On Guns and Mental Health

I would like to make a case here that “going after the mentally ill” and touting mental health legislation as a way of preventing mass shooting is a misguided approach.

While some psychiatric diagnoses are associated with violence, fewer than 5% of people with mental illness ever commit violent crimes. According to P Appelbaum, from the Division of Law, Ethics and Psychiatry at Columbia University, and many other medical studies, only 4-5% of violence is attributable to mental illness. Conversely, individuals with serious mental illness are much more likely to be victims of violence rather than perpetrators.

Of course, our society needs to expand mental health services for many reasons – foremost to alleviate the suffering of the mentally ill, rather than to protect ourselves from the myth of the “autistic shooter”, a most insidious form of profiling against the mentally ill. Autism is not associated with brutality. Psychopaths on the other hand are often secretive and difficult to detect.

Background checks should focus on people who have been convicted of violent misdemeanors, multiple DUI’s or restraining orders. Road rage and domestic violence should be red flags. A public health study reported that abused women are five times more likely to be killed by their abuser if the abuser owns a firearm.  Road rage events involving firearm deaths have doubled in the last 3 years.

Priorities should be given to implementing gun safety laws, firearm buy-back programs, anger management training, and changing the gun culture of our society. But don’t use mental illness as a diversionary tactic.

Chinh Le, MD

(Submitted Feb 20, published on Feb 25, 2018 in the Gazette Times, Corvallis, OR)

Medicare-for-All, not Medicaid-for-less

With the passage of Measure 101, many Oregonians can count again on some degree of healthcare security. At the national level however, the president and Congress can dismantle Obamacare without major legislative actions, simply by withholding funding, not implementing regulations, and gutting the insurance mandate clause. Another battleground yet is shaping up in courtrooms over arguments and decisions about how states can implement their own versions of Medicaid waivers that redefine and attach stricter conditions to coverage eligibility, benefits and access to healthcare. 

The recent Kentucky Medicaid “expansion” bill – soon to be followed by nine other, mostly Republican-led states – is a case in point. It calls for a program that includes work requirements for “able-bodied” adults and income verification, as well as cost-sharing provisions like premiums and copayments. Sounds fair enough, if our concern is mainly to restrict “abusers” from taking advantage of a “safety net” most of us don’t use but are paying for with our taxes.

Let’s step-back a moment and look at the whole picture. The vast majority of current Medicaid beneficiaries are children, working adults already employed in low paying jobs, and people with health conditions that prevent them from working, including the elderly poor. Many un-employed are often already in school or job training, or have a hard time finding jobs. Linking each eligibility case to work requirements would force health and social service personnel to identify and match “able-bodied” Medicaid applicants to jobs that are “appropriate” for them. With people moving in an out of poverty and/or fluctuating levels of physical or mental disability, the red tape is never ending, piling more bureaucratic workload on already limited resources - just to weed out a few “free loaders”.

Cost-sharing provisions – used as a way to prevent people from seeking medical care for minor illnesses and to make them more responsible in their healthcare decisions - are seen as tools to hold down insurance costs. But erecting hurdles can mean care delayed, care denied, and ultimately can increase financial and human costs – not just to the individual, but to society as a whole. More importantly, they ignore a much greater source of healthcare waste: providers prescribing marginally beneficial tests and treatments.  

Liberals and conservatives generally agree on the need for job creation, cutting wasteful spending and upgrading infrastructure. But controversies around healthcare reform epitomize our political polarization. If we can put divisive moral and ideological arguments aside (“who deserves what?”) and agree on the need to correct our social inequities to achieve better health outcomes (“what program is more cost-effective in the long run?”), then perhaps we could together build bridges, rather than dams, over our troubled waters.

Despite some flaws in the system (all fixable), our Medicare program has proven to be fundamentally cost-effective, highly popular and vital to our elderly. Why not offer Medicare eligibility and benefits to all individuals, from womb to tomb, regardless of income, employment status and health conditions? It would be administratively simpler, medically just, and financially achievable in a country as rich as ours.

Chinh Le, MD

Corvallis

(Published in the Gazette Times, Feb 8, 2018)

Beyond tears and prayers...

The same day I learned about the Las Vegas massacre, I read that Congress had been considering a vote on HR 3668, which would repeal restrictions on gun silencers - making it harder to detect the source of gunfire during mass shooting.

There is nothing new about the gun debate, which comes down to three major arguments and counter-arguments:

1. “Right to bear arms”. I wonder whether what the Founding Fathers had in mind was simply the need of our young nation to have a well-armed militia against European colonial empires.

2. “Guns don’t kill people, people do”. True, but the main purpose of guns is to make killing easier and faster.

3. “The only protection against a bad guy with a gun is a good guy with a gun”. Sounds good, but no evidence, even in states where many citizens have permits to carry concealed weapons, or where open carry is legal.

Many scholars consider gun violence a public health crisis, but we know too well that scientific studies and reasoning seldom change extremist mindsets. Our American exceptionalism prevents us from learning about gun regulations from other civil countries in Europe, Canada and Australia. President Trump labeled the Las Vegas shooting as an act of “pure evil”. I know there are many responsible gun owners out there. Perhaps they can join me in asking the question: By opposing gun control and safety regulations, are the NRA supporters and our Congress acting as enablers of evil?

October 2, 2017 - Submitted to the Gazette Times, Corvallis, OR

Medicare for all

We empathize with Mr. Ron Coffey’s frustration caused by the lack of Medicare re-imbursement for the medical services he and his wife received (GT May 17). There is no question that our current Medicare program needs more “fine-tuning” to correct gaps in coverage, minimize billing frauds, and stay sustainable for generations to come.

Our vision for “Medicare for All” has three essential components:

1. Universal coverage (“everybody’s in, nobody’s left out”). Right now, our health insurance system - a mix of employer-based and publicly-supported plans – leaves many either un-covered or at risk for adverse changes when the job or insurance market fluctuates. Expanding Medicare security and access to essential health coverage benefits to all citizens from birth to grave is the right economic, medical and moral thing to do. Choice of providers would also be “universal”, rather than limited by current, exclusive insurance plans.
2. The “single payer” term needs clarification. Currently, the multiple sources of financing healthcare is confusing and inequitable, and negatively impacts our national economy and business costs. Rather than paying for a mix of premiums and out-of-pocket expenses, everyone will be paying into a public fund specifically dedicated for health services, in a fair and progressive manner than will cost less than the unpredictable cost-sharing we have now. 
3. In a Medicare-for-All system, medical billing and provider re-imbursement, standards of care, drug pricing and administrative overhead costs can be simplified, made more efficient, transparent and accountable than under a fragmented, for-profit multi-system.  

  Respectfully submitted,

Betty Johnson

Chinh Le, MD

(Published in the Gazette Times, June 1. 2017)

An immigrant's love of America

After emphasizing that immigrants to the United States will have to undergo “severe vetting”, President Trump recently added that “we will only accept immigrants who love us”. And when asked what he would do about the surge of anti-Semitic activities since his election, he responded that “you are going to see a lot of love”…  Am I feeling the gentler and kinder side of America coming back?

Roll time back by fifty years: 1967 was the year I first landed in America, a lucky winner of a scholarship from the USAID Leadership Program launched to train young Vietnamese students for future “nation-building”. Little did I know then that the Communists would take over Vietnam a few years later, and that I would spend my professional career serving Americans rather than my people. Reality number 1: Very few humans have control of their own destiny, and refugees have even less. Swept under by historical tsunamis, we land on shores we never dreamed of, and pick up our lives again. I was very lucky and forever grateful for that chance. America has been a wonderful home for me.  Yet Vietnam and the people I left behind will always be in my heart.

But President Trump, don’t you worry! What is there not to love about America? After all, one only has to believe in the following words: “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness”.  All American school children and all immigrants live on the promises of these beautifully written words learned in their first civic class. Idealistic as they should be in a Declaration of Independence, albeit a bit utopian they would sound over the course of history. Sadly, we now know that these truths are not so self-evident, that some men are created more equal than others, and that too often, when we claim our own unalienable rights, we are likely stepping on someone else’s rights. Some lives seem to matter more than others. The four Liberties declared by FDR in 1941 and so beautifully painted by Norman Rockwell remain elusive for many in their daily struggle for survival.

And the pursuit of happiness? As my hair turned grey over the years, I realized that to pursue happiness means never to find it: by definition, when we are after something, we don’t have it. It will always be in front of us, running one step ahead of us. So I returned to the Buddhist roots of my childhood: I have to cultivate happiness within myself. I will not find it by chasing it, or by building golden towers. And certainly not by walking a path lined with the latest consumer goods or blessed by the Prosperity Gospel. But I hope this does not make me less American, Mr. President.

Tears roll down my cheeks when I sing the lyrical words by another immigrant, Irvin Berlin: “God bless America, land that I love”. But it is the sentence that follows that resonates even more, in these challenging times: “Stand beside her, and guide her, through the night with a light from above.”

There are many ways to love America. Perhaps the best way is with the dreams and the heart of an immigrant or a refugee who knows that, unfortunately, not all lives are equally endowed with unalienable rights. Ambivalent as we may be about its harsh realities, what we love about America is that dreams are still worth living for.

(Corvallis, OR, February 22, 2017)