If this post looks familiar, then you probably saw it yesterday. Not very many other people did, though, because we sent it out several hours late. So here it is again. If you did already see it, we apologize, and we’ll have something new tomorrow.
We got distracted yesterday, writing about global warming rather than a continuation of Wednesday’s look at and jumping off from a really interesting NY Times column on what is often described as a mental health crisis or epidemic, so we’re getting back to the latter today.
But first, a brief return to yesterday’s global warming-fest1, in which we looked at David Wallace-Wells insisting that the awful consequences of global warming even at the most optimistic levels are not so bad. Others were not so sanguine. We’re adding a couple of more of those for the record.
First, from The Washington Post:2
The climate news is as grim as ever. Despite the stated ambitions of the international community to take action, the world’s nations have shaved just 1 percent off their projected greenhouse gas emissions for 2030, according to a new U.N. report. The meager outcome places the planet on a path to warm by 2.4 degrees Celsius (4.3 degrees Fahrenheit) by the end of the century — below some of the greatest fears of climate watchers but still beyond the safe temperature threshold set at 1.5 degrees Celsius. It precipitates a dangerous future of extreme weather, rising sea levels and “endless suffering,” as the United Nations put it itself.
That story focuses on the Horn of Africa and East Africa, which are in desperate climate change straits. The UN Environment Programme report mentioned in the Post story is here,3 and it states, according to the UN News service,4 that we have “no credible pathway to 1.5C in place.”
“This report tells us in cold scientific terms what nature has been telling us all year, through deadly floods, storms and raging fires: we have to stop filling our atmosphere with greenhouse gases, and stop doing it fast,” said Inger Andersen, Executive Director of UNEP.
“We had our chance to make incremental changes, but that time is over. Only a root-and-branch transformation of our economies and societies can save us from accelerating climate disaster.”
“Root-and-branch” suggests certain courses of action.
Anyway: enough of that disaster. We have others. Wednesday we were talking about Danielle Carr’s New York Times opinion piece5 suggesting that we’re not experiencing a mental health crisis so much as a political one with mental health consequences.
[A]re we really in a mental health crisis? A crisis that affects mental health is not the same thing as a crisis of mental health. To be sure, symptoms of crisis abound. But in order to come up with effective solutions, we first have to ask: a crisis of what?
Some social scientists have a term, “reification,” for the process by which the effects of a political arrangement of power and resources start to seem like objective, inevitable facts about the world. Reification swaps out a political problem for a scientific or technical one; it’s how, for example, the effects of unregulated tech oligopolies become “social media addiction,” how climate catastrophe caused by corporate greed becomes a “heat wave” — and, by the way, how the effect of struggles between labor and corporations combines with high energy prices to become “inflation.” Examples are not scarce.
Carr isn’t suggesting that mental illness can’t exist independently of circumstances; only that the political or economic decisions — to the extent those can be separated, which we’re getting to — that lead to circumstances creating a mental health crisis are often left out of the equation in public discussions of mental health crises and care.
The causal relationship [between external stressors and mental illness] may be even more direct. Remarkably, all throughout decades of research on mood disorders, scientists doing animal studies had to create animal models of anxiety and depression — that is, animals that showed behaviors that looked like human anxiety and depression — by subjecting them to weeks or months of chronic stress. Zap animals with unpredictable and painful shocks they can’t escape, force them to survive barely survivable conditions for long enough, put them in social situations where they are chronically brutalized by those higher up in the social hierarchy, and just like that, the animals will consistently start behaving in a way that looks like human psychopathology.
We been zapped.
(Actually we have been zapped, literally, but we knew it was coming; we signed up for it.)
Regardless the genesis of mental illnesses, people still need treated while we are rooting-and-branching the people who created the causes. Carr’s concern isn’t only that the fundamental questions about external causes are being abracadabra-ed out of sight, as she says, hence going unaddressed — “The despair of the postindustrial underclass was methodically and intentionally milked by pharmaceutical companies for all it was worth” rather than addressing the causes for despair — but that treatment in an era of ever-expanding mental health crises will be commodified.
That’s an obviously reasonable concern. Medical care is increasingly commodified and consolidated. One can argue that commodification of mental health care is a good thing for patients who may not have had access to it before because it wasn’t profitable to keep a bunch of therapists on staff who weren’t earning their keeps, but that’s not a solution. The solution is to stop zapping people.
Instead, we have private equity firms jumping into the market as if it were a whiskey river. Kaiser Health News, not to be mistaken for the giant health care outfit, offers a handy explanation of what private equity is (video here,6 transcript here7) and what the risks of the sector's investments in health care providers are. The chief one? You can probably guess.
Private equity firms use the pooled money to invest in existing companies that are typically private — or not publicly traded. They look for ways to improve a company’s performance or value, often trying to squeeze more juice out of them to maximize profit. And then flip them quickly, generally in three to seven years (emphasis ours).
Venture capitalists and private-equity firms are pouring billions of dollars into mental-health businesses, including psychology offices, psychiatric facilities, telehealth platforms for online therapy, new drugs, meditation apps and other digital tools. Nine mental-health startups have reached private valuations exceeding $1 billion last year, including Cerebral Inc. and BetterUp Inc.
Demand for these services is rising as more people deal with grief, anxiety and loneliness amid lockdowns and the rising death toll of the Covid-19 pandemic, making the sector ripe for investment, according to bankers, consultants and investors. They say the sector has become more attractive because health plans and insurers are paying higher rates than in the past for mental-health care, and virtual platforms have made it easier for clinicians to provide remote care.
That’s from a Private Equity News8 reprint of a Wall Street Journal piece (love a look behind the most stubborn paywall around) one of whose sources told them that as startups and private equity purchases proliferate, so do new startups and existing clinics looking to make themselves attractive to outside money. “It’s a flywheel. People want to start companies where they know there’s interest in funding them.”
And fund them they do, to the tune of $5.5 billion in venture capital last year, and nearly 200 private equity healthcare acquisitions between the beginning of last year and the end of this year’s first quarter. The story is generally enthusiastic but does strike one cautionary note.
The push into mental health carries risks. A rush of private-equity firms could send prices for practices higher, reducing potential profits (emphasis ours). A risk for patients and clinicians is that new owners could focus on profits rather than outcomes, perhaps by pressuring clinicians to see more patients than they can handle.
Boy, you’d hate to be the one who bought in at the end of the boom. You’d hate to see practitioners making all the money.
The Private Equity Stakeholder Project9 keeps an eye on a variety of sectors into which private equity has inserted itself, health care being one. Of mental health care, they say that the tendency of private equity firms “to demand outsized returns in a sector that is already vastly underfunded, and serves vulnerable populations, raises serious concerns about the private equity model’s potential impact on patient care.”
The site keeps track of private equity healthcare purchases month-by-month now, as the number of them continues to accelerate.
You can’t throw an MBA off a roof these days without hitting a story about private equity depredations in health care. Returning to Kaiser Health News, we find a horror story about two rural hospitals in Missouri purchased by a private equity firm and then looted and left for dead amid a flurry of lawsuits and possible criminal investigations.10 The hospitals were purchased by Noble Health, a management company created specifically for that purpose by a private equity firm.
Once Noble owned Callaway and Audrain, the hospitals stopped paying their bills, according to lawsuits filed by contract nurses, security guards, and others. Inspection reports from the state workers coordinating with the Centers for Medicare & Medicaid Services were alarming, listing 135 pages of deficiencies that put patients “at risk for their health and safety.”
[General surgeon Dr. Joe] Corrado saw his hospital being whittled away. Supplies for surgery disappeared, crucial medicines went unstocked, paychecks never came, he said. Just days before Noble suspended operations, he told management: “We don't have the ability to do the things we need to take care of patients.”
So communities which had struggling hospitals now have none, and patients have to travel out of town to get medical care beyond what their GP can provide. For the communities themselves, trying to attract new employers and residents without comprehensive medical care available is difficult.
Returning to Danielle Carr, who sees the rapidly expanding venture capital/private equity investments in mental health care, or in companies that are meant to provide mental health care, as an exemplar of how ignoring root causes invariably funnels money into the pockets of people who support ignoring root causes.
That the status quo is once again benefiting the usual suspects is all too obvious in the booming market of venture-capital-backed mental health tech start-ups that promise to solve the crisis through a gig economy model for psychiatric care — a model that has been criticized for selling psychiatric medication irresponsibly, with little accountability.
And she notes that even where the federal government has stepped in with much needed funding, or proposals for funding, of programs for instance aimed at helping people out of opioid addictions, they still miss or avoid what sparked that particular crisis in the first place—that the despair in diseases of despair comes from concrete sources that were created by political and economic decisions benefitting what she aptly noted as “the usual suspects.”
We shall end with the inimitable Sinclair Lewis, once nearly the Socialist governor of California: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”
Root and branch, root and branch.
Got a belated start this morning with yet another J.J. Johnson and Kai Winding album, “Trombone for Two.” If you like Bebop, either you’ll love these guys or you already do. We picked “The Kid and The Brute,” by Illinois Jaquet and Ben Webster respectively, for the title. Coleman Hawkins & Ben Webster are so, soooo good in “Coleman Hawkins Encounters Ben Webster.” Then we’re getting out of here on the heels of Michael Nesmith’s “Pretty Much Your Standard Ranch Stash,” we hope. (Which didn’t happen; it was the Pernice Brothers, “Goodbye, Killer.”)
And that, comrades, is all we got. Be well, take care.
Glad you liked J. and Kai, two of my favorites. Now you can try anything by Johnny Smith on guitar.
Thank you, Weldon. You touched on the interplay between big issues here that directly impact what I do, how I'm doing it, and where we're collectively headed.
I particularly appreciate the tie-in to private equity investment. I've seen all over therapists wondering about these new companies who will pay them a decent wage to work as online therapists, wondering what downside it is that they're missing.
What they're missing is this context.