Sunday, March 18, 2018

Complexity, health care, and psychiatry

The Wall Street Journal on March 16, 2018, contains two articles, one an oped by former Senate Banking Committee Chairman Phil Gramm about how to “escape” from Obamacare, and the other (to which I can’t find a link, “Health-Law Suit May Boost Insurers” by Stephanie Armour) a report on lawsuits in connection with the Affordable Care Act. Cases currently before a panel at the U. S. Court of Appeals for the Federal Circuit may amount to the largest civil lawsuits ever.

More thinking and prognosticating and thrashing around occurs, and more is written about how to organize and pay for medical services, than almost any other human problem. Nothing gets so complicated and “important” unless it contains a lie, it’s a sure tip-off. And the more complication, the more fundamental the lie must be.

Much discussion has concerned mandated coverages. Under the ACA, it seems every policy must be standardized. E.g., “treatment” for “mental health disorders” must be included for everyone, even people who (like me) would sooner go to jail or be exiled than pay a psychiatrist or receive psychiatric “medicine”. Until a recent change, everyone also had to buy their policy, or pay a fine. I think it’s now legal again, at least in theory, to have a health care policy that doesn’t cover psychiatric services. (But I’m not sure, even though I’m a lawyer and very interested. It’s too complicated.)

The idea that not covering mental health disorders on the same basis as physical diseases is discrimination from stigma is patent nonsense. That is a rational economic risk/benefit assessment, by the people who are far and away the best economic risk/benefit assessors (insurance companies). The crusaders for “mental health parity” merely want to ignore or compensate for marketplace reality: almost nobody buys psychiatry for themselves, and they are only very occasionally willing to push or force it on others. Elite policy makers want to enforce their own value judgments on everyone else, who they presume are insufficiently enlightened to realize that we should all get “treated”.

But it seems to me that the fundamental lie underlying all off this is that human beings are all the same, and they all need and want the same things. That’s quite true for air, food and water, but it doesn’t go any further. Despite what we’re incessantly told, not everybody needs and wants sex (or at least, not the same kind). Not everybody needs and wants shelter (at least, not constantly).

An even more basic lie, however, is that human beings are their bodies, first, last and forever. Individual psychiatrists may or may not think about the implications, but the claim that depression (for example) should be considered primarily as a brain disease to be treated medically, is necessarily in conflict with any religious faith. You can’t honestly be a good Christian, Muslim or Jew, and simultaneously postulate the salvation of individuals through drugs.

The idea that all human problems of cognition, emotion and behavior can be solved by manipulating brain chemistry or neurological structure, rather than by communication alone to change a mind, is a kind of ultimate heresy against all religion.

It’s also untrue, which is the most fundamental reason why medical service delivery has become so complicated. Doctors allowed psychiatrists to follow on their coat tails.

Psychiatria delenda est!

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