It appears that the media and politicians of both parties can agree on one thing these days: We are surrounded by crisis. One of the most important areas where the system in place is fundamentally broken is the health care system. Oddly enough, it took a different crisis in the economic markets and a financial bailout bill to finally get mental health parity signed into law. While mental health parity may not pose the largest crisis we face, the Mental Health Parity Act will have a positive impact on millions of Americans across the country. It addresses a gap in health care policy, but it is also an important symbolic accomplishment in the way we view health.
We know that more than a quarter of Americans suffer from diagnosable, often treatable, mental illnesses and disorders annually. We also know that mental illnesses often go undiagnosed or untreated. In a 1999 report on mental health, the Surgeon General stated that those in need of treatment fail to seek it in the majority of cases. We have come a long way since the days when people who experienced “nervous fits” were hidden from society, but the subject remains misunderstood and taboo. The stigma associated with mental illness still keeps it from being diagnosed, discussed or insured.
The Surgeon General also acknowledged that stigma gives insurers “tacit permission to restrict coverage for mental health services in ways that would not be tolerated for other illnesses.” Insurers could restrict their coverage of mental health services or substance abuse by reducing the number of visits covered and charging higher co-pays, or cutting back on coverage of drug therapies commonly proscribed for mental illness. Patients had to choose whether to pay out of pocket or forego treatment. Studies have found that under economic strain, people are more likely to give up mental health treatment than other kinds of health care because it is seen as more discretionary.
Doug Walter of the American Psychological Association described the Mental Health Parity Act to the Washington Post as “milestone legislation… [that] ends discrimination against people who have long needed the help.” When the law goes into effect next year, employer-sponsored health insurance plans that cover mental health will be required to provide the same coverage as they do for physical ailments. The bill bans insurance companies from raising higher deductibles or co-pays, restricting the number of visits, lowering benefit levels, or enacting inequitable rules regarding out-of-network coverage. The law does not require that health care plans offer mental health coverage, only that those plans that cover mental health do so in an equivalent manner. And companies with 50 or fewer employees are exempt from the new law.
While the Mental Health Parity Act is a critical breakthrough and the first bill to require equivalent treatment of mental health disorders, much remains to be done.
This bill only addresses the portion of the population enrolled in employer-sponsored health insurance plans that already offer some mental health benefits. The bill does not apply to the individual market and lacks a requirement that all employer-sponsored plans cover mental health — this will leave millions of Americans uncovered. One recent study found that 44% of Americans either do not have mental health benefits or do not know if they do. Insurance companies on the individual market will deny coverage or set long pre-existing conditions to exclude individuals for many mental health problems. Job loss also means loss of coverage. Increases in suicide rates accompany economic downturns, in large part due to increased stress at work and layoffs. People are less able to afford mental health care at the times when they most need it.
Furthermore, there is the ongoing issue of which mental illnesses to cover. One of the continuing stigmas related to mental health is the assumption that these illnesses are somehow less “real” — particularly newer or less common disorders. The bill does not require treatment of all conditions identified by the American Psychiatric Association, only those the insurer chooses to cover. Doctors, not insurers, should decide what constitutes illness and make subsequent treatment decisions in consultation with patients.
“The service system as a whole, as opposed to treatment services considered in isolation, dictates the outcome of treatment,” according to the Surgeon General. We will never reach a goal of “mental health parity” or break free of the stigma associated with mental illness while so many people remain uneducated about and lack coverage for these disorders. Future efforts to make health care more accessible and affordable for all Americans must include parity for mental health and take into account the needs of particularly vulnerable populations such as the unemployed, uninsured and homeless. May this step, long-awaited and born in crisis, be the first of many.
Erin Boeke Burke
Erin Boeke Burke is a first-year student at the LBJ School of Public Affairs. She has struggled with bulimia and depression.