After a car accident last month, Latifa Dixon, a mother of two, arrived at the emergency room at Delaware County Memorial Hospital in suburban Philadelphia only to learn the ER had just shut down. Twenty-eight-year-old Cecilia Vizuete, who was having trouble feeding her one-year-old daughter because of a breast infection, said she was told by a security guard to search Google Maps for another hospital. Shirley Posey arrived there suffering from shortness of breath and tightness in her chest.
“This was the closest hospital to me and I needed help,” Posey said when CBS News met her outside Delaware County Memorial. Posey later recovered, but not until she raced to an urgent care, collapsed, and was transported by ambulance to another hospital.
For nearly a century, Delaware County Memorial delivered babies, treated trauma and tended to the critically ill. That all changed earlier this year, when its current owners, a Los Angeles-based for-profit company called Prospect Medical Holdings, began cutting services at the 168-bed hospital in Upper Darby, Pennsylvania. First the maternity ward went, then the operating rooms and the I.C.U., and then, last month, the emergency department closed its doors to the community’s nearly 85,000 residents.
The shutdown has raised questions about the role of private equity as it piles into the health care space, snapping up everything from local doctors’ practices to specialty clinics, even hospices. According to the consultancy Bain & Company, private equity firms posted a record year for deal volume in health care in 2021, with the total value of those deals topping $150 billion.
Backed by private equity investment, Prospect Medical Holdings rapidly grew to own 20 hospitals in six states by 2018. In 2016, it bought Crozer Health, a nonprofit Pennsylvania health system that was in danger of failing.
A CBS News investigation found that of those 20 hospitals owned by Prospect Medical, five have closed. In addition to Delaware County Memorial, Prospect Medical has suspended all services at Springfield, another acute care hospital in the same Pennsylvania health system. It also closed three hospitals in a San Antonio health system it purchased in 2012.
In court proceedings, Prospect Medical argues it is not seeking to close Delaware County Memorial for good. In a statement to CBS News, the company said it is working to transition the hospital to a “100 patient facility for those in need of behavioral health and other services.” As part of the plan, the hospital will lose inpatient “acute care services,” which includes the lone emergency room in the community of Upper Darby.
“There aren’t resources nearby and so we find that people wait longer to go to the hospital,” county official Monica Taylor told CBS News chief medical correspondent Dr. Jon LaPook, adding that closing what’s considered a safety-net hospital will hit the area’s low-income population hardest.
“We wouldn’t see a hospital closing down if this were a more affluent area,” said Taylor. “It leaves a gaping hole in this community that is going to be very hard and very difficult to fill.”
“What they cared about was making money”
In a presentation provided to Delaware County officials, Prospect Medical cited struggles with high labor costs, record inflation for supplies and pharmaceuticals, and the strain of the COVID-19 pandemic for its decision. Taylor said she believes the company has not been upfront, and has been reluctant to share its financials with the county.
“I had the sense they were not giving us all the information,” Taylor said.
Prospect Medical has faced scrutiny before. In 2019, Rhode Island Attorney General Peter Neronha’s office investigated a proposed company transaction. Prospect Medical owns two hospitals in the state, that Neronha said were “in real danger of closing” because of the debt Prospect Medical had taken on.
“This had nothing to do with the pandemic,” Neronha told CBS News. “Hospitals all over the country were facing the pandemic … but the problems here were exacerbated, frankly, by greed.”
Neronha invoked state law to force Prospect Medical to turn over its finances. A ruling by the attorney general’s office found the company put “every hospital in its system…at risk of reduction of services, sale or closure.”
“They didn’t care about health care,” Neronha said. “What they cared about was making money for their investors.”
Neronha hired two different outside experts to follow the money and discovered one reason why Prospect Medical was experiencing financial strain. In 2018, company owners took out a $1.12 billion loan, using proceeds to pay themselves and their private equity shareholders a $457 million dividend, according to the company’s financial statements, obtained by Neronha’s office in the course of the investigation.
“It’d be like a homeowner going to a bank, taking out a $100,000 loan, and instead of using it to invest in their property or pay for their kids to go to college, what they did was they just basically stuck it in their pockets as cash,” Neronha told CBS News.
The company’s financial statements revealed that to pay back that $1.12 billion loan, Prospect Medical sold the land and the buildings from hospitals they owned in California, Connecticut and Pennsylvania to a real estate investment trust for $1.386 billion. The documents show Prospect Medical then leased those hospitals back from the real estate investment trust.
“So now you’re even in a worse position because you have no equity any longer,” Neronha said. “You don’t own anything that you can then go to the bank and use as collateral to raise more money when you need it.”
In Delaware County, that lease-back arrangement instead meant the health system was saddled with $35 million a year in rent.
Delaware County Memorial Hospital in Upper Darby, Pennsylvania, was closed in November 2022 after being bought by a private equity firm, Prospect Medical Holdings.
CBS News
CBS News submitted detailed questions to Prospect Medical about these financial decisions, including about the $457 million dividend and the lease-back arrangement. The company, through a spokesman, declined to answer those questions.
“They are drawing the value out of these hospitals as they would money from a piggy bank,” said Eileen O’Grady, campaign director with the Private Equity Stakeholder Project, a nonprofit organization that has raised concerns about Prospect Medical to attorneys general in the six states where the company owned hospitals. “Meanwhile, the company’s owners have made out like bandits.”
Neronha’s office confirmed to CBS News that the Prospect Medical CEO’s personal share of the $457 million dividend was about $90 million.
“What they’ve done is extremely evil”
One of the early investors in Prospect Medical’s 2016 purchase of the Pennsylvania health system told CBS News that the company entered into the arrangement as the only bidder and “last hope for these failing hospitals.” When the purchase was announced, local officials said it came with a promise: to invest $200 million to “dramatically increase…service to the community.”
“They tried to tell us that they were going to run us the same way,” said emergency nurse Angela Neopolitano, who worked at Delaware County Memorial for 41 years. Instead Neopolitano, who was president of the local nurses’ union, says Prospect Medical dismantled the hospital piece by piece, leading to longer waits in the emergency room and forcing staff to transfer more patients to other hospitals.
“They kept on cutting services,” Neopolitano said. “Things wouldn’t get fixed. Our elevator in the back of the emergency room had been broken for over a year. When they closed the I.C.U., that was the knife in my heart.”
Neopolitano said at one point, the credit cards used by paramedics within the health system to fill their ambulances with fuel were disabled because Prospect Medical “didn’t pay their bill.”
The company did not respond to questions about its specific investments at Delaware County Memorial, but in an annual report said it had lived up to its commitment to invest $200 million in Crozer Health.
The company did not respond to a question about whether it neglected to pay fuel bills for ambulances, which was first reported in an investigation of the company by ProPublica. The company told ProPublica a company credit card was rejected because it had a charge limit as a security measure, and it increased the limit when it was brought to their attention to ensure there was not a disruption of services.
Now, the company has pivoted to a plan to convert Delaware County Memorial into a behavioral health facility. An executive with the hospital told the Philadelphia Inquirer last week that the new incarnation would not be “a moneymaker… but we go from losing $18 million a year to making $3 million and providing needed services to the community.”
The shut down of Delaware County Memorial in September has sparked a legal battle which has drawn in Pennsylvania’s attorney general and governor-elect Josh Shapiro.
In October, a judge granted an emergency injunction to keep the hospital open. Yet weeks later, the state’s health department shut it down anyway, after Prospect Medical notified the department of staffing issues.
In a statement to CBS News, Prospect Medical said the ongoing litigation limits what it can say, but that the company is communicating with state health officials about its “multiple efforts to address those staffing issues.” The company has pledged to save the facility by turning it into a “desperately needed 100-patient facility for those in need of behavioral health and other services.”
Next week, a judge will hear arguments over whether to require Prospect Medical to find a way to re-open the hospital’s doors. Shapiro’s office has asked the judge to hold Prospect Medical in contempt and to fine it $100,000 for every day it does not resolve the staffing issues.
Neopolitano told CBS News she thinks that the $457 million dividend Prospect Medical’s owners and private equity investors paid themselves should have gone back into the hospitals and into the community.
“What they’ve done is extremely evil, in my words,” said Neopolitano of Prospect Medical. “To gain a dollar, you maybe destroyed lives, maybe even ended lives, because they can’t get the help they need.”
Jon LaPook
Dr. Jonathan LaPook is the chief medical correspondent for CBS News.
Smith told WIRED that Amazon keeps patient health information confidential and secure in compliance with federal law and regulations, and in line with industry standards; Amazon Clinic customer data will be protected through the use of HIPAA-compliant encryption methods. “Protecting patient information is an important part of our business; we are not in the business of selling or sharing it,” Smith wrote.
Amazon’s recent efforts to break into health care raise a more fundamental question: Should Big Tech even be allowed in the sector? The motivations of a private company—efficiency, optimization, and above all, profit—don’t exactly square with serving the public good, says Tamar Sharon, a professor at Radboud University in the Netherlands whose work explores the politics and ethics of Big Tech in health and medicine—or as she dubs it, the “Googlization of health.”
Amazon Care, a telehealth service Amazon piloted among its employees and then rolled out to other customers, shows how things can go wrong. Its shutdown was announced a few months ago, with the senior vice president in charge of the program, Neil Lindsay, writing in an internal memo Amazon shared with WIRED: “Although our enrolled members have loved many aspects of Amazon Care, it is not a complete enough offering for the large enterprise customers we have been targeting, and wasn’t going to work long-term.”
But it was plagued by other problems, too. A Washington Post investigation alleged that moving at top speed and efficiency sometimes conflicted with best practices in medicine: For example, nurses were asked to process patient blood samples in their personal cars, the paper reported, and to store and dispose of medical supplies at home, which they protested. (Amazon told the Post that they could not find records of complaints about these matters.)
“Amazon Care followed common practices for in-home care and know them to be safe and appropriate,” Smith told WIRED. “For example, Amazon Care clinicians were always equipped with Stericycle medical waste return equipment to properly and securely return or dispose of supplies.”
For Sharon, a big concern is how reliant we risk becoming on big companies as mediators of fundamental public needs. “This is a dangerous situation—that we would become dependent on a handful of private actors for the distribution of very basic goods, like health, or education, or public services,” she says. For instance, as these companies increasingly fund and perform their own research, it’s possible they could influence how the research agenda is set. That could be a problem if tech founders’ penchant for wanting to live forever results in a focus on funding longevity research over, say, cancer treatments.
Yet private companies entering public spaces isn’t always inherently bad, says Wachter. Arguably, the multitrillion-dollar American health care system is the perfect target for new players. As Scott Galloway, a professor of marketing at the New York University Stern School of Business, points out in his newsletter, health care spending in the US far surpasses that of other rich countries, yet life expectancy is lower, creating an opportunity for new services to offer better value to patients. “The US health care industry is a wounded 7-ton seal, drifting aimlessly, bleeding into the sea. Predators are circling,” he wrote. “Amazon is the lurking megalodon, its 11-foot jaws and 7-inch teeth the largest in history.”
You could argue that Amazon is simply filling a gap in a broken system. With its new service, the company appears to be applying the same principles that made it so successful as a retailer: easy access, rapid delivery, competitive pricing—hard-to-refuse conveniences that appeal to humans’ inherent laziness, for sure, but which might also make good health care more affordable in a system divided between the haves and have-nots.
In exchange for convenience and better access, there are likely to be tradeoffs. “If we do that, we want to do it right,” says Wachter. “We just have to think about all the possible negative consequences to make sure that they don’t happen.”
Tech startup company Fast Chief Communications Officer Jason Alderman (R) talks with an employee on the first day working in the office on March 24, 2021 in San Francisco, California.
Justin Sullivan | Getty Images
Inflation has stretched household budgets near their limit. As a result, most people have reined in discretionary spending, even when it comes to health and wellness.
But just as many Americans want to scale back, U.S. health officials are expecting another pandemic wave this winter and new research underscores the importance of having comprehensive medical benefits.
Although the Biden administration is looking at ending the public health emergency over the next few months, many who get sick but survive Covid suffer from enduring health problems, studies show. And currently, as many as 23 million Americans have what’s considered long Covid, according to recent estimates from the U.S. Department of Health and Human Services.
With open enrollment season in full swing, this is an opportunity to reevaluate your coverage, saidGary Claxton, senior vice president at the Kaiser Family Foundation, a nonprofit organization focused on national health issues.
More from Your Health, Your Money
Here’s a look at more stories on the complexities and implications of long Covid:
Employees spend 18 minutes, on average, reviewing their benefit selections during open enrollment, according to Rob Grubka, CEO of Health Solutions for Voya Financial. “They spend more time deciding what to watch on Netflix.”
But this year brings added uncertainty, he said. “Between rising inflation, Covid and long Covid, we underestimate how different things may look in the future.”
At the same time, more than a quarter of employees have postponed wellness visits and screenings and consider cost the most important factor in determining their benefit choices for next year, according to benefits platform Elevate.
Employees are making choices to keep themselves afloat, said Brian Cosgray, Elevate’s CEO and co-founder. Unfortunately, some are engaging in trade-offs — like foregoing needed medical care — that could cause problems down the road, he added.
To balance your overall health and the long-term risks of illness as well as financial constraints, Claxton suggests reassessing your employer-sponsored health insurance during open enrollment, which typically runs through early December.
Almost 159 million Americans rely on employer-sponsored health insurance coverage. Here are four key considerations with open enrollment season underway:
1. Health insurance plans
For starters, consider what your health coverage costs you.
On average, workers contribute $6,106 toward the cost of a family premium, with employers pick up the rest.
However, more workers have a deductible — the amount you pay before insurance kicks in — and that deductible is also rising. In 2022, the average single deductible was $1,763, more than double what it was a decade ago.
But “don’t just look at the monthly cost of your health insurance,” Cosgray advised. “Most employers offer a few health-plan options,” he added, such as a high-deductible plan with a health savings account or a more traditional PPO.
“If you expect your health-care costs to be low for the coming year, a high deductible health-care plan paired with an HSA could be a good way to save money,” he said. “However, if you have chronic health conditions in your household and typically hit your deductible, a traditional plan paired with [a flexible spending account] may save you more over the course of a year, even if the plan’s monthly cost is higher,” Cosgray said.
“If you are going to take the high-deductible plan, you have to be able to pay the deductible if someone gets sick,” Claxton added. “The plan maybe cheaper but what if you can’t afford to use it?” Most people can’t even afford a $500 expense, he noted. “If you go to the hospital the likelihood that your out-of-pocket costs are at least $500 are pretty high.”
There are often employer-offered resources designed to help pick between benefit offerings, which can include webinars and dedicated benefits professionals.
“Many health plans now have great tools to help you manage your choices based on what you anticipate your health-care costs to be,” advised Thomas Belmont, health and benefits practice leader at Gallagher.
In both cases, you use pretax money to cover out-of-pocket expenses, including doctor visits and prescription drugs.
To be able to use an HSA, you need to be enrolled in a high-deductible health plan, or HDHP. Contributions then grow on a tax-free basis, and any money you don’t use can be rolled over year to year.
“The opportunity to save and save efficiently is there,” Grubka said.
For 2023, employees and employers can contribute a total of up to $3,850 for individual coverage and up to $7,750 for family coverage, with an additional $1,000 as a catch-up contribution for those 55 and older.
Health FSAs have lower contribution limits — $3,050 for 2023, but you also don’t need to have a high-deductible plan in order to be eligible — in fact, you don’t need health coverage at all to sign up for one. Although, you may have to use the money by year-end or you lose it, with some exceptions.
3. Life insurance and disability insurance policies
To be sure, the pandemic brought a greater awareness of financial risks associated with a critical illness.
Employer-issued life insurance policies typically amount to a year’s worth of salary, often less, but that may be a fraction of what you need to protect young children or other dependents.
The same goes for disability insurance, which can help replace a portion of your paycheck if you get sick and are unable to work.
There are two basic kinds: Short-term disability generally replaces 60{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} to 70{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of your base salary and premiums are often paid by your employer. Long-term disability, which ordinarily kicks in after three months to six months, typically replaces 40{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} to 60{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of your income.
Other voluntary benefits offered through an employer can provide additional protection, including hospital indemnity insurance, critical illness coverage and accident insurance.
“As we go into next year and the additional financial pressures, make sure you are protecting your income,” Belmont said.
4. Wellness benefits
As a result of the pandemic, many more companies have expanded wellness offerings among the health-care coverage options to help employees deal with work-life stressors and personal issues.
“We’ve got a real crisis from an emotional well-being perspective,” Belmont said.
Employees should take full advantage of the services employers provide, often at no cost, also including financial coaching, emergency savings support, stress management classes and backup child care, he advised.
With rising prices causing more Americans to feel financially strained, “one of the most underutilized benefits is financial counseling,” Belmont said.
David Goldhill is the chief executive of SesameCare.com, a digital marketplace for discounted health services.
The United States spends twice as much per person as other wealthy countries on health care. This fact is well-known, and when it is mentioned, people often point out that the governments of other developed countries leverage purchasing power to drive cheaper, more universal care. So why doesn’t the United States do the same thing?
Because we can’t. In fact, the do-what-everyone-else-does option is uniquely unavailable to us.
The world’s other health-care systems survive only because they receive a massive and ongoing, but hidden, subsidy courtesy of the inefficient U.S. system. Two unique features of our arrangement — the absence of price controls and the profit drive of doctors and hospitals — allow other countries to transfer the risk and cost of medical innovation to Americans.
And unlike in any other industry, once Americans have borne the costs of lifesaving breakthroughs as well as incremental improvements in tools and techniques, these can be used elsewhere at little extra cost. American exorbitance allows other nations to offer price-controlled universal care with none of the decline in quality, technology or productivity that would otherwise result from central planning.
A similar complaint has been made about the country’s defense alliance: U.S. allies ride free on American defense spending. Health care, indeed, is a kind of second NATO.
The United States can’t lower its costs by doing what other countries do, because what others do depends on our unique system remaining as is. Our only hope is to put in place more sensible economic structures that could introduce the competition that’s necessary to bring prices down.
The size of the U.S. health-care system is almost impossible to overstate. With barely four percent of the world’s population, the United States accounts for almost half of the world’s $8 trillion health-care economy. England’s National Health Service is tiny by comparison — barely bigger than U.S. Veterans Affairs health system funding. Canada’s total spending is comparable to the revenue of a single American company, United Health. Free-market star Singapore spends only as much as New Jersey’s Medicaid program.
The world’s top 10 spenders in pharmaceutical products
In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.
All other top 9
countries combined
Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.
The world’s top 10 spenders in pharmaceutical products
In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.
All other top 9 countries combined
Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.
The world’s top 10 spenders in pharmaceutical products
In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.
All other top 9 countries combined
Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.
This is why all health-care innovators — makers of drugs, devices, diagnostics, medical software — share the same business plan: Make money in the United States and take whatever scraps you can get in the other markets.
The pharmaceutical industry earns almost 50 percent of its worldwide revenue here, as do medical information-technology firms. Device makers earn 40 percent of their money in the United States. And this understates things, because U.S. revenue is generated from higher prices, so margins are greater. If the United States accounts for half of a company’s revenue, it probably contributes at least 75 percent of its profits.
America’s domination might not seem obvious. After all, high-tech health care exists everywhere in the world. Even in emerging economies, brilliant researchers, great universities and advanced companies perform cutting-edge research. Many have close relationships with their countries’ health-care systems, and some innovations are introduced in other nations. But the profit opportunity — the reason to invest — is always generated in the United States.
Consider the well-known miracle drug Gleevec. Before it came along in 2001, less than 30 percent of patients diagnosed with chronic myelogenous leukemia survived at least five years; today, 90 percent do.
Gleevec is also a poster drug for American dysfunction. Novartis steadily raised its price in the United States — even after its patent expired — to eventually reaching more than $123,000 per year in 2020. Yet, in Canada, Gleevec was priced at $38,000. A generic version in India now costs just $400.
Drugmakers and their opponents argue over the “fair” returns on innovation that companies need to maintain their incentive to invest in new medicines. Critics point to the share of pharma’s profits that come from barely legal anticompetitive behavior or from drugs created with heavy public support — such as the U.S. government’s $12 billion investment in coronavirus vaccines.
But enormous returns on a few blockbuster drugs compensate for drugmakers’ many unsuccessful products. That’s the business model, and these big, “unfair” returns are available only in the United States.
If the world’s largest health economy limited drug companies to “fair” returns — as other countries try to — then few new drugs would be created. The United States doesn’t pay $123,000 a year for Gleevec despite Canada paying only $38,000; Canada can pay $38,000 only because the United States pays $140,000.
And while pharmaceuticals might be the most obvious area in which the U.S. economy drives innovation, the $3.5 trillion we spend on care other than drugs makes an even greater contribution to world health-care advances.
In 2000, Intuitive Surgical Systems introduced the first commercially successful robotic surgery system. The company’s da Vinci robots carry $2 million price tags plus costly service contracts. In the first 20 years, 6,000 of the robots were sold worldwide, and American hospitals purchased roughly two-thirds of them.
Why? In the United States, the prices charged by hospitals and doctors are unrestricted. American physicians earn roughly two to three times as much as their counterparts in western Europe. Hospitals charge two to five times as much for their services.
The obvious, if rarely asked, question is: Why doesn’t competition bring U.S. health-care prices down? The answer: America’s stagnant third-party payment system allows hospitals and doctors to avoid competing on price. Instead, they compete on innovation. This is why hospitals advertise advanced, high-tech cancer therapies; surgeons build reputations for cutting-edge procedures; and even your family physician must invest to keep up.
Right now, we’re stuck. We want what every other country has. American reformers believe we’re just one clever policy tweak away from getting it — perhaps by instituting accountable care or “value-based” care.
But the only way to lower U.S. health-care costs is to rethink the system’s top-down policy structures that rely on huge, centralized payers.
What’s needed is a way to separate the safety net function that insurance provides from consumer decision-making. If insurance covered only major and unanticipated health problems, a consumer economy could drive competition in the rest of the system. This would give doctors and hospitals an economic incentive to bundle services, enhance efficiency, reduce waste and offer genuinely “value-driven” care.
In this century, the world has seen the democratization of many services considered “too complicated” for consumers — computers, finance, international travel, furniture construction, you name it. All this happened because people had enough control over their own spending to drive competition among innovators. It’s how industry managed to put supercomputer power in everyone’s pocket, while reducing price by 99 percent.
Until the same kind of competition is introduced in health care, the U.S. system will continue to subsidize the world — and cost us a fortune.
When you look at the numbers, it’s easy to gape in horror.
In Ghana, a nation of 32 million people, there are only 62 psychiatrists.
Zimbabwe, with a population of 15 million, has only 19 psychiatrists.
And in Uganda, there are 47 psychiatrists serving a country of 48 million — less than one single psychiatrist for every million people.
These are staggering ratios. To get your head around them, take the US as a comparison. There are around 45,000 psychiatrists for all 333 million Americans, which translates to about 135psychiatrists for every million people. That’s still not enough — experts are actually warning of an escalating shortage — and yet it’s a whopping 135 times more coverage than exists in Uganda.
These numbers have very real, and sometimes very brutal, implications for people’s lives. When psychiatry and other forms of professional mental health care are not accessible, people suffer in silence or turn to whatever options they can find. In Ghana, for instance, thousands of desperate families bring their ailing loved ones to “prayer camps” in hopes of healing, only to find that the self-styled prophets there chain their loved ones to trees. Instead of receiving medical treatment for, say, schizophrenia, the patients receive prayers.
The scandal of mental health care in developing countries has been well documented, and surveying it, you could be forgiven for thinking the solution is straightforward: These countries just need to train more psychiatrists and mental health professionals of the type you’d find in the US.
But that’s too simplistic. Yes, training more mental health specialists will be part of the answer for these nations. But what’s most interesting is that developing countries have also figured out a new way to tackle the deficit in mental health care — and it could hold lessons for the developed world as well.
Specifically, these nations have been serving as a proving ground for a model called community-based care, where non-specialist providers or lightly trained laypeople — picture someone like your grandmother, not a doctor — deliver brief mental health interventions in informal settings like homes or parks.
Whereas importing Western norms can alienate local populations, who may not view mental health problems as medical, brain-based problems, community-based care has found acceptance because it pays attention to cultural context. Lay counsellors meet patients where they are — both literally, in terms of physical space, and conceptually, in terms of their beliefs about mental health.
This model has turned out to be not only cheap to operate and easy to scale, but also incredibly effective for treating issues like depression. So effective, in fact, that the model is now being exported to the US, which stands to learn a lot from these poorer countries.
Dixon Chipanda, psychiatrist and founder of the NGO Friendship Bench, visits with his grandmother. He says she was part of his inspiration for the benches project.Brent Stirton/Getty Images
In 19th-century Europe, the reigning paradigm of mental health care was the asylum. The belief was that people suffering from psychiatric conditions should be institutionalized and treated on an inpatient basis. As Europeans exported this belief to the territories they colonized, asylums sprang up everywhere, from Ghana to India.
By the middle of the 20th century, asylums were becoming discredited: They were too often sites of coercion and violence, not to mention notoriously overcrowded and unhygienic. At the same time, the discovery of new psychiatric medications fostered hope that patients could be treated on an outpatient basis. In Europe, many asylums shut down.
In Accra, the capital city of Ghana, a psychiatric hospital built on this model in 1904 still houses hundreds of patients, some voluntary and some involuntary. Their issues range from depression to psychosis. It’s a resource-strapped, overcrowded institution. When I visited the hospital in 2019, I found that some patients sleep outdoors in a courtyard, where a motley collection of beds draped in mosquito nets was scattered around.
Thinking about the legacy of colonialism helps explain why this warehousing of the mentally ill persists, explained Vikram Patel, a psychiatrist and a professor of global health at Harvard Medical School.
“When the Europeans left Africa, Asia, and Latin America, they left virtually no higher education infrastructure for the native people. Basically, the colonizers left nothing,” he said. Upon gaining independence, some postcolonial countries had just one medical school for the whole nation. “And if psychiatrists can only be trained in medical schools, well, then, you know. There’s nothing.”
The very limited training capacity — and very limited funding to increase that capacity — has led to a supply-side problem. Today, that problem is aggravated by a major brain drain: The few who do train in psychiatry tend to move to richer nations offering them a more comfortable life.
And most would-be doctors in Africadon’t want to specialize in psychiatry. For some, that’s because it’s associated with institutionalization or incarceration. Others, aware that their cultures stigmatize mental illness as the work of evil spirits, may fear being viewed as “tainted” by contact with mentally ill people. And this stigma creeps all the way up to the policymakers debating how to allocate scarce resources.
“We bring these stigmas into the boardrooms and into decisions we make around fiscal planning,” Tina Ntulo, who leads the mental health nonprofit StrongMinds in Uganda, told me. “You do not budget for a person who you think is cursed or bewitched.”
Many would-be patients are also hesitant to see psychiatrists, who represent a foreign idea.
“People just don’t conceive of their mental health problem as a biomedical problem,” Patel said. “They do not say ‘I feel the way I do because I have an illness in the brain.’ That is exquisitely uncommon.”
And in cultures that don’t view mental health problems through a medical lens, stigma is a major barrier to seeking out professional care. In one large-scale survey in Nigeria, for example, 83 percent of respondents said they would be afraid to even have a conversation with someone with a mental health problem. The social costs of being branded as mentally unwell are just too high.
This is part of why some developing countries are moving toward community-based care. When you receive care from someone who’s familiar and helps you without necessarily applying a diagnostic label, it can mean there’s less stigma.
Despite being a psychiatrist himself, Patel does not believe the answer to the mental health care deficit is to just train more doctors like him. Instead, he’s become one of the most influential advocates for community-based care, where people with just a bit of training — weeks or months, not years — offer focused therapy. Empowering non-specialist providers or laypeople to take on tasks formerly done by specialists is what the World Health Organization refers to as “task-shifting” or “task-sharing.”
You might think that therapy delivered by a layperson is fine for countries that can’t afford more mental health professionals, but certainly not the ideal. Yet Patel and others who embrace the community-based model are making a much more radical claim.
“A lot of people think this is just a stopgap arrangement. It’s not,” Patel told me. “In the US itself, you need community health workers. What we need in all countries is the same model. We need to have an army of community-based health workers, nurses, social workers, delivering evidence-based interventions.”
And they are, in fact, evidence-based. Over the past two decades, dozens of randomized controlled trials (RCTs) and other studies have come out in favor of the community-based model.
Friendship Bench offers a prime example of what community-based care can look like. Rather than expecting people who are mentally unwell to seek out a psychiatrist’s office, this Zimbabwean nonprofit recruits “grandmothers” — middle-aged or older women who help out in their communities — to learn enough about depression and anxiety to recognize them, and then to treat those disorders using problem-solving therapy. That’s exactly what it sounds like: a therapy that teaches people the skills to devise their own solutions to the problems they face.
Each grandmother, recognizable in her uniform, will then go sit on a bench in a yard. People come along, wanting to talk. In fact, since Friendship Bench was created in 2006, more than 1,600 grandmothers have been trained, and they’ve already served more than 158,000 people — to great effect.
Friendship Bench counsellors attend a Sunday service at the Catholic church in Msvingo, Zimbabwe. The NGO offers free mental health counselling through trained grandmothers who work as lay health workers in clinics.Brent Stirton/Getty Images
In a 2016 study, 573 patients were assigned to either a Friendship Bench or to a bolstered version of standard psychiatric care available in Zimbabwe, which includes antidepressants. Six months later, only 14 percent of those who’d sat with a grandmother were still depressed, compared to 50 percent of those in the standard care group.
Another great example can be found in Uganda and Zambia: StrongMinds, a nonprofit founded in 2013, trains laypeople to lead group talk therapy sessions as a way to treat women with depression. Over a 12-week period, the women learn to identify the triggers of their depression and devise strategies to overcome them, using a form of therapy called group interpersonal therapy.
“This therapy is culturally appropriate. It sees interpersonal relationships as the treatment for depression,” said Tina Ntulo, the country director for Uganda. “And on this continent we are still highly relational and dependent on each other.”
Working with laypeople has enabled StrongMinds to scale up quickly, reaching more than 160,000 women to date.
“One of the amazing things our staff found is that the village volunteers [who’ve been trained to deliver the therapy] are so much better at mobilizing the women to come for therapy,” Ntulo told me. “Our staff said they never saw such high attendance for therapy when they were running it.”
Two RCTs have demonstrated that this intervention is both powerful and cost-effective. Independent researchers estimate that StrongMinds prevents the equivalent of one year of severe major depressive disorder for a woman at a cost of $248 — a pretty good deal, especially when you consider this helps the woman as well as her dependents.
Such interventions have spillover effects. The researchers note that mental health care can lead to material benefits: A non-depressed woman is more likely to be able to work, earn income, and get her kids to school so they can one day work and earn income, too.
A third example of community-based care can be found in India, where Patel co-founded an organization called Sangath. It developed a six-session program in which lay counselors treat patients with severe depression. The program showed strong results, leading to significantly lower symptom severity and higher remission than in a control group after three months.
But what’s really amazing about it is that, a full five years after researchers conducted the initial trial in India, a followup still showed significant differences between those who had received the treatment and a control group. The benefits, it turned out, could really last.
Right about now, you may be thinking: This laypeople stuff sounds all well and good for people dealing with common mental disorders like depression or anxiety, especially if they’ve got mild cases, but some people need an actual psychiatrist.
Even ardent proponents of community-based care agree with that.
“You need some psychiatrists. There’s no question that they play a role,” Patel said. That can be true even when it comes to the common mental disorders: After all, though Sangath’s community-based program for treating depression in India showed strong results, about a third of participants remained depressed after the program.
So the claim is not that community-based care should replace psychiatry. It’s that making mental health care primarily the business of psychiatrists, with little room for alternative approaches depending on context, is a mistake.
Of course, achieving the right balance between the two models is tricky.
At StrongMinds, Ntulo is very clear with the laypeople being trained about what is and isn’t within their remit. “When a person’s symptoms fall outside depression, this is not your client,” she said. “So you refer the person to the health center, and a clinician there will assess.”
At a health center, some of the tasks reserved in the West for a psychiatrist have been shifted to nurses. They can prescribe certain medications, for instance. They consult a flow chart that makes it easier to assess a patient — is he hearing voices or not? — and when symptoms indicate the patient’s problem is beyond their capacity, the nurses refer him to the next level of care above them. Essentially, laypeople handle the easier cases, nurses handle somewhat more complex cases, and the really complex cases may be referred to a psychiatrist for treatment.
StrongMinds is not anti-medication on principle, but doesn’t dispense it — partly because current-generation psychiatric medications are less available in developing countries like Uganda, and partly because much of the population would balk at the idea that a mental health condition is something they should treat with medication. Instead, StrongMinds uses the methods it thinks are most effective for the context.
It’s a system that makes sense to Ntulo, who says only a minority of people need a psychiatrist. “Everybody else could actually receive services through talk therapy and they’d probably be able to stay well for a long time,” she told me.
Patel agrees. He estimates that community-based care could probably address 80 percent of mental health morbidity. “The irony is that 80 percent of the money that’s being spent — this is my back-of-the-envelope calculation — is for that 20 percent that need hospitalization,” he said. “I think the real problem is that we do not spend enough at the base of the pyramid.”
Kwabena Kusi-Mensah, a Ghanaian psychiatrist, is a little skeptical about how far community-based care can go. “On paper, it’s a brilliant idea, really fantastic,” he said. “But having watched it be implemented for over 10 years now, there have been serious problems and challenges.”
Ghana, he explained, has trained a lot of mid-level staff called community psychiatric officers. These CPOs are like physicians’ assistants who’ve been given some additional training in psychiatry. The idea was that they would work in small villages or towns, to help bridge the treatment gap there.
In reality, the CPOs have drifted into major urban centers; now that they’ve got specialized training, they want to use it to secure a better life for themselves. But what’s even more worrying to Kusi-Mensah is that some of them are going over and above what they’ve been trained to do. He worries that this overreach could put patients at risk — if, for instance, they try to treat problems they’re not qualified to treat.
For that reason, he actually prefers task-sharing of the sort that Friendship Bench does with its grandmothers. “These are not medical people,” he said, “so they are less likely to overreach and do things they’re not supposed to do.”
A carpenter works on a bench near a Friendship Bench site.Brent Stirton/ Getty Images
When it comes to tasks that require medical know-how, he’d prefer to see psychiatrists in place to handle those, not mid-level staff. And he told me he’s “hyped up psychiatry” to many young medical students, enticing them to enter the field. But he’s careful not to entrench himself too much in either a pro-psychiatry camp or a pro-community-care camp because he doesn’t want to become too ideologically attached to one or the other.
“With extremes of ideology, if you lean too much to one way or another, you end up in a ditch,” he said. “So stay in the middle of the road, is the way I think about it.”
What all these community-based programs, and others in a similar vein, have discovered is the power of getting local laypeople to meet folks where they are.
Kusi-Mensah emphasized that importing Western norms just doesn’t work: If you want to help people in a place like West Africa, you can’t discount the importance of traditional beliefs, including religion.
“In our cultural background, where things are overspiritualized, our biggest competitors in mental health provision are the prophets,” he told me, referring to those who profess to heal patients with prayers, like in Ghana’s notorious prayer camps.
Efforts are now underway to work with, not against, faith-based healers to improve care. Some mental health professionals have gone to the prayer camps and introduced medications as a complementary treatment. Instead of saying “prayer doesn’t work, take this pill instead,” they might encourage prayers to be said alongside medical treatment. This type of collaboration has resulted in improved clinical outcomes for the patients.
But working within the camps is controversial because it could give the appearance of condoning them. Less controversial are efforts to partner with religious leaders in various towns and villages. Pastors and imams often double as informal mental health counselors anyway — that’s true in the US, too — so, the thinking goes, why not view them as another cadre of laypeople who can be trained? And for mental health problems that are beyond their ken, why not establish a referral pathway between them and the mental health care professionals?
“I’m a bit of a pragmatist,” Kusi-Mensah told me. “So I think the best we’re going to get is this sort of rapprochement, where it’s like, ‘Okay, there’s a spiritual component, so let the pastor handle that, but also there’s a medical component, so the doctor will handle that.’”
Western nations like the US favor a biomedical and highly individualistic view of mental health. Compared to, say, a Ghanaian, an American is more likely to conceive of her mental health problem as a brain problem and seek out medication from a psychiatrist. And she’s got a far better chance of accessing one.
Yet Americans’ mental health is in such bad shape that the US Preventive Services Task Force recently recommended that doctors screen every patient under 65 for anxiety. And 90 percent of American adults say the US is experiencing a mental health crisis, according to a new poll from CNN and the Kaiser Family Foundation.
To Patel, this indicates that the biomedical system can’t be the whole solution. “Mental health care is inadequate not because there’s not enough psychiatrists in most countries,” he said. “If that was the case, the US should have a perfect system. But it has a huge number of problems. It is living proof that the problem isn’t only about the lack of psychiatrists.”
America once flirted with the idea of community-based care. As Vice explained:
It’s taken a few decades, but America now seems ready to experiment with community-based care again as a supplement to psychiatry. What’s exciting is that, this time, it’s taking inspiration from poorer countries.
Zimbabwe’s Friendship Benches have made their way to New York City. Walk around Manhattan and you might see a trained layperson sitting on a big orange bench, waiting to listen or talk about issues ranging from depression to addiction. These are issues some of the laypeople have experienced themselves, so they’re nonjudgmental. They literally meet people where they are, lugging their bench around from spot to spot, as part of the Thrive NYC program aiming to create a mental health system that works for everyone.
India’s Sangath program for depression, meanwhile, is now being rolled out in Texas, where Patel is collaborating with the Meadows Mental Health Policy Institute and Baylor Scott and White, the largest not-for-profit health care system in the state.
And this year, Uganda’s StrongMinds is setting up a pilot in New Jersey. The idea is to address the US mental health gap by reaching people who can’t afford to pay for a licensed professional, with a focus on serving Black people, Indigenous people, and people of color.
“We just finished training the team in New Jersey!” Ntulo told me. “They’re going to use the same model we use. It’s an amazing solution for a health system that is so commoditized, like yours.”
As the pandemic lingers, contributing to rising inflation and looming economic recession, Americans from all walks of life may be concerned about their medical bills.
The Healthcare Freedom Act, proposed by Rep. Chip Roy (R-Texas), seeks to help Americans regain control of their healthcare expenses by creating “health freedom accounts” similar to existing health savings accounts. Health savings accounts enable patients to save pretax dollars for future medical expenses, but are limited to only those with high-deductible health plans, and contain numerous restrictions on what types of healthcare spending may qualify. Roy’s bill would allow any American, regardless of their health insurance type, to become eligible for health freedom accounts, as well as expand the list of qualified medical expenses.
As a physician, I call upon Congress to pass this legislation in order to provide patients greater autonomy over their healthcare.
Health savings accounts were first established in 2003 as part of the Medicare Prescription Drug Improvement and Modernization Act and became more prevalent as more employers began offering high-deductible health plans over the past 20 years. Many patients with high deductible plans never meet their annual deductible, and thus are forced to rely on money from their health savings account to cover routine health expenses; for these individuals, any money spent on insurance premiums by themselves or their employer is wasted. To make matters worse, current regulations also prohibit the use of health savings accounts to pay for insurance premiums. These policies serve only to enrich insurance companies at the expense of patients and private employers.
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Currently, HSAs allow maximum family contributions of up to $7,300 per year to a tax-deductible account, which enables the contributions to be untaxed for that year. In addition, the money grows tax-free and may be withdrawn from the account untaxed. These tax-protective mechanisms are how HSAs came to be known by the coveted descriptor “triple tax-free.” In addition to allowing all Americans to obtain an HSA/HFA, the Healthcare Freedom Act would nearly double the yearly contribution limit to $12,000, and allow individuals 55 years or older to contribute an additional $5,000. These changes are necessary due to the rapid growth in healthcare costs which routinely outpaces the already-astronomical rate of inflation.
The Healthcare Freedom Act would also expand the list of approved medical expenses to include insurance premiums, direct primary care physician subscriptions, and payment to Healthcare Sharing Ministries. The bill would enable money from HSAs to be spent on all of these, plus additional services that may not be covered by health insurance. For example, patients coming to dermatology clinics may use money from their HSA/HFA to pay for the removal of benign skin lesions or other procedures deemed as “cosmetic” by insurance companies. From the physician side, it allows a wider range of practice possibilities that would enable doctors to practice more personalized medicine.
If HFAs become commonplace, more patients will be able to obtain their medications through compounding and specialty pharmacies, cutting out middlemen and reducing costs. Indeed, physicians will be able to circumvent insurance headaches such as step therapy (requiring patients to fail certain categories of medications before insurance will cover alternative therapies) if patients can pay for their medications directly. As a dermatologist, I frequently use direct-to-consumer pharmacies to help patients obtain customized therapies for their skin.
Healthcare freedom accounts would expand access to these services to patient populations who may not have the financial ability to pay for these treatments out-of-pocket. Employers may also like the added flexibility of HFA’s, as they would be able to offer the new health savings account as an employee benefit without being forced to subscribe to a group high-deductible health plan.
The net effect of expanding the number of approved expenses would be increased patient and physician autonomy. From the patient side, the Healthcare Freedom Act allows them to spend their hard-earned savings in a way that most aligns with their values.
As a physician, I look forward to serving patients based on the ideals of the Hippocratic Oath rather than following arbitrary guidelines created by insurance companies.
Aamir Hussain is a resident physician practicing in Washington, DC. Rufus Sweeney, a medical student at the University of Wisconsin, assisted in the creation of this story.
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