Here's an oughta-be-required course for legislators: health policy physics, or the study of who-would-have-thunk consequences. Legislators must pass the course to stay in office. And, in the spirit of No Child Left Behind, here is a No Legislator Left Behind multiple-choice quiz, to test the savvy of our solons.
Question 1 (for state legislators): You slash spending for mental health services. What will happen?
A) Everybody, whatever the diagnosis, shapes up. This is a "shape up" society, where everybody, without the molly-coddlying of psychiatrists, counselors and social workers -- and without pharmacological supports -- gets better. Sort of like jumping into the water to learn how to swim. In a sink or swim America, we all swim. The metaphors blur, but you get the point.
B) Everybody who is mentally ill finds God, who is cheaper than the cheapest HMO. Faith-based initiatives have taken over some social services -- why not mental health too? Taxpayers don't end up paying the clerical tab. I know, I'm repeating the money benefits, but this is America 2005.
C) People who are ill seek out emergency rooms and end up in hospitals. We don't want this to happen, because even while government is slashing the mental health tab, it is slashing the hospital tab too. Because we don't want it to happen, try not to choose this answer. It marks gloomy pessimism -- which, like molly-coddlying, is taboo in America 2005.
The answer, unfortunately, is C. Consider Texas. In 2003 it slashed $14.8 million from the state's mental health centers (a 5.11% drop). The state's Indigent Care Collaboration tracked the consequences. Emergency visits with "mental health" as the diagnosis rose. So did hospital admissions with that diagnosis, by as much as 79%. And psychiatric hospital emergency rooms were overwhelmed. Parkland in Dallas now sees about 900 patients a month, up from 600 - 650 in the pre-cut days.
Hospitals are not the best places for treating mental illness. Nor are they the cheapest: A patient treated in a hospital costs more than one who might have been stabilized in a mental health center.
Fortunately, D) was not on the test: Those people who need help vent their frustrations and anguish in distinctly asocial, if not criminal, ways.
Question 2 (for federal legislators): You promise to subsidize medications for millions of Medicare enrollees, starting in 2006. You do not mention "price controls" because that is another taboo. What do drug companies do?
A) Hold prices stable. It would be crass for companies to profit from government subsidies.
B) Raise prices. It would be the prudent course for a profit-driven industry, especially one beset by economic downers like Vioxx, not to mention the fall-from-grace of estrogen replacement therapy for the millions of menopausal consumers.
C) Lower prices. A trick answer, to see whether test-takers are compis mentis.
D) Open the international floodgates, letting Americans buy drugs in Canada and Europe, where prices are lower. Another trick answer, to weed out legislators who slept through this course.
The answer is B. Drug companies, fearing that some legislators will utter the curse, "price oversight," have raised prices, so that if and when that oversight happens, the base prices will be higher. Inflation for the past year hovered at 2.5%, but prices for Zoloft, Lipitor and Pravachol rose about 5%. The price for painkiller Mobic rose 7% (7.5 milligrams) and 11% (15 milligrams). According to Delta Marketing, which tracks drug prices, last year prices for 31 of the top 50 drugs rose.
Question 3 (for federal and state legislators): Drug prices rise. Who picks up the extra tab, beyond what insurance now pays?
B) State government
C) Federal government
Only respondents in their own drug-induced euphoria answered A). For the past decade employers have passed cost increases on to employees: higher premiums, higher deductibles, multi-tiered pharmacy benefits. There is no evidence to suggest that American employers will suddenly morph into humanitarians. As for B) and C), would state legislators approve a tax increase? Would Congress? That leaves, by default, D: patients will absorb the increase.
Legislators should be forced to repeat this course until they pass.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.