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More Americans receive mental health treatment in prisons and jails than in hospitals or treatment centers. In fact, the three largest inpatient psychiatric facilities in the country are jails: Los Angeles County Jail, Rikers Island Jail in New York City and Cook County Jail in Illinois.

“We have a criminal justice system which has a very clear purpose: You get arrested. We want justice. We try you, and justice hopefully prevails. It was never built to handle people that were very, very ill, at least with mental illness,” Judge Steve Leifman tells Laura Sullivan, guest host of weekends on All Things Considered.

A failing system

When the government began closing state-run hospitals in the 1980s, people with mental illness had nowhere to turn; many ended up in jail. Leifman saw the problem first-hand decades ago in the courtroom. When individuals suffering from mental illness came before him accused of petty crimes, he didn’t have many options.

“What we used to do, which I tell people was the definition of insanity [鈥 was they would commit an offense, the police would arrest them, they’d come to court, they’d be acting out so we would order two or three psychological evaluations at great expense, we would determine that they were incompetent to stand trial and we’d re-release them back to the community and kind of held our breath and crossed our fingers and hoped that somehow they’d get better and come back and we could try them,” he says.

Instead, many disappeared and got re-arrested. Sometimes within minutes.

“They’d walk out the door, they were ill, they’d act out, because [the jail] is next to the courthouse there are several officers out there, and they’d get re-arrested,” he says.

Not only was the system inefficient, it was costly as well. When Leifman asked the University of South Florida to look at who the highest users of criminal justice and mental health services in Miami-Dade County, researchers found the prime users were 97 people, individuals diagnosed primarily with schizophrenia.

“Over a five-year period, these 97 individuals were arrested almost 2,200 times and spent 27,000 days in the Miami-Dade Jail,” Leifman says. “It cost the tax payers $13 million.”

A look Inside One Jail

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Sheriff Greg Hamilton of Travis County in Austin, Texas, also sees the flaws in the system.

“It seems to me that we have criminalized being mentally ill,” Hamilton tells Sullivan.

Hamilton has been the Sheriff of Travis County for seven years. In that time, he’s seen more and more mentally ill people filter into his jail.

He says the lack of space at the local hospitals means his jail has become the default treatment center. He says the average stay of a mentally ill person in a Travis jail is about 50-100 days. But Hamilton says the longest term he’s seen was 258 days.

Hamilton’s jail only has a handful of counselors on staff to deal with the 400 inmates they house daily. The individuals who do get stabilized find it hard to get their medication replenished or see a psychiatrist once they leave the jail.

It’s a broken system, but Hamilton notes that this was never the way the mentally ill were suppose to be treated.

“The jail was never meant to be a state hospital or a treatment facility,” he says, “but we have been thrown out there and we’ve got to take the hand that we were dealt.”

Reforming the system

Judge Leifman is trying to prevent individuals with mental illnesses who have committed minor crimes from ending up in jail. He’s creating a novel facility in Miami-Dade that will serve as what’s known as a “forensic diversion facility.” The program provides a sentencing alternative in cases where the offender has mental health issues. Those entering will begin in a higher-security area, more like a jail, and once stabilized move to a different part of the building for treatment.

“They’ll continue to step down until they’re actually ready to go back to the community,” Leifman says.

The facility will be run on a “clubhouse model,” meaning people with mental illnesses will take an active role in planning activities.

Leifman acknowledges the facility won’t keep everyone with mental illness out of jails, but says “if we can keep 50 percent of the people who are coming into our jail out who have serious mental illness we’ve made a huge dent in the problem.”

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Once Gov. Peter Shumlin signs a bill on May 26, the state will be on track to having a single-payer health care system.

“We’re actually trying to design the first single-payer health care system for America,” Shumlin told Guy Raz, host of weekends on All Things Considered.

“Basically what our system will do is treat health care as a right and not a privilege,” he says. “We want to design a system where health care will follow the individual, and not be a requirement of the employer, which we think will be a huge jobs creator.”

Most importantly, Shumlin says, it’ll be a publicly financed system. Everyone pays, and the state uses those “health care dollars to make us healthier, not to enrich insurance companies, inefficiency, waste, and the current fee-for-service system, which bills providers based on how much service they do.”

But don’t break out the Canada comparisons just yet.

Vermonters aren’t going to wake up to a single-payer system overnight. What’s being passed is more of a framework. They are using the Affordable Care Act, the hotly contested bill passed last year by Congress, as a bridge for the state to get there. When that bill becomes law in 2014, so will Vermont’s plan.

The basic outline looks like this: The federal government, Vermont’s state government and employers will all still pay in for health insurance. That money will then all flow through Green Mountain Care, Vermont’s official health insurance. To equalize the rates consumers pay, the state will ask the federal government for Medicaid waivers. The state government must also court national employers that do business in Vermont to put their employees on Green Mountain Care.

The bill doesn’t lay out hard specifics on how to pay for it all, which has critics nervous. A financial exploratory committee has the task of putting together a proposal due January 2013, but for now Shumlin isn’t worried. He says there are only a few different options to choose from in order to pay for a publicly financed system, like using Medicaid vouchers.

The logistics will come in time, he says. Right now, the cost of health care is swelling and Shumlin believes setting Vermont up on a single-payer system will create a more sustainable way to take care of everybody.

“We have a crisis,” he says. “What I find alarming is that so many of us are willing to pretend that everything is going to be OK if we stick with the current system. So we’re taking the bull by the horns up here in Vermont.”

If Vermont does get it right, it could see more businesses and jobs coming in. Shumlin sees this type of health insurance as a big financial ease for employers, especially small-business owners.

That’s a big economic incentive, but it wasn’t enough to save the single-payer provision of the Affordable Care Act from being axed by Congress last year. Yet Vermont might be the right size and the right political environment to be a sandbox for a single-payer system in America, and Shumlin believes it could serve as a model for other states.

“We want to figure this one out and get it right,” Shumlin says, “Then we hope that perhaps others might follow.”

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“I imagine so,” he says. “I paid taxes all my life.”

Today, Jones is retired. He volunteers and calls bingo once a week at his local community center. But for 30 years, he worked in Pittsburgh’s steel mills.

“I’d mostly run a 983-Caterpillar,” he says, “and I’d clean up the molten slag after the the ladle ran over.”

It was hard, hot work. And Jones – like many seniors his age – says because he’s paid in, he’s earned the benefits Medicare pays out.

In Seattle, 68-year-old retired librarian Diane Rosolowsky qualified for Medicare shortly after a traumatic brain injury. She was grateful for the benefits she received.

Years earlier, when she helped run her husband’s veterinary clinic, she told employees who scoffed at Medicare tax deductions on their paycheck, “鈥楾hat’s your prepaid medical care for when you are a senior citizen!’ ”

And in Brookline, Mass., 86-year-old Elane Shapiro says she didn’t have to struggle with medical bills after her husband died and she was diagnosed with cancer.

“I was taken care of. I’ve always paid my taxes.” she says.

“I think most people feel the way I do. If anyone talks about changing Medicare, we get very nervous.”

In and Out

Some seniors get more than nervous, as U.S. Rep. Paul Ryan learned in a town hall meeting in his home state of Wisconsin this past week.

“Hey, c’mon!” Ryan told an increasingly hostile crowd. “If you’re yelling, I just want to ask you to leave.”

Ryan is the Republican point person for budget reform in the House. And Democrats are painting his plan as as an attack on Medicare, even as some Senate Democrats support a bipartisan plan that includes cuts similar to Ryan’s.

There’s a reason system current system is unsustainable, says Eugene Steuerle, a former Treasury Department official and senior fellow at Washington’s Urban Institute. He boils it down to two simple numbers.

“An average couple retiring today has paid just a little over $100,000 in Medicare taxes” over the course of their working lives, Steuerle tells Guy Raz, host of weekends on All Things Considered.

And what do they receive?

“About $300,000 in benefits” – even after adjusting for inflation.

No One To Say 鈥楴o’

How did the current system become so unbalanced?

It has to do, Steuerle says, with the way Medicare was built to work – by passing on an individual retiree’s health care costs to the wide pool of current taxpayers.

“The incentive for me as a consumer to worry about the cost isn’t very high,” he says. “But the incentive for providers have this incentive to keep listing as many services as possible. The more services the hospital can list, the more they can collect.”

A system like that works all right if health care costs stay low. But over the past few decades, they’ve risen dramatically. There are more and more people entering the Medicare system. Those people live increasingly longer lives. And most importantly, Steuerle says, no one is in charge of saying “no” to medical-cost inflation.

The result is a Medicare system that only pays for one third of itself. The shortfall is made up – in part – from other sources of revenue.

“It’s also borrowing from China and Germany and a lot of other countries,” Steuerle says.

Paying For Your Parents

That average, 66-year-old couple Steuerle talks about didn’t really pay taxes for their own Medicare benefits, he says; they paid for their parents’. That’s the way the system works: Current taxes pay for the benefits that go to current Medicare recipients.

But say demographics shift, health care costs rise. and fewer children are born to pay into the system. Then, the child-to-parent cost chain breaks down.

“Suppose you have a household with three children,” Steuerle says. Those children pay for their parents’ health care. But if those three children only have two children?

“To what extent does that mean I am entitled – from my children – to have all my health costs covered?” he says.

Stephanie Rennane, a research associate and colleague of Steuerle’s, represents the generation struggling with that question. She’s 25.

“If I talk to my friends, other people who are 25 right now, they say, 鈥楩orget [Medicare]; it’s not going to be around for us.’ “

Slowing Growth

And bringing that system into balance, Steuerle says, is going to cost all of us.

“I don’t see any way we can exempt any broad portion of the population from tackling our broad budget issues,” he says.

That could mean higher taxes for everyone – including people currently on Medicare. And possible cuts to the program.

“But when we’re talking about cuts in things like health care and elderly support programs,” Steuerle says, “we’re basically talking about cuts in a rate of growth.”

Health care, in other words, is always growing. If it’s going to grow by $100 billion next year but is trimmed to grow only by $80 billion, that’s still called “a cut.”

“So the language can be very misleading,” Steuerle says. A rate of sustainable growth is the real goal of any sensible Medicare reform proposal, he says.

“That doesn’t mean that your children aren’t going to get more health care in the future. They are – partly because we’re going to invent a lot better things to provide them with,” Steuerle says.

“It just means the rate of growth that we now promise is totally unsustainable.”

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Though the oath has been rewritten over the centuries, the essence of it has remained the same: “In each house I go, I go only for the good of my patients.”

But the principles of the oath, says Dr. Gregg Bloche, are under an “unprecedented threat.” In The Hippocratic Myth, Bloche details how doctors are under constant pressure to compromise or ration their care in order to please lawmakers, lawyers and insurance companies.

Bloche says that doctors are increasingly expected to decide which expensive tests and treatments they can and cannot provide for their patients. Their dual role as examiner and cost-cutter can then potentially compromise patients’ care, he says, particularly when insurers and hospital administrators urge physicians to only perform “medically necessary” treatment.

The Hippocratic Myth: Why Doctors Have to Ration Care, Practice Politics, and Compromise their Promise to Heal By M. Gregg Bloche M.D., Hardcover, 272 pages, Palgrave Macmillan List Price: $27

“The average person thinks that 鈥榤edically necessary’ care means all care that might potentially be beneficial,” he says. “But the reality is that it’s a wide-open term.”

Care may be denied, says Bloche, for a variety of reasons, including whether patients have consented to cheaper treatment options through their health insurance plans. What that means, he says, is that doctors who ration care on behalf of insurance providers may simply be following their patients’ wishes – even if patients are not aware that they’re receiving subpar treatment.

“In the real world, the choices aren’t made clear in the employee benefits office,” he says. “In the real world, the cheap health plan and the expensive health plan both promise you 鈥榤edically necessary’ care and you don’t really know what that means. So you sign up for this care and you think, 鈥楢ha! This one’s cheaper than the other. And it’s promising medically necessary care. You don’t really know that one car is a Lexus and one car is a Chevy. These two plans are being presented to you as Lexuses. And so you say, 鈥業’ll buy it.’ But in fact, in terms of the care it makes available, it’s cheap because it’s a Chevy, not a Lexus.”

Talking about potential tradeoffs in care is a conversation that doctors and policymakers need to have, says Bloche, because it’s inevitable that our health care system will need to find ways to set limits on care.

“We cannot afford anything like what we’re spending on health care today, and we’re certainly not going to be able to afford what we’re projected to spend in the future,” he says. “We spend almost a fifth of our national income today on medical care. And within 25 years, unless we change dramatically, we’re going to be spending a third of our national income on medical care. And we’re doing that by borrowing from our kids.”

Interview Highlights

On the rationale of withholding care:

“The rationale there is that the doctor who stints on care three years later when you get really sick is acting in accordance with your preferences as you expressed them in the employee benefits office three years before,” says Bloche. “And therefore, the doctor is not violating the Hippocratic Oath. The doctor is merely complying with your preferences when you rolled the dice in the employee benefits office.”

On insurers not being required to reveal their criteria to providers for what claims they’ll pay:

“This is a walk on the wild side. I’ve taken on some of these cases for people that I know, and one thing about it, if you know the system’s hypocrisies, then you can beat the system. One of the hypocrisies is that the companies take the position that their guidelines for what they will and will not pay for are trade secrets – that they’re proprietary. Now imagine a legal system in which the laws were considered trade secrets and their lawyers weren’t allowed to know the laws in advance because that would mean they could game the system. That doesn’t fit with our legal values, our due-process values – but that is what happens for many, not all, health plans. They take the position that they’re not going to reveal in advance the rules for what they’ll pay for and won’t pay for because that would enable doctors and patients to game the system.”

On randomized clinical trials:

“What’s amazing is that probably only 10 to 20 percent of the treatments that doctors use today have been tested [in] randomized clinical trials. Even when a treatment is shown to work really well for the sample that’s studied in the clinical trial, in the real world patients are all different. [They] vary hugely. So we’re never going to be able to have solid science that can tell us for sure whether the treatment is going to work or not. So let’s do the research but let’s be realistic and pragmatic about the limits of that research.”

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“I think that we need to repeal the health care law and replace it with common-sense steps that will lower the cost of health insurance in America,” Boehner (R-OH) tells NPR’s Steve Inskeep.

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• Audio:

Boehner and the Republicans are hoping for a repeat of 1994, when the GOP swept the midterm elections. He says the party is engaging with the public to develop the agenda it will enact if it secures a majority in November.

The party that controls the White House typically loses House seats during midterm elections, and Democrats are bracing for losses: 37 governorships, 36 Senate seats and the entire 435-member House are at stake.

Boehner says he’s optimistic about his party’s prospects, citing public anger over spending and debt. He says he believes “at least 100 seats” are in play.

“If [Republican Sen.] Scott Brown can win in Massachusetts, there isn’t a seat in America the Republicans can’t win,” Boehner says. “What we’re seeing every day is the playing field widen, widen beyond anything we’ve seen around here during my 20 years.”

But Republicans face criticism that much of their time in the minority has been spent opposing Democratic proposals. Boehner rejects that charge, saying his party offered ideas on the stimulus bill, the budget and health care.

“If you look over the course of the last 16 months, every time we’ve had to oppose our Democrat colleagues, we’ve offered what we thought was a better solution,” he says.

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