Tagged: Book Reviews


Getting Mental Health Coverage Wrong

Thanks to Frank for inviting me to review Barak Richman, Daniel Grossman, and Frank Sloan’s chapter,  Fragmentation in Mental Health Benefits and Services, in Our Fragmented Health Care System: Causes and Solutions (Einer Elhauge, ed. 2010).  The book is important and provocative.  The chapter on the fragmentation of mental health care couldn’t address a more timely issue.

People with serious mental illness, more than most other patients, struggle with health system fragmentation. As the Institute of Medicine described it,

Mental and substance-use (M/SU) problems and illnesses seldom occur in isolation. They frequently accompany each other, as well as a substantial number of general medical illnesses such as heart disease, cancers, diabetes, and neurological illnesses. *** Improving the quality of M/SU health care—and general health care—depends upon the effective collaboration of all mental, substance-use, general health care, and other human service providers in coordinating the care of their patients. *** However, these diverse providers often fail to detect and treat (or refer to other providers to treat) these co-occurring problems and also fail to collaborate in the care of these multiple health conditions—placing their patients’ health and recovery in jeopardy.

By some estimates, formerly institutionalized people with serious mental illness experience about 25 fewer years of life, mostly due to the effects of treatable physical illnesses such as cardiovascular, pulmonary and infectious diseases.  The effects of this health system fragmentation are experienced notwithstanding parity legislation, and they are felt also by people in the community with less serious mental illness, often because their primary care providers can’t find mental health providers to whom they can refer.

In Fragmentation in Mental Health Benefits and Services, the authors approach mental health system fragmentation by telling a story of the relationship between health insurance structure and income redistribution. The authors address the interrelationship between insurance “carve-outs” for mental health care and the growth of mental health parity laws. They assert that the carve out of behavioral health coverage from medical insurance provokes states to pass mental health parity laws. According to the authors, these parity laws fail to help their “intended” beneficiaries, and instead serve to redistribute resources away from low income and non-White employees.

To make their case, they mine a database of claims data for privately insured North Carolina patients. These claims data allow them to track employees’ (and, presumably, their dependents’) use of mental health services. Along the way, they raise several important issues. For example, they suggest that care provided by mental health providers may not be particularly efficacious. (299) Few would disagree that in most areas of health care – including mental health care – comparative effectiveness research is essential.   In addition, they suggest that access to and benefit from covered services varies by income and race. (298-99) It is undoubtedly true that there are class-based and race-based disparities in access to health care; this is so much discussed, in fact, that it somewhat puzzling that the authors would characterize as a “regularly overlooked question” the fact that “equal insurance and access does not translate into equitable consumption.” (279)

On some points, the authors seem to go a bit beyond their data. First, the authors assert (without citation) that mental health parity is “often” pursued “to benefit low-income and traditionally vulnerable populations.” (284) Many advocates (myself included) have argued for parity as a civil rights matter: as people with physical illness have access to insurance coverage, so should people with mental illness.  Certainly, insurance coverage is most valuable for those without the means to pay for care out of pocket, but that is as true for cardiac care as for mental health care. From this perspective, parity legislation seems no more a redistributive move than any other form of health insurance.

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Future of the Internet Symposium: Casting a Wider Net

The project behind writing a book like The Future of the Internet is not only admirable, it should and does inspire people to think about major philosophical and social questions about the inherent politics in technological infrastructure. The project is also hard, and likely to draw critics, both valid and not. When you set out to talk about the future of something as broad and culturally revolutionary as the internet, you can’t possibly hope to succeed, you can only hope to fail better over time.

To continue the evolving failure, I’d like to take an ecological approach to The Future of the Internet and ask what context do Zittrain’s points exist in? We are told that more developers are writing for iPhone and Facebook than Linux, that iPhones dominate the landscape, that iPads might determine something of our political future. But this is only true for something that is already a walled garden– the American socio-economic middle and upper class. Beyond this barrier of perspective the landscape is very different. Is it true that people develop for the iPhone in favor of other platforms in Kenya? What about China or South Korea? Probably not, but the transnational nature of the net means we have to care about those places as well if we want to come up with a true picture of what’s going on, or going to happen.

Skype is one of the most often cited examples of an application people want to protect in the net neutrality debate. It was developed by Estonian hackers previously famous for the illegal file sharing app Kazaa. When Kazaa came out, no analysts and tech pundits were saying “Look to Estonia to revolutionize the telecommunications debate.” But it’s obvious that Skype was informed by the peer-to-peer nature of Kazaa, and by the legal and technical troubles the Kazaa builders wrestled with. Now the walled gardens of the net have to quickly take and maintain a stance on Skype, both on a technical and political level. What these kinds of applications ultimately demonstrate is that the next killer app has no pre-definable vector, and if you lock down one part of the net, chain up one cohort, then some other will be the source of disruption. To imagine that the governments of the world will somehow line up and cooperate on a net policy that universally kills this creative impulse is like waiting for a one world government to solve the problems of climate change. Sure, it seems possible on paper, but don’t hold your breath.

Even if we could reliably regulate the internet, what is the internet? It’s a specific implementation of telecommunication infrastructure. But not terribly specific. It’s easy to say what is definitely the internet, harder to say what isn’t. Is text messaging part of the internet? My first instinct is to say no, but it’s an interface and control on many internet applications. It’s been a key part of monitoring and tightly integrated at administrative levels of the net for as long as it’s been around. So perhaps we have to allow it in the pool. What about phone calls themselves? Again, problematic, as telecom companies will sometimes use the same protocols and wires to transit calls as net traffic. African, Afghani, and Filipino programs that move banking onto cell phones show that generativity  moves to the edges of the net/telecom division when you can’t access the net itself for some reason.

What is generative? This is also hard. The telecom infrastructure was built to be non-generative, non-open, and not user friendly. It was built top-down and tightly regulated. But the net was built on top of it, so it ultimately was generative despite the intentions of its builders. The net nested a bottom-up social structure in that top-down architecture. The total generativity of a system can only be determined in retrospect from how it was used, not from how it was architected. To focus only on the protocols as written to understand whether a technology will be generative is like trying to determine whether an artist has a good eye by looking at his DNA.

Generative and non-generative systems have always emerged from strange parents, and given birth to strange children. I’ve seen nothing to make me fear for the future of the net in general, though I think Facebook, Apple, and Zittrain’s points make me fear that the respectable net will be an increasingly boring place. Nevertheless they will fall in time. To keep their captive audience happy Apple has to be right all the time. The general purpose environment only has to be right once. People are not sticky, and getting less sticky by the day, and a change that captures their imagination  will drag them away from a platform or a business model or a political system with scary haste. We can’t see these changes coming from looking at how things are structured to work. We have to look at the limits of how they might be messed with.

If you want to understand the future of the internet, or the future in general, you have to look past how technology is used, and see how it’s misused. Can the net go horribly wrong? Oh yes, but not only in the ways we can predict here, now. The radio was key to allied victory in WWII, and to instigating the Rwandan genocide 50 years later. Undoubtedly the net and cell phones will grow closer together, and have their moments of glory and horror in human history.