdly expensive - and none of the $4 Rx lists I've seen include more than a few psych drugs - mostly lithium, fluoxetine, and some tricyclics. COBRA is a nice idea, but it doesn't work in practice. Heck - one of my former employers stole 6 months' worth of COBRA premiums I paid in good faith. The insurance carrier said I had to keep paying because the policy was still in force, then they retroactively cancelled me because said former employer had been pocketing my cash and feeding the insurance company a line of bull for that six-month period. There are an awful lot of people that believe life is fair and you can get care and medication you need from bene olent organizations. I hate to dispel your dreams, folks, but for people with pre-existing conditions that can't afford COBRA, are ineligible for state/federal aid and have to make choices about feeding and clothing their kids or trying to pay for medicine they need, it can truly be a life or death decision. Shadowfax, my thoughts and prayers are with you and your patient's family.

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  33. SuperBadJack12/12/2008 8:53 AM

    "
    So anyone who wants to bitch about it... Well, I hope you never need it, but if you do, I wish someone at the counter would just stamp a big "denied" on any request for help. Because, of course, when you go it will be different, right? It would be justified and special because you're better than everyone who went before you, right?

    "

    Really? You're intolerance of others viewpoints is showing.

    Those right-wing friends of yours are angry because the Government is trying to inject itself into our lives.

    Please, please read the Constitution for the first time in your life and show me where the Federal Government has the power to do half the things it does, and, if you think it should have the power, fine amend the Constitution, it's been done before.

    People who believe in Conservatism believe that, in the end, we are responsible for our own outcomes. In good times or bad, we are the only ones to blame for our failures, and the only ones to credit for our success.

    We don't think we're better than anyone, we want to work hard, and be rewarded for our work. That's all.

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  34. People who believe in Conservatism believe that, in the end, we are responsible for our own outcomes. In good times or bad, we are the only ones to blame for our failures, and the only ones to credit for our success.

    You're completely deluded, in other words. Most of the people who believe that (my parents come to mind) have had more than their share of good fortune along with the hard work. Other people, who work equally hard, confront more difficulties than they can handle.

    We all know people who cause most of their own problems; and all of us cause quite a few of our own problems; but no one causes ALL of their own problems.

    Rather than wishing you well, I hope those of you who hold the arrogant belief you're in complete control of both your successes and failures (including your good health) get a dose of reality so you have a chance to develop some humility before you die.

    Otherwise, I hope you're doomed to an eternity of tacky tract housing in hell.

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  35. Rather than wishing you well, I hope those of you who hold the arrogant belief you're in complete control of both your successes and failures (including your good health) get a dose of reality so you have a chance to develop some humility before you die.

    Here's the little problem, with your "Life isn't faiiir" rant.

    If I don't take responsibility for everything in my life I am powerless to change any of it.

    America was founded on this idea of rugged individualism, it's allowed us to become the greatest country the world has ever seen.

    So, let me ask you, if YOU aren't responsible for EVERYTHING in your life, who is? And, how will you change any of it if you don't take responsibility for it?

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  36. Hey, did *I* tank the economy? Am *I* responsible for the stock market falling so far? Did *I* put hundreds of thousands of people out of work?

    No.

    Is it their own fault? In most cases, no.

    Is life fair? Of course not. I wasn't whining; I was saying you need a reality check.

    It sounds like you'd rather see people die of starvation or lack of health care than part with any of your precious money to help those who've fallen on hard times.

    What I'm saying is, you need to walk a mile or two or three in someone else's shoes, and get rid of the American Individualism Patriotic Bullshit, which roughly translates to complete selfishness.

    If other people experience difficulty through no fault of their own, so can you, whether you choose to believe it or not. You could develop a devastating illness, even if you take good care of your body. Sometimes BAD THINGS HAPPEN. Not only are you not immune, you're not even prepared for every contingency. Unless you have a crystal ball, there's no way you could be.

    There may come a day when you need help, and you won't be protected by your denial.

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  37. Heather --

    Dude, Seroquel sucks.

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  38. Also, I'm very confused.

    If the Constitution was written now...what would they have to say about slavery? the internet?

    Why do people act like it's infallible when they fuckin' wrote the elastic clause into the constitution?

    Why are conservatives so backwards?

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  39. Hannah- yeah, seroquel is a bitch on a few levels. It's expensive as all get out. What it does to my cravings and metabolism sucks. But I'd rather be broke and fat than dead. I'm incredibly thankful for it at the end of the day, though.

    SuperBad- wow. First- your rant on the constitution is... confusing to me. So you're saying that the gov't shouldn't be providing assistance to those who need it. Funny- we seem to give to everyone else in the world. I'm not really sure what the constitution has to do with my argument at all.

    People LOVE to make your weak argument- "Take control of your life!" "Make your own destiny!" I have to agree with the person who called you deluded. You act as though people who fall on hard times did so because they failed to plan or something. Tragedy isn't something you can ever really be ready for. And many people find themselves in situations they cannot handle that they are not responsible for. We have an incredibly broken system, and it really sucks.

    What I have been through to get where I am in my life is a long story. I was the victim of sexual abuse from toddlerhood until my teens- my mother stood by and watched. I was raised first by an unstable, bipolar parapegic, and then removed by the state and sent to live with an absent, alcoholic father. I graduated and moved out at 17. I'm putting myself through college without a DIME of help from anyone. I am bipolar and struggle with chronic pain from a back deformity. I'm single and I fend for myself- 100%.

    People that think it's just a matter of working harder or trying harder have no idea what it's like to NOT have that ability. I was raised in poverty, abandoned and abused. I don't have anyone to fall back on, I didn't have anyone to take care of me. I'm NOT lazy. I work my ASS off going to school and working to make ends meet. And I also know that I'm much more blessed than many- so I don't look down on people who need to use the system that we have in place.

    So before you go bitching about working hard and getting what you deserve- let's have someone kick your legs out from under you. Let's see you HONESTLY start from nothing (or, like some, from a deficit) and see how easy it is to make it. The honest truth is that our system is very broken and sometimes- the way out isn't easy or even possible. Some of us have many more strikes against them than others do- and that's not something you can possibly understand unless you have been there. So are you going to be like John McCain and tell me to get a second job and skip my vacation? (which I haven't taken in years.)

    Sorry for the rant, OP, but that stuff just gets me beyond pissed off.

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  40. Wow! I, too, am bipolar (hypomanic), controlled very well with a combination of paroxetine HCL and oxcarbazepine, and I would sooner go without a KIDNEY than go without my meds.

    My condolences to the family who lost a loved one in this tragedy.

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  41. SuperBadJack12/16/2008 6:15 AM

    So are you going to be like John McCain and tell me to get a second job and skip my vacation? (which I haven't taken in years.

    John McCain was one of the worst candidates my party has run in a long time. The only reason I voted for him was Palin.

    Now, let's take a look what you wrote, you're saying...you're in college with no ones help but your own... GREAT! That's what I'm talking about, you overcame your circumstances and are doing very well.

    Also, I don't want to sound cliche here or compare bad situation to bad situation, but I lost my Father when I was a teenager, he died with no will or life insurance. It took years for the State to decide what to do with what he left, since he owned his own business. I'm 22, and I have worked my ass off, I don't have college but I am successful because I am willing to do what it takes.

    So as for "Starting from nothing", yeah I did. And I made it.

    My gripe is with the Federal Government being like a parent. If a State wants to go all out and be your Nanny, fine, whatever, if they can afford it more power to em.

    My point about the constitution was that the Federal Gov. has very limited powers in what it can and cannot do.

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  42. "Chose" not to purchase COBRA??? Have you even a CLUE how expensive COBRA is?

    People who have never had to struggle, truly struggle, will never understand and will always be good at pointing their fingers.

    MM...you're a realist. You seem to have the ability to think about situations other than the one you're in.

    Love you blog.

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