The Financing of “Mental Illness” Treatment
The interplay between medicine and money has always been very important in determining the level of influence and the directions taken by the medical industry (and related industries such as pharmacology and medical technology). In the United States, for instance, medical doctors during the 19th and early 20th Century were paid directly by their patients. They strongly opposed the intrusion of any third party into the trusting and in many ways “intimate” relationship that existed between themselves and their patients. These men (very few female physicians) certainly did not some non-physician determining who and how much should be paid for specific medical procedures. All of this began to change in the early 1920s. There were now fewer physicians (many of them being thrown out of the profession by acts passed by the United States Congress during the 1910s). With fewer physicians to serve the public, the price of health care began to increase, and many patients could no longer afford these services. With some third-party payment plan in place (health insurance), the physicians could still charge a high fee while serving an expanding population of patients.
The health insurance business soon benefited from the introduction of benefit plans in American corporations. Employees now were being paid not only as wage-earners, but also as recipients of health and retirement plans. The United States government soon got involved too, passing legislation during the 1930s that provided some financial support for citizens who could not afford health insurance, were not covered by their employer, or were too old, too young or too infirmed to be eligible for any existing financial assistance. The stage was set for health care policies and procedures to be strongly influenced by the allocation of money (Bergquist, Guest and Rooney, 2004)
A similar story can be told about health care elsewhere in the world—though in most cases the primary financial player has been government. We see evidence of this today in the almost universal adoption of national health insurance or government controlled or even operated health care facilities. We find that physicians no longer run the show in most countries. As I noted in the first essay, social constructions are often reflected in the language (semantics) being used: in health care around the world we find financially related terms driving medical decision-making by both the providers and recipients. Terms such as “cost centers” (medical services being delivered to patients) and “reimbursables” (medical services being initially paid for by patients but later paid for by a third party) are filling the offices and corridors of medical centers and hospitals. Related marketing-based perspectives are also prevalent. Patient satisfaction surveys have replaced rating of medical success—for the patient has to be satisfied if they are to be continuing “income-centers” (either directly or through third party payers.
What then do we do about patients who are categorized as “mentally ill”? Can their treatment be reimbursed by a health insurance company or government agency? Initially, the answer was “no” in most countries. Only “legitimate” illnesses are eligible for compensation: the ghosts of the first three assumptive worlds lingered in the halls of government and corporations: “we don’t help people out who are either crazy or can’t handle their own emotional problems!” But what happens when you move from a social deviance or spiritual aberration world to a world in which these poor men, women (and children) have been afflicted with a “mental disease” or are born with a “mental deformity.”? Aren’t they just as much victims as a man struggling with diabetes, a woman suffering from cancer, or a child afflicted with polio?
