The dark side of psychiatric hospitals

Stories about bad mental health care aren't new. They also serve an outsized role, given the lack of patient safety information.

• "At the moment, journalists appear to be the only consistent source of information on patient safety," said Morgan Shields, a Ph.D. candidate researching psychiatric inpatient care at Brandeis University.

Driving the news:

• In September, the Tampa Bay Times published an investigation of North Tampa Behavioral Health, a psychiatric hospital that "makes huge profits by exploiting patients held under Florida’s mental health law."
• Earlier this month, the Seattle Times reported on 10 private psychiatric hospitals in Washington state that have been approved or expanded since 2012. The paper found a series of safety issues, bad record-keeping and instances of hospitals trying to keep voluntary patients from leaving.
• A few days later, the Los Angeles Times published an account of one patient allegedly murdering another at Kedren Community Health Center, a psychiatric hospital that the LA Times found guilty of "serious failures of oversight in the care of patients."

Between the lines: Psychiatric hospitals, like nursing homes, by definition care for a vulnerable population who often struggle to advocate for themselves.

• Facilities may then exploit patients' vulnerability in order to drive profits higher.
• "Patients often are not able to choose where they go ... and, even if they could choose a hospital, patients and family often do not have any information on the quality of care provided," Shields said.

Further complicating the issue is that the U.S. has a shortage of mental health care to begin with; there aren't enough beds for all of the patients who need treatment.

• "In effect, psychiatric hospitals might be too big to fail depending on the local context; hospitals might be aware of this and therefore not fear being sanctioned," Shields said.

Romney, who wrote in his wife, Ann, when he voted in 2016, has only soured on Trump since then:

• On race: "The places where I would be most critical of the president would be in matters that were divisive, that appeared to be appealing to racism or misogyny. And those are the kinds of things I think that have been most, most harmful long term to the foundation of America's virtuous character."
• On Trump’s personal life: "He has elements, I'm sure, of honor in his life. And there's things that I think are not honorable. And I mention that because of the payment to a porn star for sexual relations outside of marriage. Look, I'm one of those who believes that we have a responsibility to be honorable and faithful to our wives."
• On calling on China to probe Joe Biden: "We certainly can't have presidents asking foreign countries to provide something of political value. That is, after all, against the law."
• On abandoning the Kurds: “A very dark spot in America's history. We should never abandon our friends.”
• Comparing Trump’s actions to Barack Obama’s ignoring the red line he drew in Syria: "This is worse than that, because it says ... America will walk away from his friends and from its allies."
• On character: "People will recognize that character really is important in our leaders and that it's important for our leaders to do things that unify us, that welcome people who come here legally as immigrants, that in no way signal to anybody in America that they're less of an American because of where they came from or their sexual orientation or their race or their religion."

Talking to me at his home outside Salt Lake City, Romney made it clear that he's open to voting to remove Trump.

• Romney — a former Massachusetts governor, and his party's presidential candidate in 2012 — wants to be seen as a fair juror, and would have a high bar: He pointed out that presidents have done things that were wrong or perhaps even illegal, and not been removed from office.
• But Romney, who has called Trump's pleas for China and Ukraine to investigate the Bidens "wrong and appalling," went even further with me: "It was shocking, in my opinion, for the president to do so — and a mistake for him to do. I can't imagine coming to a different point of view."

Go deeper:

• Lindsey Graham open to other evidence on impeachment
• Mitt Romney: Republicans keep quiet on Trump because they fear Elizabeth Warren
• Mitt Romney opposes cutting capital gains tax rate for the rich

• Giuliani has a wide range of foreign clients despite serving as Trump's personal attorney, which has put many on edge.
• "There's this sense of paranoia here," one administration official tells me.
• More alarm bells rang this week after the Washington Post reportedthat Giuliani had privately urged Trump to extradite Fethullah Gulen, a Turkish cleric living in exile in Pennsylvania, something Turkish President Recep Tayyip Erdogan has asked for repeatedly.

On Capitol Hill, those investigating Trump tell me they are still committed to keeping their investigation tightly focused on Ukraine in order to wrap up their impeachment inquiry as quickly and efficiently as possible.

• However, that could change if more information about Giuliani emerges.
• "I think Rudy has a lot to answer for," said Democratic Rep. Raja Krishnamoorthi, who sits on the House Oversight and Intelligence committees.
• "We don't know who he was working on behalf of at any given time — it's not just President Trump."
• Giuliani did not respond to requests for comment.

Meanwhile, some Trump officials say the only person who can rein in Giuliani is the president himself.

• Trump's former special envoy to Ukraine, Kurt Volker, told members of Congress earlier this month that Secretary of State Mike Pompeo was helpless to stop Giuliani's involvement, according to sources with direct knowledge of his closed-door testimony.
• "I'm sure [Pompeo] could have called Rudy Giuliani, but would Rudy Giuliani stop what he's doing because the secretary of state calls him? I'd be surprised," Volker said.

This morning on "ABC This Week," George Stephanopoulos asked Pompeo whether he gave Giuliani his blessing to act on behalf of the State Department.

• Pompeo said it's his policy not to discuss internal deliberations publicly, despite the fact that Giuliani does not work for the administration.
• Pompeo also refused to answer whether Giuliani was reviewed for potential conflicts of interest, amid revelations that he had business interests in Ukraine at the same time he was pushing officials to open an investigation into Joe Biden, Axios' Zach Basu notes.

Trump transition flagged Rudy concerns in 2016

These concerns with Giuliani aren't new:

• As far back as November 2016, a source who worked on the Trump transition team told Jonathan Swan, a colleague “walked back into the war room after an hour on the phone with Giuliani. He had a few pieces of notebook paper covered front and back with notes on red flags, and he looked like he’d just seen a ghost."
• “Not good, guys. Not. Good,” the colleague said, according to the source. A second source with direct knowledge confirmed the account.

In June, Axios broke a story about leaked vetting documents that the Trump transition team and the Republican National Committee compiled in the fall of 2016. While vetting Giuliani, they found so many red flags that he was ultimately prevented from serving at the State Department.

• Giuliani’s file was so thick, they took the rare step of producing a separate dossier to cover his extensive foreign business entanglements.
• A former Trump transition team member said senior Trump aides made clear that Giuliani could not be confirmed as secretary of state because of his foreign business ties, and the job of the vetting team was to show Giuliani why “he really shouldn’t put himself through a Senate confirmation.”
• "The extensive amount of work that I've done in the 80 or plus countries that I've been to in the last 17 years is what would've qualified me to be an excellent secretary of state," Giuliani said after Axios explained the contents of the documents to him in June. "Would you prefer someone who hasn't been overseas?"

"Sure. I mean ... show me something that ... is a crime," Graham told Axios' Jonathan Swan. "If you could show me that, you know, Trump actually was engaging in a quid pro quo, outside the phone call, that would be very disturbing."

• "As to asking China to look into Biden, that was stupid. ... Bad idea. That didn't last very long. I think that's a frustrated Trump."

But Trump's Ukraine call isn't impeachable on its own, Graham said: "I've read the transcript of the Ukrainian phone call. That's not a quid pro quo to me."

• The interview was Tuesday, before acting White House Chief of Staff Mick Mulvaney gave Thursday's "quid pro quo" briefing.
• Graham's spokesperson, Kevin Bishop, said Friday that Graham still has not heard or seen anything that he deems impeachable.

The big picture: Trump's loosening hold on Graham reflects the mess the president has created for himself in the past two weeks.

• At the very time he needs a Republican fortress against impeachment, GOP lawmakers are furious at him over his rash pullback in Syria.
• In the interview, Graham called Trump's abandonment of the Kurds "dishonorable" and a "sh*tshow."

Graham said he's changed his view of Trump's character since opposing him during the 2016 primaries:

• "I've got to know him, and I find him to be a handful," Graham said. "I find him to be an equal opportunity abuser of people. But at the end of the day, he can be very charming and be very gracious, and I'm judging him by his conduct."

Graham, a Trump golfing companion, said he continues to support Trump's presidency because he's "a Republican. I like his domestic policies. So you play the ball as it lies."

• "If I spent all day analyzing every tweet he issued, I'd go nuts."