Sunday, October 12, 2008

The Irony of Mental Health Parity

(Note: This is my ninth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

In June of this year, I reported on Nurse LinkUp that Congress was poised to once again begin a concerted push to pass legislation bringing parity for insurance coverage for mental health, including addiction, eating disorders, and any illness classified in the DSM-IV. That effort basically failed, and it is only now, just prior to the end of this Congress, that mental health parity legislation has actually become law.

We are all by now (nauseatingly) familiar with the $700 billion financial bailout recently passed by Congress and signed into law by President Bush in the waning days of his presidency (more on that in future). As a part of that package, most health plans are now required to cover mental illness and addiction with the same level of access and cost as any physical illness. After years of struggle, editorials abound, almost ubiquitously praising the legislation which was added to the latest---and ultimately successful---version of the bailout plan.

Beginning, I believe, in 2009, all group insurance plans and companies with more than 50 employees must offer health insurance coverage that provides equal benefits for mental health treatment, potentially benefiting 113 million insured Americans, as well as approximately 82 million self-insured Americans who are not protected by state-mandated mental health parity legislation. Interestingly, 38 states currently have some form of parity laws on the books, a fact of which I was previously ignorant.

Paul Wellstone (D-MN), the late Senator from Minnesota, was one of the great champions of the mental health parity cause, along with his colleague Pete Domenici (R-NM). The bill, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, was named for the two senators and honors the posthumous legacy of Wellstone's tireless fight for the rights of Americans living with mental illness and addiction. And it was Senator Edward Kennedy (D-MA) and his son Representative Patrick Kennedy (D-RI), who used their political muscle and clout to ease the bill through the Senate and the House.

As someone who has struggled with depression since childhood, I can attest that obtaining coverage for mental health can be a challenge, especially if one needs ongoing treatment rather than the "episodic care" often covered by many health plans. I can also confirm that many health insurance plans charge much higher co-payments for mental health visits, and impose nonsensical and arbitrary limits on the number of outpatient visits per year.

In terms of inpatient care, insurance regulations regarding mental health are notorious for prematurely cutting short crucial inpatient treatment for mental illness, addiction, and eating disorders. It is plainly obvious that inpatient treatment teams know best vis-a-vis the length of stay which would be most efficacious for a particular patient. Naturally, some oversight should be involved so that billing abuses do not occur, but bureaucrats and statisticians should not be making decisions that only clinically trained professionals should make. The imposition of arbitrary limits on the length of stay for the treatment of such chronic conditions belies the fact that insurance companies are generally more concerned with profitability than the effectiveness and quality of care. In fact, I would hazard a guess that forcing a patient out of detox or an inpatient psychiatric unit before they are clinically ready for discharge more than likely leads to worse outcomes, more frequent relapse, and higher costs over the long term.

Global Ironies: Mind the Gap

Ironically, on October 10th, World Mental Health Day (one week after mental health parity became a legal reality in the United States), the World Health Organization announced that as many as 75% of people living with mental disorders in developing countries receive no care or treatment of any kind. The irony is that while we in the United States pine for lower co-payments and equal access to care, those living in war-torn nations, developing nations, and non-industrialized countries suffer immeasurable harm without even the merest hope of treatment.

The WHO study points out that nine out of ten people in Africa who live with epilepsy are entirely untreated. It also starkly points out that while most countries spend approximately 2% of their health dollars on mental health, one-third of people with schizophrenia, half of those living with depression, and seventy-five percent of those struggling with addiction go untreated worldwide. And tragically, one person dies from a completed suicide every forty seconds of every day, somewhere in the world, mostly due to untreated mental illness.

These numbers tell a story, and even as the United States prepares to tackle the issues of mental illness and substance abuse more fairly, the WHO is calling for governments, foundations, donors and mental health activists to increase funding for treatment worldwide. The program, entitled Mental Health Gap Action Program (mhGAP): Scaling Up Care for Mental Health and Substance Use Disorders, asserts, according to the WHO press release, that "with proper care, psychosocial assistance and medication, tens of millions could be treated for diseases such as depression, schizophrenia, and epilepsy and begin to lead healthy lives, even where resources are scarce."

To bolster their case, the WHO's recent studies demonstrate that "in low-income countries, scaling up a package of essential interventions for three mental disorders – schizophrenia, bipolar disorder and depression – and for one risk factor – hazardous alcohol use – requires an additional investment as low as $US 0.20 per person per year." Claiming that treatment of mental illness, addiction and neurological disorders such as epilepsy should not only be "evidence-based" but "value-based", the WHO plan includes "assessing countries' needs and resources; developing sound mental health policy and legislation; and increasing human and financial resources" in order that "people with these disorders are not denied opportunities to contribute to social and economic life and that their human rights are protected."

Global Parity: A Laudable Goal

So, as mental health parity becomes law in the United States and we continue to wrestle with the needs of the uninsured and the under-insured, the rest of the world---especially the developing world---needs our assistance to offer even the most basic of mental health care to millions and millions of deserving citizens. Mental health is not a luxury, and many in the fields of mind-body medicine (and also mainstream medicine, for that matter) strongly believe that good physical health is simply not possible without solid mental health. In fact, recent research demonstrates quite clearly that untreated depression can absolutely lead to physical symptoms including chronic pain.

I would assert that those who have so valiantly and tirelessly fought for the rights of the mentally ill here in the United States should now challenge themselves to broaden their visual field, take in the big picture of global mental health, and direct some of their energies in supporting the timely efforts of the World Health Organization.

As the global financial system continues its apparent implosion, we can naturally expect the incidence of anxiety, depression and substance abuse to rise as people attempt to manage lives thrown into chaos by economic hardship. We in the United States recently won a long twelve-year battle, happily enough. But now is not the time to rest on our laurels. Now is the time for action on a global scale. It is in humanity's best interest to see that all people have access to treatment for improved mental health, and it is our moral and ethical duty to further that cause.
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