Vig Subramanian

America’s Youth Suicide Crisis: How An Unprecedented Epidemic Spiraled Out of Control

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by Vignesh Subramanian, May 15, 2024

In 2023, the Centers for Disease Control and Prevention (CDC) published up-to-date data on suicide rates among American youth that stunned public health and medical professionals nationwide. The federal report, issued in June, found that the overall suicide rate among U.S. youth ages 10 to 24 had surged 62% over the prior two decades (2001-2021), after decades of prior decline (Curtin & Garnett, 2023). On average, 11 young Americans died by suicide out of every 100,000 each year during this period; for children ages 10-14, the suicide rate had tripled from 2007-2018 (from 0.9 to 2.9 people per 100,000); for adolescents ages 15-19, it rose 57% from 2009-2017 (from 7.5 to 11.8 people per 100,000); and for young adults ages 20-24, it rose 63% over the entire period (from 11.9 people in 2001 to 19.4 in 2021 per 100,000). The findings painted a stark picture of a nation in the throes of a full-fledged crisis, with millions of its young people suffering in silence and thousands compelled by circumstance to take their own lives. 

Yet this grim milestone was seen by many as preceded by years of warning signs. Well before the COVID-19 pandemic, CDC reports noted that suicide rates among U.S. youth ages 10-24 had jumped 57.4% from 2007-2018 (rising from less than 7 deaths per 100,000 to nearly 11), with even such states as New York, New Jersey, and Massachusetts – widely viewed as having strong safety nets for at-risk youth – seeing increases in youth suicide rates ranging from 40% to 60% over that single decade (Curtin, 2020). The issue notably remained pervasive for young Americans of all ages. Between 2007 and 2019, the suicide rate among pre-teens ages 8 to 12 surged a disturbing 166% (Penfold, 2021), with 8.4% of children as young as nine and ten years old reporting suicidal thoughts and 1.3% even making attempts (Janiri et al., 2020). From 2018-2019, 18.8% of adolescents ages 12-17 seriously considered attempting suicide, with 15.7% making a suicide plan, 8.9% attempting suicide at least once, and 2.5% making an attempt that required medical treatment (Ivey-Stephenson et al., 2020), corresponding to around 1.24 million medically attended suicide attempts by American teenagers nationwide. This data came on the heels of separate studies finding that suicide rates more than doubled in the preceding decade (from approximately 2 deaths per 100,000 people in 2008 to 5 per 100,000 in 2018) for adolescents as young as thirteen and fourteen years old (Levine et al., 2023). And since 2019, emerging American adults ages 18-25 have demonstrated the highest prevalence of both serious suicidal thoughts (11.8% in 2019, rising to 13.6% by 2022) and suicide attempts made (1.8% in 2019, rising to 2.7% by 2021 before dropping to 2.1% by 2022) among adults across all age groups (National Institute of Mental Health, 2024; Richesson et al., 2022; Keating & Rudd-Arieta, 2021).

In 2023, the Centers for Disease Control and Prevention (CDC) published up-to-date data on suicide rates among American youth that stunned public health and medical professionals nationwide. The federal report, issued in June, found that the overall suicide rate among U.S. youth ages 10 to 24 had surged 62% over the prior two decades (2001-2021), after decades of prior decline (Curtin & Garnett, 2023). On average, 11 young Americans died by suicide out of every 100,000 each year during this period; for children ages 10-14, the suicide rate had tripled from 2007-2018 (from 0.9 to 2.9 people per 100,000); for adolescents ages 15-19, it rose 57% from 2009-2017 (from 7.5 to 11.8 people per 100,000); and for young adults ages 20-24, it rose 63% over the entire period (from 11.9 people in 2001 to 19.4 in 2021 per 100,000). The findings painted a stark picture of a nation in the throes of a full-fledged crisis, with millions of its young people suffering in silence and thousands compelled by circumstance to take their own lives. 

Yet this grim milestone was seen by many as preceded by years of warning signs. Well before the COVID-19 pandemic, CDC reports noted that suicide rates among U.S. youth ages 10-24 had jumped 57.4% from 2007-2018 (rising from less than 7 deaths per 100,000 to nearly 11), with even such states as New York, New Jersey, and Massachusetts – widely viewed as having strong safety nets for at-risk youth – seeing increases in youth suicide rates ranging from 40% to 60% over that single decade (Curtin, 2020). The issue notably remained pervasive for young Americans of all ages. Between 2007 and 2019, the suicide rate among pre-teens ages 8 to 12 surged a disturbing 166% (Penfold, 2021), with 8.4% of children as young as nine and ten years old reporting suicidal thoughts and 1.3% even making attempts (Janiri et al., 2020). From 2018-2019, 18.8% of adolescents ages 12-17 seriously considered attempting suicide, with 15.7% making a suicide plan, 8.9% attempting suicide at least once, and 2.5% making an attempt that required medical treatment (Ivey-Stephenson et al., 2020), corresponding to around 1.24 million medically attended suicide attempts by American teenagers nationwide. This data came on the heels of separate studies finding that suicide rates more than doubled in the preceding decade (from approximately 2 deaths per 100,000 people in 2008 to 5 per 100,000 in 2018) for adolescents as young as thirteen and fourteen years old (Levine et al., 2023). And since 2019, emerging American adults ages 18-25 have demonstrated the highest prevalence of both serious suicidal thoughts (11.8% in 2019, rising to 13.6% by 2022) and suicide attempts made (1.8% in 2019, rising to 2.7% by 2021 before dropping to 2.1% by 2022) among adults across all age groups (National Institute of Mental Health, 2024; Richesson et al., 2022; Keating & Rudd-Arieta, 2021).

Surges in suicidal ideation and attempts among young Americans subsequently contributed to sharp increases in long-running trends of associated emergency department (ED) visits and hospitalizations. From 2011-2020, pediatric ED visits by children, adolescents, and young adults ages 6-24 nearly doubled nationwide (from 4.8 million visits, or 7.7% of all pediatric ED visits, to 7.5 million, or 13.1% of all visits), even as the overall number of pediatric ED visits for all causes decreased (Bommersbach et al., 2023). This spike in visits included a five-fold increase in the number of pediatric ED visits for suicide-related symptoms (from 0.9% of all visits in 2011 to 4.2% in 2020), which now make up an average of 5% of all visits by this age group. This alarming trend has been substantiated by other large national studies examining related healthcare data. Analyses of insurance claims for 24.5 million youths ages 1-21 found that mental health-related inpatient hospital admissions surged 61% among this population between 2016-2021, alongside a 45% increase in mental health-related ED visits and a 74% increase in ED visits for suicidal ideation, attempts, and self-harm by 2022, with the increases being most pronounced for adolescents and young adults (Clarify Health Institute, 2022; Clarify Health Institute, 2023). A review of 4.8 million pediatric hospitalizations from 2009-2019 at U.S. acute care hospitals revealed that a diagnosis of suicide or self-injury made up 64% of all mental health-related hospitalizations (Arakelyan et al., 2023). Other studies have found that all mental-related pediatric ED visits among youths ages 3-17 rose 8% annually from October 2015 to February 2020 (compared to an average increase of just 1.5% for visits for other reasons) (Cushing et al., 2022), with 13% of all patients revisiting within 6 months, and that from 2019-2020 – the last full year before the pandemic – the overall number of behavioral health cases for youth under 18 increased 30%, with pediatric ED cases of suicide attempts and self-injury in particular having jumped 50% (Children’s Hospital Association, 2023). 

It was this already escalating crisis that proceeded to become severely exacerbated by the pandemic: in 2021, the first full year of the pandemic in the United States, the national suicide rate among youths 10-24 years old returned to 2018 highs after two years of moderate declines (Stone et al, 2023; Curtin et al., 2022). The stressful impacts of the period were acutely felt by young Americans of varied educational levels. The CDC found that 22% of U.S. high school students – including roughly a third (30%) of female students (Gaylor et al., 2023) – had seriously considered suicide the previous year, with 18% making a plan and 10% attempting at least once (drastically up from 16%, 13%, and 8% a decade prior, respectively) (CDC, 2023b). Separate reports also noted that three months into the pandemic, roughly a quarter (25.5%) of young people ages 18-24 – the largest age demographic on college campuses – had seriously considered suicide in the prior 30 days (Czeisler et al., 2020), and a Healthy Minds Survey found that 15% of U.S. college students surveyed during the 2021-2022 school year had seriously considered suicide, the highest rate in the survey’s 15-year history (Eisenberg et al., 2023). The CDC further found that beginning in April 2020 – shortly after the start of the pandemic in the United States – and proceeding through October of that same year, the proportion of mental health emergency-related visits among all pediatric ED visits surged 24% for children ages 5 to 11 and 31% for those ages 12 to 17 relative to 2019 levels (Leeb et al., 2020). In the second full year of the pandemic (from March 2021 to February 2022), pediatric mental health-related ED visits for youths ages 5-17 collectively jumped another 7%; the percentage of their ED visits resulting in psychiatric inpatient admission rose 8%; and the mean length of their stay increased 4%, with youth in both years of the pandemic more likely to spend two or more nights experiencing prolonged boarding (Overhage et al., 2023). 

Overall, amid the pandemic, U.S. youth and young adults ages 10-24 began to represent 15% of all suicides nationally, and demonstrated exorbitantly high rates of ED visits for mental health emergencies and self-harm in particular, with 354.4 such visits per 100,000 members of this population in 2020 (compared to 128.9 visits per 100,000 people for middle-aged adults) (CDC, 2023a). Adolescent girls were noted to be at particularly high risk, with the proportion of ED visits for suicide attempts among those ages 12-17 jumping 50.6% from February-March 2019 to February-March 2021 (compared to just a 3.7% increase for boys and young men of the same ages) (Yard et al., 2021). Girls and young women ages 10-24 overall demonstrated a 43.6% increase in visits for suicidal ideation over the past two decades (Overhage et al., 2023), as well as an associated ED visit rate in 2021 measuring roughly double that of boys and young men (though the latter themselves consistently report some of the largest increases in suicide rates, including an 8% increase among those ages 15-24 in the same year) (CDC, 2023a; Curtin et al., 2022). Even more stark disparities in suicide rates have been discovered among other marginalized groups – with over a quarter of LGBTQ+ youths reporting attempting suicide in 2021, a significantly higher rate than that of their peers (Jones et al., 2022); higher percentages of American Indian and Alaska Native (AI/AN) youths experiencing suicidality than any other race or ethnicity that same year; Latina adolescents consistently being twice as likely to attempt suicide than their peers of the same race (Ivey-Stephenson et al., 2020); Black youths experiencing the largest percentage increases in suicides among any racial group in recent years (Stone et al., 2023); and Asian American/Pacific Islander (AAPI) adolescents and young adults being the only racial group to have suicide rank as their leading cause of death (CDC, 2018) – that merit an entirely separate article beyond the limitations of this paper.

For several years, U.S. lawmakers have demonstrated a propensity to pin the blame for the country’s youth suicide crisis entirely on the pandemic – despite such claims not covering the full story (Warner & Zhang, 2022). It is clear that this crisis had already reached epidemic proportions by the time COVID-19 took hold in early 2020. Yet even if this myopic view of its origins is genuinely held by those in elected office, it has failed to translate into substantive policy reforms that might address the widespread and life-threatening struggles with mental health currently faced by millions of young Americans. Nearly two full years into the pandemic (in October 2021), the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association joined together to issue the unprecedented declaration of a national state of emergency in children’s mental health (AAP et al., 2021). The declaration took into account “dramatic increases” in rates of pediatric suicidality and ED visits for mental health emergencies, and called upon “policymakers at all levels of government and advocates for children and adolescents to join us” in working to institute a series of reforms, including securing sustainable funding for mental health screenings, establishing suicide prevention programs and risk assessments in schools and primary care, and addressing acute care needs in hospital settings by expanding access to adequate numbers of beds, step-down programs from inpatient units, and short-stay stabilization units, among other measures (Hua et al., 2024). Less than two months later, the U.S. Surgeon General echoed these calls, issuing an advisory highlighting the scope of the youth mental health crisis and outlining recommendations for governments and private healthcare organizations to collaborate to support children’s emotional and social well-being (Office of the U.S. Surgeon General, 2021), and roughly a year later, the AAP and over 130 other healthcare organizations explicitly called upon the Biden administration to declare a federal national emergency in children’s mental health (AAP et al., 2022). Yet despite these high-profile calls to action, no comprehensive federal legislation has been passed to support crisis identification, prevention, and intervention services for youth in either community or hospital settings (Roubein & Beard, 2022), and President Biden has yet to declare a national emergency in youth mental health, neglecting an opportunity to mobilize the full leverage and resources of the federal government to address the crisis.

At the state and local levels, attempts to contend with the youth suicide crisis have hardly fared better. As of June 2023, while half of all U.S. states and D.C. have enacted laws over the past decade that uniformly require their K-12 schools and school districts to adopt suicide prevention and intervention policies and guidelines outlining how staff should respond to students exhibiting suicidal ideation, 25 states have still not done so, according to the American Foundation for Suicide Prevention (AFSP, 2023). Furthermore, while 13 states uniformly require K-12 school personnel to be annually trained in such prevention and intervention protocols, a plurality of states (24, plus D.C.) do not mandate such training to occur every year – raising the risk that recall of key protocols may be poor in an emergency – and another 13 states do not require training at all. 22 states also uniformly require schools to develop curricula for student education in either suicide awareness and prevention and/or mental health more generally, but a majority (28, plus D.C.) continue not to do so. Statewide policy is even less consistent at the collegiate level, with 22 states having enacted laws uniformly requiring colleges and universities to adopt various specified suicide prevention policies – ranging from printing hotline numbers on student ID cards and publicizing student mental health resource information to adopting institutional awareness programs or prevention and intervention strategies – while the majority of states (28, plus D.C.) lacked any laws establishing a uniform standard of preparedness for higher education institutions as of December 2022 (AFSP, 2022). The resulting patchwork of policies, fragmented across thousands of campuses and communities, fails to offer a comprehensive response to the nationwide youth suicide crisis that transcends their outskirts and borders. Meanwhile, conflicting guidelines on the ages at which youths are recommended to be screened early in childhood for suicide risk (the AAP recommends those ages 12 and up be universally screened annually, with those ages 8-11 screened when clinically indicated, while the U.S. Preventive Services Task Force argues there is insufficient evidence to justify screening any asymptomatic youths for suicide risk) continue to confuse localities and providers seeking to address the root causes of such ideation (Jenco, 2022). Hospitals and inpatient facilities are also becoming overwhelmed by surging numbers of suicidal young adults, adolescents, and increasingly younger-aged children who arrive in EDs already at their crisis point (Richtel & Flanagan, 2022), with no end to this epidemic in sight as of yet.

Today, suicide is the third leading cause of death among young Americans ages 15-24 and the second leading cause of death among those ages 10-14. The United States loses far more of its young people to suicide than any other developed nation each year, with the total number of lives lost representing a disproportionately large segment of its youth population (Doran & Kinchin, 2020). For every young person lost to suicide, roughly 1,000 others are estimated to be considering and struggling with the idea of attempting (National Alliance on Mental Illness, 2024) – but every one of these suicides is preventable. Despite having an abundance of options with which to act, the nation’s leaders have collectively and inexcusably allowed this crisis to spiral out of control, and in so doing, have left millions of vulnerable children, adolescents, and young adults at risk. We must act swiftly and decisively to change course, advancing reforms that will reshape national policy to confront these harsh clinical realities – and ultimately save lives. 

Works Cited

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Hidden Costs, Dirty Lies, and The Illusion of Choice: The Worst of American Healthcare

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by Vignesh Subramanian, April 12, 2022

The headlines are the same every year, and have been so for the last half-century: U.S. Health Care Ranked Worst in the Developed World (TIME, 2014); US health spending twice other countries’ with worse results (Reuters, 2018); U.S. health-care system ranks last among 11 high-income countries (Washington Post, 2021). The United States spends more on health care expenditures – both as a proportion of its gross domestic product and on a per capita basis – than any other developed nation, with annual accelerated growth rates in health spending exceeding those of OECD counterparts (Tikkanen and Abrams, Schneider). It is increasingly being understood that the U.S.’s outlier status is the result of higher prices and cost barriers rather than comparatively greater service utilization, with higher payments to hospitals and physicians as well as administrative overheads largely driving the outsized differences in spending (Kurani and Cox). Exactly how egregious the bills sent to American patients can be, however, is hidden in the fine print – an abusive doctrine formulated by medical bureaucracies and providers alike to obscure the truth about how far they are willing to go for profit.

Among the most obvious and decried examples of deceptive charging practices by providers are the various forms of surprise billing that often follow already costly care. Patients who unknowingly receive treatment from physicians who are not in their insurance network are prime targets for additional charges that may amount to tens of thousands of dollars (Kliff and Sanger-Katz). These patients typically do not choose the treating doctors themselves and are not made aware in advance of their out-of-network statuses (usually because of the urgency of required treatment or the availability of specialized providers, as is the case with emergency care or complex surgeries); some may have even sought care at an in-network hospital or urgent care center, reasonably assuming that these facilities employed providers that were similarly covered by their insurance. Nevertheless, these patients end up faced with the prospect of their insurance company refusing to pay an out-of-network balance bill, while collection agencies abandon good-faith protocols as they move to seize debt (Weber). Surprise billing often involves high initial reimbursements demanded by providers, procedures intentionally being redirected to more expensive ‘affiliated’ or ‘consolidated’ sites, and separate facility fees being tacked on; it can also affect non-emergency routine or scheduled care, making the issue a common woe for patients who cannot ‘shop’ for more affordable provider options while under any degree of duress.

The contributions of such bills to soaring healthcare spending cannot be overstated, but represent just the tip of a larger iceberg of unnecessary and inexplicable costs to the average American patient. Surprise bills would not be possible if not for deliberate schemes characterized by so-called “chargemasters” – the comprehensive, hospital-specific compendiums of all services said hospitals may charge for – to keep the realized costs of care hidden until after delivery. Such measures work to withhold, clutter, or bury procedure price lists from or on hospitals’ public sites and web search queries, while selectively publishing ‘starting point’ and ‘prospective’ rates far below those used for Medicare reimbursements and private insurance payments with little basis in market transactions (McGinty). They quietly tuck arbitrarily applied fees, such as those for basic consultation, testing, and diagnostic procedures (e.g. blood draws) or for care that was ‘seriously considered’ or ‘activated’ but not ultimately provided (e.g. trauma response fees), into final bills without patient notification (Gold and Kliff). They enshrine refusals to bring sticker prices for the use of certain technologies (e.g. MRIs) or operative procedures (e.g. hip replacements) in line with those of lower-tier doctor’s offices or otherwise justify or address variation and make comparison feasible across emergency departments, trauma centers, and surgery centers in a given geographic area (Pflanzer). Hospital systems are even willing to charge patients for minimal labor costs (fees charged to new mothers who have just given birth for “skin-to-skin contact” with their newborns are an infamous example), for basic health products like over-the-counter pharmaceuticals, toiletries, and first aid supplies that cost far less at neighboring pharmacies, and for services supporting other parts of the continuum of care at exorbitant levels (e.g. transport services like ambulance rides, despite the fact that EMS crews themselves are not reimbursed for patients not transported to emergency rooms) (Earl, Reed). Collectively, these ‘grab-every-last-dollar’ tactics take gross advantage of the necessity of critical care to bleed American patients dry, making every step into treating facilities as financially punishing as possible while denying them even the fundamental privilege of foresight to predict the final bill.

In a legitimately free market – indeed, of the kind defenders of the U.S. healthcare model contend it is and must remain – the ‘consumer’ is assumed to be able to make choices of free will, with the most accurate information possible on the prices of the goods and services available to them. This premise holds that such informed decisions will in turn guarantee a higher quality of service provided, improving consumer satisfaction while reducing costs as providers compete in a ‘race to the bottom.’ Yet neither that transparency of information nor that freedom of choice are available for U.S. healthcare’s consumer, the American patient. Deliberate and disingenuous attempts by hospital associations and physicians’ groups to bury costs and coerce acceptance of their terms instead take options away from the average American while triggering even more adverse reactions from elsewhere in the market. Insurers, supposedly the representatives of patients’ financial interests, have felt compelled to respond to providers’ effective price gouging by abruptly terminating physician contracts and leaving marketplaces (leaving many patients out in the cold with smaller networks), or else by secretly negotiating with hospitals to establish ‘adjusted payment rates’ and so-called “anti-steering clauses” (long-term agreements to avoid moving policyholders to other providers with lower costs), all without providing adequate notice to policyholders (Miller, Allen, Mathews). Governmental interventions, meanwhile, leave a lot to be desired in substance; recently enacted federal legislation that bans surprise billing and mandates that out-of-network cost sharing must match in-network provider rates, for example, only covers emergency services (and even then does not cover ground ambulances), meaning surprise billing is still possible in a large range of healthcare settings (Mensik). Other promulgated rules requiring hospitals to post price lists and insurers to inform members of discounted rates upfront fail to establish guidelines on making the provided information decipherable, while coming under sustained legal assault by healthcare and business groups seeking to shield their dealings from public view (Chiwaya and Kimelman, Weixel).

The hidden costs and false illusions of choice of service perpetuated by U.S. healthcare providers amount to a dirty lie – one that paints the patient’s inability to find affordable care as a personal failing rather than a carefully constructed outcome. The American system is not broken, but rather working perfectly as designed: to maximize profits by harassing and charging patients to the point of bankruptcy, by any and all means. It is despicable that those means have come to include openly deceiving patients about the true value of costs incurred, rendering them less willing consumers and more cash cows on which any number of charges may be whimsically levied. As our white coat-adorned saviors in operating rooms and I.C.U.s become existential threats to the pocketbook, it becomes extraordinarily difficult not to ask the question: was I, the patient, really the priority?

Works Cited

Allen, Marshall. “Why Your Health Insurer Doesn’t Care About Your Big Bills.” ProPublica, 25 May 2018, propublica.org/article/why-your-health-insurer-does-not-care-about-your-big-bills. 

Chiwaya, Nigel, and Jeremia Kimelman. “You Can Now Get Your Hospital’s Price List. Good Luck Making Sense of It.” NBC News, 15 Jan. 2019, nbcnews.com/news/us-news/hospital-price-list-chargemaster-rules-trump-mandate-2019-n959006.

Earl, Jennifer. “Doula Explains Why Hospital Charged Parents $39 to Hold Newborn in Viral Post.” CBS News, 13 Oct. 2016, cbsnews.com/news/doula-explains-why-hospital-charged-parents-39-to-hold-newborn-baby-in-viral-post/.

Gold, Jenny, and Sarah Kliff. “ER Bills: A Baby Was Treated with a Nap and a Bottle of Formula. His Parents Received an $18,000 Bill.” Vox, 28 June 2018, vox.com/2018/6/28/17506232/emergency-room-bill-fees-health-insurance-baby.

Kliff, Sarah, and Margot Sanger-Katz. “Surprise Medical Bills Cost Americans Millions. Congress Finally Banned Most of Them.” The New York Times, 21 Dec. 2020, nytimes.com/2020/12/20/upshot/surprise-medical-bills-congress-ban.html.

Kurani, Nisha, and Cynthia Cox. “What Drives Health Spending in the U.S. Compared to Other Countries.” Health Spending, 20 July 2021, healthsystemtracker.org/brief/what-drives-health-spending-in-the-u-s-compared-to-other-countries/

Mathews, Anna Wilde. “Behind Your Rising Health-Care Bills: Secret Hospital Deals That Squelch Competition.” The Wall Street Journal, 3 Oct. 2018, wsj.com/articles/behind-your-rising-health-care-bills-secret-hospital-deals-that-squelch-competition-1537281963.

McGinty, Tom, et al. “Hospitals Hide Pricing Data From Search Results.” The Wall Street Journal, 22 Mar. 2021, wsj.com/articles/hospitals-hide-pricing-data-from-search-results-11616405402.

Mensik, Hailey. “Ground Ambulances, Excluded from Surprise Billing Ban, to Get Scrutiny from Federal Committee.” Healthcare Dive, 22 Nov. 2021, healthcaredive.com/news/federal-committee-ground-ambulances-no-surprises-act/610451/.

Miller, Andy. “Patients Are Getting Stuck out-of-Network Due to Rifts between Insurers and Hospitals.” Fortune, 16 Nov. 2021, fortune.com/2021/11/16/out-of-network-insurance-companies-health-care-systems-hospitals-contracts/.

Pflanzer, Lydia Ramsey. “The Cost of an MRI Can Vary by Thousands of Dollars Depending on Where You Go.” Business Insider, 28 Mar. 2017, businessinsider.com/how-much-an-mri-costs-by-state-2017-3.

Reed, Tina. “Ambulance Rides Are Getting a Lot More Expensive.” Axios, 22 Feb. 2022, axios.com/ambulance-rides-are-getting-a-lot-more-expensive-cee897fe-63b7-4412-aa67-718109773e79.html.

Schneider, Eric C., et al. “Mirror, Mirror 2021: Reflecting Poorly | Health Care in the U.S. Compared to Other High-Income Countries.” Improving Health Care Quality, Commonwealth Fund, 4 Aug. 2021, commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly.

Tikkanen, Roosa, and Melinda K. Abrams. “U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?” U.S. Health Care from a Global Perspective, 2019, Commonwealth Fund, 30 Jan. 2020, commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019.

Weber, Lauren. “Patients Stuck With Bills After Insurers Don’t Pay As Promised.” Kaiser Health News, USA Today, 11 Feb. 2020, khn.org/news/prior-authorization-revoked-patients-stuck-with-bills-after-insurers-dont-pay-as-promised/.

Weixel, Nathaniel. “New Trump Policy Will Force Insurers to Disclose Prices up Front.” The Hill, 29 Oct. 2020, thehill.com/policy/healthcare/523328-new-trump-policy-will-force-insurers-to-disclose-prices-upfront/.

Today’s Crisis Standards of Care: A Death Knell for the Less-Abled

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by Vignesh Subramanian, December 3, 2021

As of November 2021, nine U.S. states – Alaska, Idaho, Montana, Washington, Colorado, Wyoming, New Mexico, Utah and Arizona – have either officially activated statewide crisis standards of care or have been on the brink of declaring their activation. The news comes as several more states, including the southern bloc of Georgia, Kentucky, Mississippi, Arkansas, and Texas, have warned that I.C.U.s are rapidly approaching capacity (Knowles). Amid waves of largely unvaccinated COVID-19 patients besieging weary hospitals, authorities have attempted to ease this burden by hastily formulating policies that will decide the relative value of human life during public health crises for decades to come. But what does all of this mean?

Crisis standards of care institute substantial changes to the delivery of healthcare services amid pervasive or catastrophic disasters, with the understanding that standard levels or quality of care can no longer be wholly provided to patient populations. In the United States, activation of these standards is formally declared by state governments and directly alters the evaluation criteria on which decisions about triage, transfers, and use of scarce resources are made. The criteria are far-reaching but vary immensely; some incorporate ‘inclusion criteria’– encouraging treatment of patients in good standing following assessments of their major organ health, life expectancy, and the order of the first-come/first-serve basis — while others also incorporate ‘exclusion criteria’– rejecting critical care for patients with low likelihood of immediate survival or poor ‘quality of life,’ or those patients for whom it is assumed that increased sustenance will not substantially provide significant benefit (Auriemma). 

Physicians’ use of this last-resort discretion can be frightening; beyond the more expected measures of postponed elective, cosmetic, and nonurgent surgeries and longer wait times in general, patients are often subject to crucial decisions made on mere whims. Physicians can send patients home to rely on inadequate in-home medical equipment, transfer them to hospice care or other centers without the appropriate specialized facilities, and even remove them from life support entirely, all over their objections. Universal ‘do-not-resuscitate’ and ‘do-not-intubate’ orders are applied as blanket protocols to all patients in cardiac or respiratory arrest if insufficient staff are available, even without consideration of patient statuses on a case-by-case basis. Ventilators are given to those who are most likely to restore their normal breathing function, nearly defeating the purpose of the devices; ambulances are not guaranteed upon emergency calls; and patients may even be denied admittance into a hospital to begin with (Chin and Harris). As the systemic capacity to treat large patient volumes shrinks, so too does sympathy for those whose lives are simply deemed worth less.

Do not resuscitate (DNR) order — A written order from a physician, issued at a patient’s request, instructing healthcare providers not to perform any form of cardiopulmonary resuscitation (CPR) – including chest compressions, cardiac drugs, or placement of a breathing tube – on the patient should respiratory or cardiac arrest occur.

(Breu and Herzig)

Do not intubate (DNI) order — A written order from a physician, issued at a patient’s request, instructing healthcare providers not to place a breathing tube to assist the patient’s breathing should respiratory or cardiac arrest occur. Unlike a DNR, a DNI still allows providers to administer chest compressions and cardiac drugs as necessary.

(Breu and Herzig)

It is therefore not surprising that crisis standards of care amount to a death knell for the less-abled. Already, reports are being made of elderly patients and those with disabilities receiving subjective evaluations of their ‘quality of life’ from their physicians in violation of civil right statutes, being denied care at hospitals without resource shortages due to mere anticipation of capacity being reached, and being pressured — especially in the cases of patients with intellectual disabilities, and in the absence of caregivers — to sign off on advance directives they do not understand. Despite their relative inability to accurately predict the long-term survival probability of patients with disabilities, or whether or not such patients will require use of greater treatment resources, many doctors and lawmakers continue to place ableist judgement above sound scientific knowledge. Of the twenty-nine U.S. states that issued crisis standards of care guidelines before or at the start of the COVID-19 pandemic, the vast majority did not include language prohibiting discrimination against elderly or disabled patients in the provision of critical care, and few used their administrative processes to close such loopholes. Some state plans actually explicitly prioritize younger patients and those without comorbidities, while others prohibit people with specific disabilities from being offered life-sustaining ventilation support or throw discretion to hospital policy (Cleveland Manchanda). Such fragmentation of standards forces the current array of disability rights groups engaged in litigation against these hospitals to base their petitions on tort law claims rather than righteous grounds of disability discrimination, leaving patients at the mercy of an indifferent medical bureaucracy.

Ableist — The quality of being prejudiced or discriminatory against individuals with disabilities.

(Neilson)

It is inexcusable that demonstrably false stereotypes about the ‘quality of life’ experienced by a patient with disabilities or old age are allowed to dictate the quality of care they receive. While the U.S. has made tangible progress towards extricating such biases from medical practice — one could certainly point to the Americans with Disabilities Act, Title VI of the 1964 Civil Rights Act, Section 504 of the Rehabilitation Act, and Section 1557 of the Affordable Care Act (DOJ, HHS) as prominent examples — those gains have evidently not been fully incorporated into the healthcare pathway. Even during a public health crisis, acute episodes of illness must not determine the relative value of a patient’s life simply because providers are under duress. Instead, moments such as these call for the best of physicians’ work ethic and equity in screening criteria and treatment allocation decisions.

Works Cited

“A Guide to Disability Rights Laws.” Civil Rights Division, U.S. Department of Justice (DOJ), Feb. 2020, https://www.ada.gov/cguide.htm#anchor64984.

Auriemma, Catherine L., et al. “Eliminating Categorical Exclusion Criteria in Crisis Standards of Care Frameworks.” American Journal of Bioethics, 18 May 2020, https://www.tandfonline.com/doi/full/10.1080/15265161.2020.1764141.

Breu, Anthony C., and Shoshana J. Herzig. “Differentiating DNI from DNR: Combating Code Status Conflation.” Journal of Hospital Medicine, Oct. 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5240781/.

Chin, Natalie M., and Jasmine Harris. “Examining How Crisis Standards of Care May Lead to Intersectional Medical Discrimination Against COVID-19 Patients.” Center for Public Representation, UC Davis School of Law, Feb. 2021, https://www.centerforpublicrep.org/wp-content/uploads/FINAL-Intersectional-Guide-Crisis-Care-PDF.pdf.

Cleveland Manchanda, Emily C., et al. “Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity amidst COVID-19.” Journal of Racial and Ethnic Health Disparities, Aug. 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425256/.

Knowles, Hannah. “Hospitals Overwhelmed by Covid Are Turning to ‘Crisis Standards of Care.’ What Does That Mean?” The Washington Post, 23 Sept. 2021, https://www.washingtonpost.com/health/2021/09/22/crisis-standards-of-care/.

Neilson, Shane. “Ableism in the Medical Profession.” Canadian Medical Association Journal, Joule Inc., 14 Apr. 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162445/.

“Section 1557 of the Patient Protection and Affordable Care Act.” Office for Civil Rights, U.S. Department of Health and Human Services (HHS), 27 Oct. 2021, https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html.

Addiction and Brain Disease: Intertwined but Not One and the Same

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by Vignesh Subramanian, October 18, 2021

Today, nearly every major medical organization in the United States defines drug addiction as a primary brain disease – a progressive, relapsing disorder driven not by choice, but rather by neural dysfunction. From patient advocacy organizations like the American Medical Association and the American Society of Addiction Medicine to top research organizations like the National Institutes of Health and the National Institute on Drug Abuse, this characterization of compulsive substance misuse is believed to effectively counter stigmatization of treatment while still accounting for biological and psychological realities. Yet if one is to evaluate other possible classifications and the present state of diagnostic protocols in fair measure, it could be reasonably asserted that a discussion is still to be had about the addict’s role in their own entrapment. The degree to which addiction may be considered a chronic illness is therefore contingent on not just the relativity of its prognosis, but also on what physicians believe to be appropriate recourse. 

The scientific tenets of addiction agreed on by psychologists, neurobiologists, and practitioners alike are key to judging the applicability of the brain disease model. Unwarranted assumptions about either the appositeness of a standard of comparison or a propensity for self-domestication can derail precedents set and determinations previously made by the discipline in question. It is fair to accept the medical discipline’s rhetoric on the need for restrictiveness in exposition, defining “chronic illness” as controllable but hitherto incurable conditions often identifiable by long periods of latency and protracted clinical course [3].

Proponents and opponents of the brain disease model also concur on the neurochemistry behind addiction. It starts with unregulated surges of the neurotransmitter dopamine in response to drug consumption occurring in the basal ganglia, the area of the brain tasked with executive functions that, among other behavior, enable learning from the ‘reward’ of brief ecstasy [5]. An affinity for a substance leading to increased use will cause neural circuits to adapt by restructuring receptors, by scaling back sensitivity to the drug’s effects – requiring more consumption to attain the same euphoric “high” – and by increasing tolerance of the substance as this subconscious demand is satisfied, completing the cycle [8]. The patient eventually develops dependence (inability to function without the substance) and dysphoria (a state of unease in the drug’s absence), fomenting cravings that prioritize reducing pain over experiencing pleasure [11]. The cycle is ultimately difficult to break, for reasons that demonstrate the true interplay of biology and behaviorism: parallel remodeling of the extended amygdala – tasked with controlling responses to stress – and the prefrontal cortex, which manages decision making, drives the user to form associations between increased consumption and decreased stress, causing inhibitory pathways to shut down as short-term reward is favored and sought after [5].

At no point in this slippery slope beyond the first ‘gateway’ use is the chemical compulsion of a drug resistible or reversible; indeed, the same reward circuits that drive addiction account for most human physiological needs, including reproductive activities [2]. In that regard, addiction is not just subconscious, but natural, solely dangerous in excess; patients of more socially sanctioned chronic illnesses – diabetes, heart disease, skin cancer – are victims of similar bet-hedging, whether it be by consumption of processed carbohydrates and meats, lack of exercise, or even sun exposure. Opponents of the brain disease model argue that the problem is initial awareness of risk: addicts must understand that intoxication is a precursor of worse to come, and addiction has a spectrum of severity, making accurate diagnosis difficult if not impossible [4]. With no physical measures of identifying mental health disorders (such as objective lab tests using biomarkers) yet deployed in medical practice, physicians must rely on neuropsychological assessments and dissociated imaging scans to compare a patient’s cognitive impairment with normal executive function and processing abilities. Such measures have found that neural changes associated with addiction matched those of “deep habits, Pavlovian learning, and prefrontal disengagement”, but did not match the “development-learning orientations” of various mental illnesses [1]. In other words, addiction stimulates synaptic pruning and neuroplasticity (the ability of neurons in the brain to change connections and reorganize) just as a conventionally developed brain does, but in atypical patterns poorly reflecting normal maturation and psychological tendencies. This information only sharpens the question of whether addiction is truly an aberration of the mind’s development or simply a collection of varying and even rectifiable effects elicited by the drug itself; to put it metaphorically, would a stabbing through the heart be considered cardiovascular illness? The concept of placing addiction on par with the likes of Alzheimer’s and Parkinson’s disease – surrounded by questions of whether all manipulated neuroplasticity is pathogenic, whether addicts can be responsible for consciously committed actions, and what even constitutes a problem with the brain – is thus far from conclusive. 

Acceptance – or lack thereof – of substance addiction as a brain disease has had and will continue to have wide-ranging implications for patient protections under law and avenues of treatment. Distinguishing between the public perceptions of users’ behavior and the intimate worldviews of addicts as shaped by their battles for recovery help sustain the idea that addiction medicine can be entirely recontextualized into being a centerpiece of public health. For example, even if addiction is not to be considered a disease of the brain, its contribution to the later development of chronic illnesses such as lung disease, stroke and HIV/AIDS makes addiction treatment itself a form of preventative medicine rather than rehabilitation alone [10]. Conversely, if classification of addiction as a brain disease remains the status quo, it might justify dependence as a ‘side effect’ of self-medication started because of lack of access to care, much the way it is for some substances with addictive potential – like selective serotonin reuptake inhibitors (SSRIs) and opiates – that are used and abused as antidepressants and for pain management, respectively [2][7]. As is clearly evident, proponents and opponents of the brain disease model ultimately do not disagree on the facts of addiction, but simply emphasize different contexts that, when taken to their conclusions, have different implications for diagnosis and stigmatization; both camps have proven willing, however, to oversee an explosion of medicalization that address those biological and psychological realities [6]. Today, trained physicians can administer pharmaceutical agonists and antagonists in clinics and other outpatient settings; the importance of psychosocial therapy, monitoring and follow-up in addiction treatment has been amplified; and the establishment of drug courts and diversion and harm reduction programs attests to the idea that drug consumption is not inherently a moral failing and that natural reactions to its effects can be less painfully anticipated and controlled [9]. 

Addiction is a convoluted condition: it has an onset influenced by environmental conditions but no infection agent, has little known pathological prognosis but a tendency to run in families, and displays outward behavioral changes but is not anatomically degenerative. A disease model that assumes partial responsibility on the part of the addict but recognizes the extent to which addiction rewires the brain is perhaps the best road on which to pursue a patient freedom-centric means of battling dependency and decay.

Works Cited

  1. Lewis, Mark. “Addiction and the Brain: Development, Not Disease.” Neuroethics, vol. 10, 2017, pp. 7–18, doi:10.1007/s12152-016-9293-4.
  2. Hammer, Rachel, et al. “Addiction: Current Criticism of the Brain Disease Paradigm.” AJOB Neuroscience Journal, vol. 4, no. 3, 2013, pp. 27–32. doi:10.1080/21507740.2013.796328.
  3. “Is Addiction a Disease?” Partnership to End Addiction, July 2020, drugfree.org/article/is-addiction-a-disease.
  4. Levy, Neil. “Addiction is not a brain disease (and it matters).” Frontiers in Psychiatry, vol. 4, no. 24, 2013. doi:10.3389/fpsyt.2013.00024.
  5. United States, Department of Health and Human Services. “The Neurobiology of Substance Use, Misuse, and Addiction.” The Surgeon General’s Report, 2016. addiction.surgeongeneral.gov/sites/default/files/chapter-2-neurobiology.pdf.
  6. NIDA. “Preventing Drug Misuse and Addiction: The Best Strategy.” National Institute on Drug Abuse, 10 July 2020, http://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/preventing-drug-misuse-addiction-best-strategy.
  7. Satel, Sally, and Scott O. Lilienfeld. “Addiction and the Brain-Disease Fallacy.” Frontiers in Psychiatry, vol. 4, no. 141, 2014. doi:10.3389/fpsyt.2013.00141.
  8. “The Science of Drug Use and Addiction: The Basics.” National Institute of Drug Abuse, 25 June 2020, http://www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics.
  9. Smith, David E. “The Evolution of Addiction Medicine as a Medical Specialty.” AMA Journal of Ethics, vol. 13, no. 12, 2011, pp. 900–905. doi:10.1001/virtualmentor.2011.13.12.mhst1-1112.