Mending Mental Health Coverage?

Image has not been found. URL: /wp-content/uploads/2008/09/pelosi4.jpgSpeaker of the House Nancy Pelosi (D-Calif.) (WDCpix)

For the estimated 60 million Americans suffering from mental illness, treatment can be an elusive and costly ordeal. Many health care plans don’t cover mental care, and those that do usually provide lesser benefits for mental disorders than for physical ailments. Co-payments, for mental patients, are usually higher. In addition, the last major federal law tackling the problem is 12 years old.

Now Congress is hoping to fix some of that. Bills passed in both the House and Senate would require most employer-based health plans to eliminate the current pay discrepancies between coverage for mental and physical conditions. Supporters say that equating the two — and thus establishing “parity” — is long overdue. Helping their push, the stigma that’s contributed to the legal discrimination has slowly faded as scientists uncover the biological and genetic causes of mental disorders.

Illustration by: Matt Mahurin

“There is no shame in mental illness,” House Speaker Nancy Pelosi (D-Cal.) said following passage of the House bill in March. “The great shame would be if Congress had not taken action.”

But much work remains. Significant disparities between the Senate and House bills have forced sponsors into informal but delicate negotiations. The saga has aligned senators of both parties, the White House, business groups and the insurance industry — all of whom support more business-friendly reforms — against House lawmakers pushing for broader patient benefits.

The negotiations could prove a dilemma for House Democrats, who have increasingly shown an eagerness to stand firm on non-compulsory legislation in lieu of caving to the demands of industry and the administration. Led by Pelosi, Democrats in Congress’s lower chamber have confronted the White House head-on over wiretapping legislation and a free trade deal with Columbia, for example — in each case supporting the populist agenda that swept the party into power two years ago. The resulting stalemates seem to indicate that Democrats would be willing to kick these issues to next year, when the party is expected to command larger congressional majorities and, perhaps, control the White House.

Mental health advocates are optimistic the parity reforms will move this year — and they have several things working in their favor. First, the Senate bill has broad bipartisan support, with Sen. Edward M. Kennedy (D-Mass.) a leading force behind it. Also, two long-time champions of parity — Sen. Pete Domenici (R-N.M.) and Rep. Jim Ramstad (R-Minn.) — are retiring at the end of the year, putting pressure on lawmakers in both chambers to honor their work by enacting reforms before they depart. Both lawmakers have personal investments in the the parity push: Domenici’s daughter has schizophrenia, and Ramstad is a recovering alcoholic.

In the eyes of Washington’s power-brokers, their cause hardly constitutes must-pass legislation, but with some momentum behind it, the parity legislation could be a rare instance of an election-year success.

Neither the House nor Senate bill forces insurers to cover mental treatments. But under both proposals, group health plans that opt to cover such care could no longer make the mental benefits more restrictive or costly than those for comparable medical and surgical treatments.

A 1996 law took a step in this direction, preventing insurers from applying different limits on annual or lifetime payments. But plans may still discriminate in other ways, like charging mental patients higher co-pays and restricting the number of days they can spend in the hospital.

Elizabeth Prewitt, government relations director for the National Assn. of State Mental Health Program Directors, which supports the House bill, said that roughly 67 percent of adults and 80 percent of children requiring mental health services go without — a trend exacerbated by discriminatory insurance practices.

“If the patient has financial limitations,” Prewitt said, “they often don’t seek treatment at all.”

Both the House and Senate bills apply only to group health plans covering 50 people or more.

In a controversial break from the Senate proposal, the House bill mandates that group plans “include benefits” for any condition contained in the American Psychiatric Assn.’s most recent reference guide for diagnosing mental ailments, called the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The manual lists serious conditions — like schizophrenia, bipolar disorder and severe depression — but also includes jet lag, caffeine addiction and sibling rivalry. Employers and insurance groups are quick to criticize the House bill for that provision, saying it will drive up costs and force employers to drop mental health coverage altogether.

“Nowhere else do you employ a professional manual to specify the conditions that have to be covered,” said E. Neil Trautwein, a vice president at the National Retail Federation and leader of an ad hoc industry coalition lobbying the bill. “The practical effect is to require each and every thing in the DSM to be potentially subject to coverage.”

The Senate proposal, in contrast, caters more to businesses, allowing the plans — not the DSM — to define their scope of coverage. Under both bills, however, insurers would pay only for those conditions they deem medically necessary. Supporters of the House bill contend that the medical necessity limitation makes much of the DSM criticism unjustified. Neither bill mandates mental health coverage. Yet business groups worry that the House language would drive coverage decisions into the courts.

“The issue is, how is the language in the House bill interpreted?” said Mohit Ghose, spokesman for America’s Health Insurance Plans, a trade group. “What is the definition of medical necessity?”

As is often the case with congressional proposals, the debate hinges more on how the bill is perceived than on what it would do. Peter Newbould, director of congressional and political affairs at the American Psychological Assn., said the DSM provision doesn’t deserve the scrutiny it’s received.

“It’s something that conservative senators latch on to — perhaps supported by business and insurers — and say, ‘No, that’s too much,’” Newbould said. “The problem is not the reality, it’s the perception.”

Newbould added, “Whether or not the DSM language is problematic misses the point that it’s DOA in the Senate.”

The White House has bolstered this Republican opposition. The administration issued a statement in March charging that the House bill “would effectively mandate coverage of a broad range of diseases and conditions and would have a negative effect on the accessibility and affordability of employer-provided health benefits.”

Recognizing the political realities, Senate negotiators — including Democrats — have accepted the industry’s compromise for the sake of passing reforms this year. Kennedy and Domenici have sent a newer version of their bill to House leaders. That bill moves closer to the House proposal but does not contain the DSM language. The question remains whether House leaders will accept the changes or hold out for a more patient-friendly bill.

All sides agree that time is short. With a new administration taking the helm next year, health care reform is expected to be among the top priorities of the new White House. Mental health advocates fear that the parity issue might lose priority in the shuffle.

“Time is of the essence,” Newbould said. “If nothing gets done [this year], we’ll get lost in the health care tornado that’s soon coming in.”