Wednesday, October 8, 2008

Bailout and Psychiatric Ethics

I haven't read the fine print of the economic bailout bill, but I learned from the New York Times and Wall Street Journal that in order to win votes for the bailout, stalled legislation on parity for mental health was tucked into the bill to attract votes from parity supporters who had previously voted "no" on the bailout.

I believe that even the wealthiest societies must set limits to health care. Cost containment is an ethical responsibility, but doing it by systematically disadvantaging mental health conditions cannot be justified clinically or ethically. 12 years ago Senator Pete Domenici proposed legislation to require insurers to cover mental illness in the same way as other medical conditions. The late Senator Paul Wellstone was co-sponsor. Despite continuing efforts by Senator Domenici and multiple advocacy groups, supporters of parity haven't been able to close the deal until last week.

Parity is the right policy choice, but abstract arguments don't inspire passion. Personal experience does. Senator Domenici's daughter Clare has schizophrenia. Senator Wellstone's brother had severe mental illness. Senator Domenici is a conservative Republican. Senator Wellstone was a liberal Democrat. But their family experiences drove a passion for fairness in relation to mental illness, and they worked together.

The New York Times identified five reasons parity has gained support. I've quoted them below, following each with my comments (in italics):
• "Researchers have found biological causes and effective treatments for numerous mental illnesses." [Etiology is important for treatment, but it shouldn't matter for insurance coverage. We know that psychological stress can trigger arrhythmias. That doesn't mean that insurance shouldn't cover the conditions.]

• "A number of companies now specialize in managing mental health benefits, making the costs to insurers and employers more affordable. The law allows these companies to continue managing benefits." [Mental health clinicians despise managed care. For 20 years I've argued within my profession that (a) it is unethical not to manage care and that (b) the ethical challenge is doing it right, not whether to do it. Ironically, if it weren't for the track record of the "carve out" companies that specialize in managing mental health insurance benefits, the Domenici-Wellstone bill would never have passed.]

• "Employers have found that productivity tends to increase after workers are treated for mental illnesses and drug or alcohol dependence. Such treatments can reduce the number of lost work days." [The American Psychiatric Association has been making this case for many years. This is a excellent example of a situation in which the self interest of the profession (insurance coverage for what psychiatrists do) and the public good coincide.]

• "The stigma of mental illness may have faded as people see members of the armed forces returning from Iraq and Afghanistan with serious mental problems." [Stories about the mental health problems of returning soldiers are only the latest element in an effort to bring those who suffer from psychiatric ailments into the tent of shared humanity. This is the hundredth anniversary of the publication of Clifford Beers's "A Mind That Found Itself: An Autobiography," which is often cited as the first major effort to overcome stigma.]

• "Parity has proved workable when tried at the state level and in the health insurance program for federal employees, including members of Congress." [Parity has proved workable when care has been managed. Given the out of control health care costs, in the future the U.S. health system will need to bring a similar form of managerial oversight to all of medicine.]
The Congressional Budget Office predicts that mental health parity will, on average, increase insurance premiums by two-tenths of 1 percent. Achieving parity has nothing to do with the effort to get the economy back on its feet. But in the midst of all the bad news it is an achievement worth celebrating!

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