Health insurance typically subjects mental health services to more stringent coverage limitations and higher cost sharing than are applied to physical health services. Parity, which means equal insurance coverage for mental and other medical conditions, has been a central – but elusive – advocacy goal for decades.
There are two main reasons for the selective restrictions on mental health care. Both connect to ethics.
Stigma is the oldest. People with major mental illnesses such as schizophrenia and bipolar disorder, have historically been seen as “other,” a category to be set apart from the rest of humanity, like lepers. And, at the other end of the illness/stigma spectrum, Woody Allen, who portrays characters in lifelong psychoanalysis, stands for a view of mental health patients as narcissists who whine interminably about life’s ordinary frustrations.
The second reason is that even if we cure ourselves of stigma, actuaries fear that mental health services represent a black hole of expenditure.
Mental health costs can actually be managed. As Glied and Frank point out, “recent studies have shown that parity need not lead to unnecessary care under modern managed- care arrangements. The parity requirement in the Federal Employees Health Benefit (FEHB) Program, for example, led to equality in coverage but not to an explosion in the costs of care.”
In other words, if clinicians, patients, and the public, can agree that limits must be set, and that individual clinicians and individual patients can not, on their own, decide how to spend our collective health funds, we can afford mental health parity.
In this Congressional session, for the first time, both houses have passed parity legislation. The bills, however, differ in important ways, and it is unclear whether a compromise will emerge. The House bill defines the conditions covered under the law as all conditions listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the compendium of diagnoses developed by the American Psychiatric Association and used world wide. The Senate bill leaves it to the insurers to decide what will be covered.
What’s at stake in the difference between the House and the Senate versions?
By specifying the full range of DSM diagnoses, the House is trying to prevent insurers from excluding too many conditions. It is indeed possible, and likely, that in unregulated markets, some insurers would seek competitive economic advantage by excluding as many patients with mental health needs as possible. The House bill seeks to ensure access, and shows distrust for the concept of managed care. But skeptics about mental health parity fear that in its quest for access, the House bill risks mandating coverage for conditions that may meet diagnostic criteria but do not create significant suffering and, by reasonable criteria, do not require medical intervention.
By leaving the definition of what will be covered to the insurer, the Senate version allows insurers to make flexible determinations of “medical necessity,” as is done with medical conditions. I had direct experience of this system when I practiced in the not for profit Harvard Community Health Plan HMO. In the right circumstances, patients and clinicians can collaborate in setting fair limits on the use of resources.
Glied and Frank end their discussion with a recommendation for compromise that is clinically wise, economically sound, and ethically admirable:
"Insurers should not be permitted to exclude entire categories of conditions from coverage. On the other hand, they should be permitted, and even encouraged, to use the existing criterion of “medical necessity” to ensure that covered services are directed to the types of mental disorders that are most impairing and disruptive and that can be treated effectively with medical care. Parity in mental health should not mean mental health services for all problems, for everyone, at any time — that’s not how good insurance works for any condition. But the promise of parity is that treatment for people with mental illnesses that cause impairment, disability, and suffering will not be excluded from insurance coverage, and effective legislation needs to make sure that happens."