Help for the Mentally Ill?

Last Friday, Congress used HR 1424, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, to carry the massive mortgage industry bailout bill to victory. The bailout bill was added onto the mental health parity bill to help pass both bills, as both failed during their first runs through Congress. Evidently our legislators decided it would be a good idea to merge the bills, throw in some bacon, and call it an emergency bailout plan.

Besides the billions of dollars the questionable bailout plan will cost taxpayers for the next generation or two, one of the most significant changes brought about by the new law is the mental health and addiction parity plan.  The new law requires health insurance companies that offer any sort of coverage for mental health and addiction treatment to treat them as they treat any other illness. That is, the health insurance company may no longer charge higher premiums and co-payments to individuals needing such services, nor may they impose shorter treatment lengths or otherwise discriminate against DSM-IV diagnosable mental disorders, which include addictions. This means that disorders such as alcoholism, drug addiction, autism, bipolar disorder, ADHD, depression, anxiety disorders, and other commonly-diagnosed mental disorders are to be treated equitably by health insurers from now on. Most people would probably agree that it is a good bill, and that it’s high time something like this was done; this is the good news part of the bailout law.

The bad news is that the law does not require coverage of mental disorders. Insurance companies may still decide whether they want to cover any mental disorders or not. Some companies may decide that it will be too costly to provide lifetime coverage for mental disorders and discontinue their plans, or require different classes of health insurance consumers to subscribe to different tiers of coverage. This is likely to occur, because unlike the Germans or Scandinavians, we are not truly a cohesive, homogenized culture bent on giving everyone a fair shake at health care. We like to think that we’re fair, but we’ve never been fair. Our culture of rugged individualism and taking care of your own has expressed itself in every part of our society, especially in the area of health care.

Information about the mental health parity bill and many interesting comments can be found at WashingtonWatch.com. In short, pushed by many consumers for a variety of good personal reasons, the bill was passed in divergent versions by the House and Senate in the spring; but the two houses couldn’t agree on the legislation. Over the summer of 2008, a consensus version of the bill was drafted, and in late September, the House passed a stand-alone version of the bill, while the Senate attached the measure to a bill that extended tax breaks for alternative-energy projects. This hodgepodge of a bill was combined by conspirators on both sides of the aisle with the emergency bailout plan to give us what we’re calling the Emergency Economic Stabilization Act of 2008. But one of the few positive aspects of the bailout bill is, in my opinion, the mental health parity portion.

Insurance company shenanigans

Health care consumers have had to alert their legislators before to the inequities of the health insurance industry and have had to legislate fair behavior. In the most litigious nation on earth, we surely need our insurance companies; but they’re always up to some sort of shenanigan that from time to time requires government or judicial intervention.  

There was a time in this country when adopted children with pre-existing conditions could be denied coverage—and many were. For example, we adopted our daughter Fern at age seven months from South Korea. She weighed only 12 pounds and could not sit, roll over, or do anything a normal seven-month-old could do. She’d had low birth weight and had spent the majority of her infancy hospitalized for one thing or another, and had been diagnosed with developmental disorder.

When we adopted Fern, our health insurance company, ironically called Golden Rule, denied coverage for what they called her pre-existing conditions. They couldn’t have done this with a child born to us; but they slyly used their pre-existing conditions clauses to deny coverage to our tiny new daughter. Naturally, any health problem that might arise after she was adopted would be deemed a pre-existing condition and would be refused coverage. We fought the insurance company, only to have them summarily dismiss our entire family from coverage. Since our coverage was privately-paid (we ran a mom-and-pop business), we had no advocate anywhere who would help us. We spent the next five years without health insurance, hoping and praying that nothing major would happen to bankrupt our family. And nothing did; but I will never forget the fear I felt that a disaster might occur at any moment that would plunge our family into ruin.

As time went by, we learned that many other adoptive and even foster parents were experiencing the same problems. Along with these parents, I began to talk with legislators and urge them to introduce legislation that would force insurance companies to treat adopted children like all other children. If a baby is born into a family and has birth defects or becomes ill immediately after birth, the insurance company covers that child; there is no virtuous or just reason for denying coverage to an adopted child. And yet across the country, insurance companies were denying coverage to children born crack addicted, those born to alcoholics or to mothers with a history of mental illness, or those born in other countries but adopted by United States citizens, using any information at all in the genetic or birth history to deny coverage for all future possibilities.

Eventually states began to change their laws, and in 1993 the federal government mandated equal treatment of adopted and foster children through the Omnibus Budget Reconciliation Act of 1993 (OBRA 1993), which amended the Employee Retirement Income Security Act of 1974 (ERISA).  Health insurers were told that if they covered any dependents at all, they had to also cover children placed for adoption whether the adoption had been finalized or not; the same rules applied to foster children when they had been placed by authorized child-placing agencies. Families like ours who had to pay for private health insurance and weren’t covered by ERISA had to turn to our own states for help; many who had to pay for their own insurance plans could still be denied coverage. Fortunately, our state passed equity legislation and finally our foster and adopted children received equal treatment by health insurance companies.

Coverage for adopted children, those placed for adoption, and foster children not receiving state-paid medical coverage expanded dramatically in 1996 with the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-91, which also amended ERISA. HIPAA extended the prohibition against discrimination to governmental employers and made health insurance coverage for adopted children is available to all families covered by group health plans as soon as those families assume financial responsibility for the child.

Families with children or other dependents who have mental illnesses have found themselves in a pickle similar to the one adoptive families faced prior to 1993. Their loved ones have been treated differently because they’ve had mental illnesses. Health insurance companies have not wanted to fully cover treatment for mental disorders for a variety of reasons that generally boil down to the bottom line: treatment for mental disorders often fails and is costly. Consumers argued that treatment for cancer, diabetes, and other chronic diseases are also costly and also often fail to cure the patient—and they won their argument. The health insurance company must be fair. This is the good news about our new law.

False hope for consumers

As a Ph.D. psychologist, I have much to say about issues related to the Wellstone-Domenici part of the bailout bill, most of it good. But I have concerns. On the one hand, I have to agree that if a health insurance plan covers mental health and addiction at all, it should cover them like any other illness. Families with autistic children, those with mentally ill or addicted members, or hair-pulling moms who manage to have their children diagnosed with the very silly sounding (but bona-fide) Sibling Rivalry Disorder ought to have their doctor visits, treatment, medication, and other health care needs addressed equitably. Few of us would argue with that.

What is arguable, though, is whether mental health practitioners and legislators, who ought to know about these things if they’re going to legislate them, know that giving people increased insurance coverage for mental disorders will not go far to curing what ails them. A person can easily reach a lifetime limit for insurance coverage by receiving usually ineffective or marginally effective “treatment” for a mental disorder, and then be medically bankrupt when it comes to treating a subsequent medical problem that may, in fact, be curable or treatable.  

There are 394 separate DSM-IV mental disorders. According to former American Psychological Association (APA) president and psychiatrist Martin Seligman, only 14 have effective, well-established treatments. The Journal of Psychotherapy Practice and Research identifies the mental disorders with one or more well-established treatments as:

• Some aspects of developmental disability
• Erectile dysfunction
• Panic disorder
• Anxiety disorder
• Agoraphobia
• Specific phobia
• Obsessive-Compulsive Disorder
• Depression
• Enuresis
• Oppositional-Behavior Disorder
• Marital problems
• Relapse prevention for smoking cessation
• Pain control for rheumatic disease
• Stress inoculation training

In addition, there are probably efficacious treatments for:

• Post-traumatic stress disorder (PTSD)
• Public Speaking Anxiety
• Social Anxiety
• Cocaine Dependency
• Childhood Obesity
• Chronic Lower Back Pain
• Binge eating disorder
• Irritable bowel syndrome
• Pain of sickle cell disease
• Biofeedback for migraine
• Couples therapy for moderately distressed couples
• Encopresis
• Anxious children
• Female hypoactive sexual desire
• Female orgasmic dysfunction
• Sex offender behavior modification
• Family intervention for schizophrenia
• Habit reversal and control techniques
• Social skills training for schizophrenics
• Supported employment for severely mentally ill clients

Psychology is over 100 years old as a profession, and we still can heal only a handful of mental disorders. In addition to the list above, four kinds of substance dependence (cocaine, opiate, cocaine, and alcohol) have probably efficacious treatments, with those “probably” effective treatments not administered by psychologists or psychologists, but by self-help groups. The majority of real, life-changing help comes through free 12-Step recovery programs, and that’s a known and well-established empirical fact.

There are no simple solutions (or even complicated ones) to the problems of mental disorders, or to the problems caused to families and society by our inability to effectively treat most of them. So, while I’m glad that the mental health parity portion of the bailout bill was passed, I fear that its passage will be felt and received by consumers initially as an answer to their prayers. And perhaps, in part, it will be an answer to the hopes and prayers of many.

Only later, after time for implementation has passed and the insurance companies start dishing up their predictable (and, some would argue, necessary) bottom-line responses, will the other shoe drop. Only later, when two or more years of treatment have occurred, or (worse) once the lifetime coverage has been exhausted and families find themselves bankrupted by care for their mentally ill loved one in spite of this new law, will the other shoe drop. This is my concern.