Wednesday, March 28, 2012

Health Care Reform, the Supreme Court and Implications for People Living with Mental Illness

By Ron Honberg, NAMI Director for Policy and Legal Affairs

This week, the U.S. Supreme Court is hearing arguments on the constitutionality of the Affordable Care Act (ACA), the health care reform law enacted in 2010. The case has engendered strong reactions among Americans, with some fervently arguing that the new law should be upheld, others arguing equally fervently that the law is unconstitutional and should be repealed. Sifting aside for the moment political arguments for and against the ACA, there are two main issues before the Court.

First, is the provision in the law requiring Americans to purchase health insurance (the “mandate”) an impermissible tax? Second, does the requirement in the law that all states participating in Medicaid must cover everyone at or below 133 percent of the federal poverty level (FPL) by 2014 exceed Congressional authority under the Constitution?

Irrespective of how you feel about the overall law, the Supreme Court’s decision in this case has significant potential implications for people living with mental illnesses and their families.

First, the expansion of Medicaid in 2014 to cover all individuals at or below 133 percent of the FPL will impact millions of Americans with mental illnesses who currently do not qualify for Medicaid for a variety of reasons, including pending SSI applications, lack of a fixed address, or those with part time employment whose income may exceed current Medicaid eligibility levels.

Second, many individuals living with mental illnesses will be included among those able to purchase federally subsidized health insurance policies in 2014 through state health insurance exchanges established by the ACA. And, these policies must cover mental health and substance abuse treatment at parity with other medical conditions.

Third, if the entire ACA were struck down this would negate important provisions in the law expanding federal mental health and substance abuse parity to millions of Americans currently not protected by the law, including those who purchase health insurance through state insurance exchanges and those who are added to Medicaid through the expansion.

Finally, if the Supreme Court were to strike down the requirement in the ACA that all uninsured Americans purchase health insurance, it is not clear at present whether the ruling would negate the entire law or just the operation of the health insurance exchanges. If the entire law were to be negated, this would eliminate other aspects of the ACA beneficial to individuals living with serious mental illnesses.

For example, the nullification of the ACA would eliminate the provision in the law establishing a Medicaid Health Home option for integrating health and specialty care for individuals with chronic disabilities. A number of states are currently moving aggressively to implement these health homes. The nullification of the entire ACA would also eliminate important insurance reforms, such as the requirement that all individuals be issued insurance regardless of pre-existing conditions.  And, it would eliminate provisions designed to fix problems in the Medicare Part D program, such as subsidies for those who reach the so-called “Donut Hole.”

Clearly, much is at stake for individuals living with serious mental illnesses and their families. The Supreme Court is expected to issue its decision in June.

For more information about the ACA and its impact on people living with serious mental illnesses, click here.

For more information about the issues currently before the Supreme Court, click here.

And, for those interested in accessing the legal transcripts of the oral arguments taking place this week before the Supreme Court, click here. The name of the case is U.S. Department of Health and Human Services v. Florida.

Tuesday, March 13, 2012

Language, Stigma and Political Correctness: How We Talk about Mental illness

By Bob Carolla, NAMI Director of Media Relations

NAMI recently engaged in a dialogue with National Public Radio (NPR) over language, stigma and mental illness. It in turn led to discussion of what is meant by “political correctness.”

It started with NPR’s coverage of a pending Supreme Court case in which a man is appealing a conviction for falsely claiming to have received the Congressional Medal of Honor. In an interview with the man’s lawyer, NPR reporter Nina Totenberg asked whether his client, a habitual liar, was a “nutcase.”

NPR received many complaints. In consultation with NAMI, the NPR Ombudsman column on its website launched discussion  about language, stigma and mental illness.

NAMI pointed them to the U.S. Surgeon General’s Report on Mental Health, which frames stigma as a public health issue. We also acknowledged that assessing stigma can involve “balancing” several considerations. Particularly in entertainment media, NAMI’s “red flags” of stigma include:

  • Overall context
  • Inaccuracy
  • Stereotypes
  • Disparaging language
  • Devaluation (trivialization) of mental illness as a concern
  • Using mental illness as the butt of a joke
  • People with mental illness portrayed only as an antagonist or villain
  • Linkage of mental illness to violence
  • Offensive or insensitive symbols (e.g., straitjackets)

In the case of the NPR interview, “nutcase” waved at least three red flags. First, the context: it was used to describe a person (Description of a legal argument as “nutty” for example would not have been as great a concern).” Second, the word is often used to describe people disparagingly—with at least a suggestion that they live with mental illness. Finally, the word has an almost cartoonish impact that tends to trivialize mental illness, devaluing it as a social concern.

One of the best strategies in fighting stigma is to turn protest into dialogue. Dialogue does not necessarily lead to agreement, but it does heighten awareness and potentially connect to broader social concerns.

That’s exactly what happened in this case.

One NPR listener complained: “I’m sick to death of political correctness rules ... we use words like 'nutcase,' there's no reason to avoid them."

NPR’s Ombudsman replied: “Political correctness can surely get out of hand, but stop and think for a minute: It is highly likely that you or a family member or friend has at some point had some kind of mental illness.

“We often stigmatize it in ways that we no longer do with physical ailments, or race, or any of a number of human conditions. Calling someone a "nutcase" for something they can't help and others may share is out of bounds.”

The mention of “political correctness” led to a second discussion in the next NPR Ombudsman column.

And then a third.

One can empathize with people who sometimes feel that there’s too much “political correctness” today. But what does the phrase actually mean? Shouldn't we always try to do the right thing? Shouldn’t there be civic dialogue about language and attitudes? In many respects, invoking political correctness is only a way to duck an issue, rather than consider it.

What do you think? What do you consider most stigmatizing? Language, stereotypes, offensive symbols or something else?

Does the mental health community’s concern about stigma ever reach a point of too much political correctness?

Tuesday, March 6, 2012

The New Normal: Actress Claire Danes, Homeland and Hollywood's New Take on Mental Illness

By Courtney Reyers, NAMI Publications Manager
Claire Danes - Stuart Crawford

Showtime’s original series Homeland is one of the first TV shows to feature a female protagonist living with bipolar disorder—and one many say isn’t wholly defined by her illness.

Golden Globe winner Claire Danes (My So-Called Life, Temple Grandin, Romeo + Juliet) plays CIA officer Carrie Mathison in Showtime’s thriller-drama series based around homeland security, terrorism and politics. The first season, which premiered in 2011, follows Carrie’s efforts to uncover a U.S. Marine who is thought to have been turned while trying to target an Al-Qaeda kingpin while she struggles with (and hides) her mental illness from everyone but her sister.

The juxtaposition between Carrie’s determination to do her job well and sacrifice everything—including her own mental health—while unraveling a mystery reels the viewer in. As Carrie begins to uncover the truth, she forgoes taking her medication and enters a severe manic episode followed by a severe depression that costs her not only her romantic relationship, but also her job, which, in turn, almost ends in international devastation.

“I was enticed by [the role] because I'd not played anyone like her in any medium,” Danes told the Sunday Telegraph in February. “She's full of contradictions. She's so capable in so many ways and in others she's so ultimately unreliable.”

As Carrie’s authority is undermined by the discovery of her illness by coworkers, her mania also serves as a useful tool and helps her begin to solve the case. While even close allies turn on her, other central characters begin to realize she is hot on their trail as she pieces together the conspiracy—and they use her illness against her to throw her off the scent.

Homeland realistically shows the ups and downs, the perks and flaws, of living with mental illness. Additionally, it reveals the stigma surrounding mental illness in a job that requires a cool head and a sharp mind—her validity instantly goes out the window. In the end, Carrie’s bipolar depression is so severe and unresponsive that she elects to undergo ECT… just as she remembers a key element to the plot.

What’s crucial about this television series is its realistic portrayal of mental illness as well as real life—how in a matter of days mental illness can turn a life upside down, how peers, loved ones and coworkers can turn on you. How you start to doubt your own reality, and even how people can manipulate that reality. What’s really key, though, is that Carrie as a person, her work and her passion come first: Her mental illness is simply another hurdle she must overcome. Her illness is seen on the same playing field as countless other hurdles in her life, from political schemers to master plots of terrorism and deception to a strained family life.

"Playing someone with bipolar and taking the mystery out of that is a responsibility I don't take lightly," Danes said. “I really spent a lot of time doing my research to make it a specific portrayal and not just a generalized portrait of ‘being crazy.’ I didn't want to play crazy—that’s not bipolar disorder."

Watch the first episode of Homeland online for free, even if you don’t subscribe to Showtime. The second season of Homeland airs this fall.

Friday, March 2, 2012

Improving Lives, Improving America

By Mike Fitzpatrick, NAMI Executive Director

Mental illnesses are bipartisan, pervasive and have profound consequences for people’s lives. In the course of a year, about one in four people has a diagnosable mental illness every year. Almost everyone’s life has been touched in some way by mental illness. The face of mental illness is not the face of some stranger. It is the face of our neighbors and coworkers, our friends and family and sometimes us.

The good news is that the rates of improvement for serious mental illness like major depression and bipolar disorder are as good as if not better than those for chronic physical diseases like heart disease and diabetes. These rates of improvement are predicated on the person getting the right treatment when they need it. The bad news is that notwithstanding the existence of effective treatments and services and the real opportunities for recovery, 80 percent of Americans with mental illnesses do not seek or find the help that they need.

It is well documented that mental health care in this country is broken. The system that confronts families seeking care is too often fragmented, unorganized, and despite the best efforts by many, uneven at best in its quality. Too often what passes for the system of care sentences people to lifelong disability, the risk of premature death, and creates an impoverished underclass through poverty, crisis-focused care, treatment that relies primarily on medication, and the lack of supports in the community.

Every day people contact NAMI seeking advice on how to access mental health services. People face difficulty finding inpatient and outpatient services, supportive housing, job supports, in-home supports, affordable health insurance, family support, medication, peer-directed and self- help programs and more. The time is now during these times of dramatic change in our health care systems to push back against this discrimination and injustice and create a community care system that emphasizes early intervention and is flexible, accessible and integrated at all levels. None of these changes require additional study. It simply requires political and social will.

As we approach Super Tuesday in the Republican Primaries we are reminded that health care is an important but contentious issue. However, the potential ramifications for individuals living with mental illness have not been discussed. We must remind the candidates that funding mental health services means funding America’s future.