We need better involuntary commitment rules for mentally ill

Tomorrow will mark three weeks since the Newtown, Conn., school massacre. The wretchedness of that day has touched off a national debate about preventing mass murders -- as it should. But lately the conversation has narrowed to gun control.

In a year-end interview, responding to a question about the political fights ahead, President Barack Obama voiced his support for banning assault rifles and high-capacity clips, and for better background checks for gun buyers. What I didn't hear from the president was a vow to strengthen our mental health system to treat people like Adam Lanza before they descend into madness. Whatever Lanza's technical diagnosis -- schizophrenia? -- executing two classrooms of first-graders is by definition mad.

Gun control is easier to discuss, because there is an identifiable, organized opposition in the National Rifle Association. But mental illness is harder to recognize, reach and heal.

Consider the divergent responses I received to a column that ran right after the Sandy Hook killings. I wrote that in New York, as in most states, the law allows for involuntary commitments of those who are mentally ill. What's more, New York permits someone to alert the authorities to dangerous behavior while remaining anonymous.

Some readers wondered about the potential for abuse of involuntary commitment -- also called civil commitment. "How do [the authorities] know that you are just not furthering a neighborly feud or personal vendetta?" one man emailed.

Others said that even though such laws exist, they are almost unenforceable in practice. A mental-health group home administrator said he has often been frustrated when calling for help: "There is no mechanism for involuntary admission unless the person is either violent or expresses violent ideas in front of a psychiatrist or police."

And so there is the conundrum. The problem isn't the law, exactly, but the judgment, resources and political will to enforce it.

We have yet to find the place where the pendulum should rest since deinstitutionalization began in the 1960s. The idea was to wipe out the abuse of mentally ill people, to respect their civil rights by closing psychiatric hospitals and moving toward community-based care, such as group homes and outpatient treatment. But the system that was supposed to take the place of psychiatric hospitals has never been adequately funded or built out.

The results are cruelly inadequate. Twenty percent of prison inmates, and at least one-third of the homeless, are seriously mentally ill, according to the national Treatment Advocacy Center. Mostly, they are not receiving the care they need to heal, stabilize and lead full lives.

And, as appears to be the case with Lanza, responsibility for care falls to individual families -- sometimes with disastrous results. In two other recent mass murders -- the killing of 12 people and injuring 58 at a Colorado movie theater in July, and the wounding of Rep. Gabrielle Giffords and killing of six others in Tucson two years ago -- family, acquaintances and school officials had been alarmed about the behavior of the two men who became suspects. Yet no one stopped them.

Most mentally ill people are not violent, but statistics favor stronger civil commitment laws. According to a 2011 study by the University of California, Berkeley, states with stronger laws have homicide rates about one-third lower.

Vice President Joe Biden is preparing a report on preventing mass shootings. If he wants a place to start, he might consider our patchwork of state civil commitment laws -- both how they are written and how they work in practice.

This essay was first published in Newsday.

Time for a 'living wage' for the middle class?

With millions out of work, complaints about the decline in middle-class wages may seem misplaced. But without some shoring up, the middle class will remain dispirited -- and our economy, which is 70 percent dependent on consumer spending, will remain in the dumper.

It may be that there's a role for government to play in buttressing these eroding wages, which result not only in a declining standard of living, but also in a family life so pressure-filled that it leads to its own problems: angry homes, fast-food diets, dependence on alcohol and drugs.

Calling for any sort of government role during these tea party times can raise charges of socialism. But the idea of a wage that supports some minimum standard of living -- shelter, clothing, food -- has been broached on and off for more than a century.

In the late 1800s, social activists began protesting wages earned by a working-class man that were not sufficient to sustain his family, without the additional wages of working children and mothers. The Catholic Church published a fundamental social teaching, "Rerum Novarum" (on capital and labor), that read, "Wealthy owners of the means of production and employers must never forget that both divine and human law forbid them to squeeze the poor and wretched for the sake of gain or to profit from the helplessness of others."

Shortly afterward, Australia's courts ruled that an employer must pay a wage that guaranteed a standard of living that was reasonable for "a human being in a civilized community" for a family of four to live in "frugal comfort."

In the United States, these ideas led to laws forbidding child labor, making education compulsory and protecting women from exploitive labor conditions. The campaign to establish a "family wage" was defeated, but in 1938, a lower standard, the federal minimum wage, was passed.

The Rev. Martin Luther King Jr., Daniel Patrick Moynihan and in 1968, a group of 1,200 economists including Paul Samuelson and John Kenneth Galbraith, have all supported some kind of minium income guarantee.

Echoes of this debate are being heard now, in the Vatican's critique last week of the global financial system, and in places where labor unions still have some sway: In the New York City Council, which at the urging of retail workers may require employers in commercial developments built with public subsidies to pay at least $10 an hour, a "living wage" higher than the minimum wage of $7.25; and in Albany, where the State Legislature in April passed an increase to $9 an hour for home health aides, who are represented by the influential 1199 SEIU United Health Care Workers East. That increase takes effect on Long Island in 2013.

It's easy to see why the lowest-paid workers would need a boost from someone powerful enough to argue on their behalf. But to make the argument for the middle class, one has to believe that this great swath of America, nearly half the country, has special value. And it does: The stability and upward mobility of the middle class not only underpin the U.S. economy but give America its famously optimistic and innovative spirit.

That spirit is on display as the middle class makes the best of things today: The average American has added around a month's worth of work, 164 hours per year, in the last two decades. One-third of American families have reduced their savings for college, according to a 2010 Sallie Mae/Gallup poll, and another 15 percent are not saving at all. Retirement savings are in similar decline.

How much more can the middle class cinch in its belt, before we lose what's precious about this way of life?

First published in Newsday.

Health bill threatens to bankrupt man

A year ago, Tom Carlo's back was killing him. And now it's simply threatening to send him into bankruptcy.

Carlo, 63, has struggled for more than 40 years with back pain, since falling out of the second floor of an Air Force barracks in 1968, when his unit was under attack in Vietnam. Last spring, he was unable to sit for very long because of the pain, and he was taking drugs that were wrecking his stomach. He opted for a spinal surgery -- his third -- recommended by a doctor.

The surgery was supposed to lead to a cure from pain, and Carlo has found some relief. But his financial problems were just beginning. In June, his insurance carrier, CareAllies, OK'd the operation. In July, Carlo checked into Winthrop-University Hospital in Mineola. In August, CareAllies reversed its decision and denied payment to the two surgeons who operated.

"When the insurance company gives you the OK, you figure, let's do it," Carlo said. "Two months later they told me I should have tried physical therapy or shots -- well, it's too late now."

This is an unpredictable moment in the business of medicine, with costs soaring, the federal government rewriting rules, and insurance companies and doctors vying for some control over the inevitable changes. But people like Tom Carlo, a retired U.S. Postal Service letter carrier who drives a school bus in Garden City, shouldn't have to bear the brunt of these tectonic shifts. He appears to be caught by an insurance carrier balking at astronomical fees from an out-of-network doctor.

New York, unlike other states such as New Jersey, doesn't have a law against excessive billing.

CareAllies, a unit of Cigna, provides health services under contract to the National Association of Letter Carriers. Carlo's plan is a PPO -- a preferred provider organization -- which supposedly gives him the freedom to shop around for a surgeon, provided he shoulders a greater share of the bill. PPOs often pay 70 percent of the "usual and customary" costs of out-of-network care.

The whopper surgeons' bills may have had something to do with CareAllies' change of heart. The primary surgeon billed $355,000, and the assistant surgeon $160,750. Enough to pay for Carlo's tidy Wantagh house and then some.

He has appealed the decision up the chain to the U.S. Office of Personnel Management, which is ultimately responsible for the letter carriers' insurance contract. A representative of that office didn't return phone calls for this story. In a letter to Carlo, CareAllies said that his records had been checked as part of a random audit, and that an independent reviewer had determined the surgery was not medically necessary. Winthrop Hospital and Cigna said they will look into Carlo's case.

In Nassau County, the "usual and customary" rate for this surgery would have ranged between $49,750 and $64,750, according to Empire BlueCross BlueShield. Dr. Scott Breidbart, Empire's chief medical officer, said that out-of-network billings are an area of heated dispute between insurance companies and doctors.

Normally, the insurance company and the doctor would try to negotiate. But Carlo has been appealing CareAllies' decision for 10 months. If the Office of Personnel Management denies his claim, the next resort will be to sue in federal court -- an exhausting and expensive prospect.

Carlo's tale isn't unique. Medical expenses are a leading cause of bankruptcy. But it's an example of why we need health care reform. It doesn't get much worse than having a $515,750 bill dumped in your lap.

First published in Newsday