Proper Bid for Compromise on Mental Illness Coverage : Senate bill aims the right way, but flaws must be excised

Nary a murmur of disagreement was heard in the U.S. Senate a month ago when it unanimously passed a health care reform bill that, among other things, would require insurers to cover mental illness as fully as they now cover medical problems like heart disease and cancer. It was a heady day, following emotional testimony from senators whose relatives or constituents had suffered tragedy because their mental illnesses were stigmatized, unrecognized or untreated. Sen. Alan K. Simpson (R-Wyo.) spoke poignantly about his niece, “a most beautiful girl” who bought a gun one day, retreated to an isolated field and “blew her chest away.” Bob Boorstin, a former Clinton administration staffer who suffers from manic depression, proclaimed that the 1990s could be for mental illness “what the 1980s were for alcoholism .J.J. people will realize that it is a disease.”

In recent days, however, equanimity has settled on Capitol Hill as senators have begun working to reconcile their health bill with one from the House that contains no provision for mental health parity. The pragmatism of the House-Senate negotiations is welcome, for the Senate bill is in fact too radical to be endorsed hastily. It would directly conflict with the 1974 Employment Retirement Security Act, which prohibits all states except Hawaii from regulating an employer’s welfare program. And it could, according to estimates from the nonpartisan Congressional Budget Office, strip 400,000 workers of coverage deemed too expensive by their employers.

Even so, many arguments made for the bill are unassailable. First, proponents cite recent scientific advances--including PET and MRI scanning of brain activity and the mapping of the human genome--showing that some forms of mental illness are biologically predetermined and thus should be treated no differently than other brain disorders--Alzheimer’s disease and Parkinson’s disease, for instance. Second, they point to a 1994 MIT study concluding that clinical depression alone costs private industry $23 billion a year in worker absenteeism, inattentiveness and lack of productivity. Finally, there is former First Lady Rosalynn Carter’s persuasive observation that “when we don’t pay for mental health services through the health care system, we pay for the lack of these services through higher costs of medical care for physical illnesses, through the welfare system, the criminal justice system.” A manic-depressive patient who fails to take mood-stabilizing medications, for example, could soon become so belligerent and psychotic that he or she would end up spending weeks in a private hospital draining private insurance funds or at a state hospital draining public tax dollars. Such costs can be eliminated if psychologists or social workers successfully intervene to ensure that the patient remain on the prescribed medical regimen.

Supporters of the Senate measure emphasize that managed care plans now offering near-parity have successfully reined in costs at companies like IBM, Federal Express and Honeywell. But the legislation, however well-intentioned, offers little reassurance that other companies would be able to control costs similarly, for it requires parity for “mental illness” and “medical necessity” without defining those key terms. Unless the language of the Senate bill is refined to distinguish the “worried well” seeking long-term psychotherapy from the seriously ill suffering from chronic, biochemically based disorders, employers could find their resources taxed and workers could find themselves without any kind of health coverage at all.