Gray Areas Fuel Mental Health Coverage Debate

WASHINGTON — Joan was suffering from chest pains, dizziness and difficulties with breathing. After more than $50,000 worth of tests--all paid for by her health insurance--the source of her symptoms remained elusive.

Then, while reading a magazine article, Joan (not her real name) realized that she had all the classic signs of panic disorder. A specialist in anxiety disorders confirmed the diagnosis and estimated that her total treatment would cost about $2,000.

At this point, however, her insurance company refused to pay--because it was a mental disorder.

The irony of this story has not been lost on those who have been fighting for mental health insurance coverage equal to that provided for other ailments.

“It’s not even penny-wise and pound-foolish--it’s simply foolish,” said psychotherapist Jerilyn Ross, who diagnosed Joan’s illness and successfully treated it. “It was a real struggle. She had to pay most of it out of her own pocket.”

In any given year, more than 5 million Americans suffer an acute episode of a major mental illness, according to the National Alliance for the Mentally Ill. These include schizophrenia, manic depression, severe depression, obsessive-compulsive disorder and panic disorder. One in five families in the U.S. will have to deal with someone who suffers one of these conditions during a lifetime, the group says.

Now Congress is grappling with the issue in health care reform legislation that has cleared both houses. The Senate version requires insurers to treat mental illness no differently from other diseases, and a conference committee of House and Senate members is deciding whether to include that provision in the final version of the bill.

Opponents, raising the specter of endless treatment for substance abusers and those who need general psychotherapy, warn that the controversial provision would send health costs skyrocketing. As a result, they say, many people could ultimately lose all their health insurance.

But proponents respond that scientific advances in recent years have brought new understanding about the biological origins of major mental illnesses, making them no different from such brain disorders as epilepsy, Parkinson’s disease and Alzheimer’s disease--all of which are typically covered by insurance.

Most severe mental illnesses are the result of genetic disorders, faulty brain “wiring” or imbalances in brain chemicals.

Many of these conditions can now be treated effectively with a combination of drugs and psychotherapy. The options are no longer limited to highly expensive stays in hospitals or other institutions.

“Part of the problem is that mental illness still has the stigma of being regarded as untreatable, or looked at as just treating the ‘worried well,’ ” Ross said. “Mental illnesses are often dismissed, even by doctors, as being ‘all in the head.’ But the head is a part of the body. If the brain isn’t working right, why should access to care be any different than if an arm or a leg or a heart isn’t working?”

This, advocates of parity believe, strikes at the heart of the current debate: How does society define an illness?

“Societies decide what they want to consider a disease or not,” said Paul Root Wolpe, a University of Pennsylvania sociologist who specializes in social psychiatry.

“There is a much larger cultural and political component to illness than anyone thinks,” Wolpe said. “Getting something considered a disease is a much more political process than a discovery in a lab. That’s the battle that psychiatry is fighting right now.”

Wolpe believes that health insurance eventually will cover clear cases of major depression and schizophrenia.

“It’s the other ones I’m concerned about,” he said, “not major clinical depression, but treatment for people who feel depressed and have trouble coping. It’s that murky area that the fight is really over.”

Mark Olson, a Chicago health care attorney who represents many managed-care plans, said that opponents of parity fear that “the majority of dollars will be spent on chemical dependency and other behavioral disorders, some of which can be treated with drugs, but others which might require what could be seen as unending therapy.”

But Dr. Laura Lee Hall, a neuroscientist and deputy director of policy and research at the National Alliance for the Mentally Ill, argues that mental health professionals today are much more adept at making the appropriate diagnosis.

“Diagnostic criteria are much clearer,” she said. “It’s not a perfectly black-and-white line--but nor is much of medicine for physical illnesses. We’ve had remarkable progress in diagnosis; there’s not much room for abuse.”

Wolpe agrees that a case can be made that mental health treatment would be no more expensive than non-mental care if the treatment relied on drugs alone. In fact, he said, care would probably be cheaper because people suffering from psychiatric disorders “rarely need surgery, which is the single most expensive procedure people go through.”

Most experts believe, however, that drugs must be used in conjunction with non-drug therapy. “Most psychiatrists believe that if you want to treat most of these disorders correctly, you must have both,” Wolpe acknowledged. “That’s where it can begin to get expensive.”

He sees an irony in the resistance to paying for “talk” therapy for mental illness. One of the great shortcomings of treatment for physical illness, he argues, is the absence of communication.

“Doctors don’t talk to their patients the way health care is practiced today,” he said. “People get thrown in the hospital, and out. There is not nearly enough social and psychological support in the system. What they should be doing is pay more for people to get this support because in the long run, it ends up being cheaper.”

Most health insurance coverage provides much more restricted benefits for mental disorders than for physical. A typical plan, for example, does not limit hospitalization for a physical ailment but might cap inpatient mental health treatment at 30 days annually. The number of visits to a counselor, psychologist, therapist or psychiatrist might be sharply curtailed, in contrast to unrestricted access to other health professionals. And there are often strict limits on total annual spending for mental health services.

Opponents--among them the U.S. Chamber of Commerce, the Health Insurance Assn. of American and the Assn. of Private Pension and Welfare Plans--insist that costs will increase to the point where many employers will simply opt to eliminate coverage altogether, or find ways to pass cost increases along to their workers.

They point out that most employers provide health care benefits to their workers voluntarily, while the Senate provision amounts to a federal mandate.

“Do you want to pile on additional costs to the folks who are doing the right thing?” said Heidi Kendall, deputy director for health care policy for the Assn. of Private Pension and Welfare Plans.

“Also, is this a decision appropriately made by the federal government?” she added. “Shouldn’t the employer and the employee have a say in this?”

Richard Coorsh, a spokesman for the Health Insurance Assn. of America, said employers are very concerned about the cost of coverage. “After all, if employers--and, by extension, their employees--are priced out of the marketplace, the effect will be to increase the number of people without coverage.”

Both sides have marshaled studies and experts with lots of numbers to support their views.

The pension group, for example, cites a recent study by the Congressional Budget Office that estimates the cost of parity for the treatment of mental illness at $11.6 billion in 1998. As many as 400,000 workers and their dependents, the CBO predicted, could lose their health insurance as a result.

The CBO said that if employers took no action to reduce benefits generally, annual premiums would rise by an average of about 4%, or $190 for each policy.

But Hall, of the National Alliance for the Mentally Ill, said other studies in states that already have parity have shown only minimal premium increases. Maine, New Hampshire and Rhode Island prohibit discrimination against those with the major disorders, while Texas has this provision for its state employees. Maryland, Minnesota and North Carolina ban insurance discrimination against all mental health treatment.

The alliance said the mental health portion of insurance payouts from the North Carolina State Health Plan was 7.1% in 1988--four years before the plan put mental health on an equal footing. Mental health payments as a portion of total health payments have declined every year since, accounting for only 3.7% of all medical claims paid in 1995, it said. This represented a total annual cost per member of $55.

Mental health coverage advocates, emphasizing the efficacy of current treatments, have estimated the direct and indirect costs of treating severe mental illnesses at $74 billion in 1990--compared with $159 billion that same year for all cardiovascular diseases alone.

“The bottom line is that it costs more money not to treat,” Ross said. “One of my patients said to me one time: ‘Doesn’t the system understand that we’d rather get well and go back to work? That we’d rather be taxpayers than tax burdens?’ ”