Mind Games: The Senate’s mental health parity bill is ill-conceived.

The Weekly Standard, October 4, 2003

By Sally Satel and Keith Humphreys

Mental health parity is back as an important issue in Congress. The idea is to have the government require employers to pay for treating mental conditions the same way they pay for treating physical diseases. This approach sounds like a boon for people with psychiatric illness, but it’s not. It would end up restricting care for the most desperately ill patients.

The impetus for the legislation comes from two senators with sad family histories of mental illness. During his lifetime, the late senator Paul Wellstone spoke movingly of his older brother’s struggle with schizophrenia. Senator Pete Domenici, a passionate advocate for the mentally ill, has a daughter who is afflicted with schizophrenia. For years the two men cosponsored legislation that would mandate equal treatment by employers’ health plans of mental and physical illness, ending the need for workers to pay more out-of-pocket for mental health care. The measure almost passed last year, and the Senate is now poised to take it up again.

Advocates of the Senator Paul Wellstone Mental Health Equitable Treatment Act claim it will end “insurance discrimination” against people with serious psychiatric conditions. Coverage for catastrophic mental illnesses such as psychosis or a near-lethal suicide attempt would finally be put on the same basis as that for, say, a heart attack. Unfortunately the Senate bill, like its House counterpart, makes no distinction between serious conditions and garden-variety neuroses.

Indeed, the bill would require coverage for every emotional and behavioral condition listed in the “Diagnostic and Statistical Manual of Mental Disorders” (DSM), the 850-page handbook published by the American Psychiatric Association. As practicing clinicians, we have seen DSM categories treated like elastic waistbands that stretch to any psychological size. For example, a person experiencing angst over an approaching 50th birthday could be diagnosed as having an “adjustment disorder with mixed emotional features.” Says psychiatrist Mark Schiller, president of the Association of American Physicians and Surgeons, “I have frequently seen psychiatrists diagnose patients with a range of psychiatric diagnoses that aren’t justified, to obtain third-party reimbursements. That problem will only get worse with this current mental health parity legislation.”

Our 50-year-old would be entitled to the same number of doctor visits, the same deductibles, and the same dollar limits on annual and lifetime care as a 20-year-old college student beginning to suffer the hallucinations and suicidal thoughts of manic-depressive illness. What’s more, the two patients would be on a par not only with each other but with someone else being treated for cancer. It is double jeopardy for employers: They will be required to cover all mental conditions on a par with physical illnesses, and then required to cover all mental conditions equally.

Although estimates of the cost of mental health parity vary widely, few dispute the possibility that some employers will react to increases in cost by dropping their mental health benefits entirely. Parity will likely create a situation like that of the 1970s and ’80s, when long-term psychotherapy for people with minimal distress fueled inflation in employers’ mental health benefits costs. In response, employers cut back coverage across the board.

Parity advocates like the National Mental Health Association scoff at these concerns. They tout a recent HHS analysis of Vermont’s mental health parity law, showing that costs barely budged. What they gloss over is how Vermont’s modest price tag was achieved: by managing care tightly through utilization review, a process by which the insurer determines whether a minimally acceptable level of care has been provided. As the association itself says, “Introducing mental health parity in conjunction with managed care results in a 30 to 50 percent decrease in total mental health costs.”

This is not a triumph of equitable care, but rather a different way of rationing it. As a 2000 GAO report concluded, after Congress passed the last mental health parity mandate in 1996–one that required only that any cap on annual and lifetime mental health benefits be the same as any dollar cap on physical health benefits–health insurance benefits for the mentally ill were actually reduced to offset the higher caps.

Such accounting maneuvers have the most dire effect on the sickest patients, who need costly hospitalization. Typically, psychiatric patients are now approved for about nine days of hospital care, according to the National Association of Psychiatric Health Systems, compared with 23 days in 1991. Hospital administrators and psychiatrists must battle insurers to squeeze out additional days of treatment. The emphasis, according to the association, is on “stabilizing patients and discharging them to outpatient care as soon as possible.” Or, as some of our colleagues describe it, “Treat ’em and street ’em.” This means that many patients are forced out of the hospital while still sick and are soon readmitted, often to a state mental hospital.

The solution? First, we must recognize that catastrophic mental illnesses are as incapacitating and devastating as physical ones and deserve equivalent resources. However, the proposed legislation, while it would open the door to greater treatment of people with low-level anxieties, would do little about the propensity of utilization reviewers to rush the most vulnerable out of their beds. They could well be sent on their way even faster than they already are.

Second, Congress should not make the mistake of tying parity to the entire DSM. Many of the diagnoses it contains are not really mental illnesses at all. They are signifiers of unhappiness, dissatisfaction, or troubling character traits. Lawmakers should focus benefits on the sickest people, for whom it is medically and morally unjustifiable to limit care.

Targeted parity should extend equitable benefits to serious, debilitating diseases like schizophrenia and other psychoses, autism, major depression, manic-depressive illness, and obsessive-compulsive disorder. These conditions have distinct diagnostic criteria and many have established treatment guidelines, so it is possible to evaluate quality of care. Most of the 33 states that have adopted parity laws in the past decade, such as Texas, Delaware, Maine, and Colorado, have targeted benefits in this way.

Many of the beneficiaries of targeted parity, it turns out, will be children. The most serious psychiatric disorders, such as schizophrenia, often appear during late adolescence and the college years, when children are still covered under their parents’ policies. The devastation of serious mental illness in a child is compounded by the prospect of enormous debt the families incur.

This is what Senator Domenici was referring to when he told a reporter last year, “You get into the world of these dread diseases–you hear stories–they’re terrible from the standpoint of what’s happening to these people and what’s happening to their families.” In a recent survey of 19 states, the General Accounting Office found that almost 13,000 children were placed into the welfare or juvenile justice systems in 2001 so they could obtain mental health services that their families could not afford themselves.

What to do for workers who are not seriously mentally ill but nonetheless distraught and likely to benefit from therapy? Or for those with mild symptoms of depression or anxiety who are in the beginning stages of a more serious condition and for whom early treatment could avert clinical disaster? Remember that targeted parity does not affect the status quo. Extending full coverage only to severe illnesses still leaves intact current coverage of therapy for less serious problems–it’s just that limits apply. This is appropriate because we have good, tested brief therapies for people afflicted with lower-grade conditions. Furthermore, most companies that currently offer health coverage also contract with employee assistance programs that provide counseling for employees whose problems with work performance are linked to family issues or personal woes.

Covering disabling mental illnesses on a par with serious medical illness would be great clinical progress even if costs rise a bit. But it would not be worth it if the people suffering from the most devastating mental illnesses are not helped as they should be. As currently written, the parity bills are so expansive they endanger their own worthy mission.