It wasn’t so much that President Clinton said mental-health services would be included as a basic benefit in his health-care reform plan.
It was Congress’ reaction.
On both sides of the aisle, lawmakers rose and cheered the concept of equating illnesses of the brain with illnesses that occur elsewhere in the body.
“For those of us in mental health it was a highlight of 20 years of work,” said Keith Dixon, chief executive officer of Vista Health Plans, a managed mental-health care company based in San Diego.
Dr. Bernie Arons, a Washington psychiatrist who has served in federal government and chaired Clinton’s subcommittee on mental health, was equally astonished.
“I couldn’t believe the spontaneous response. When the (plan) hits Congress, it will be very tough for someone to get on the floor and oppose this,” he predicted.
Mental disorders have been traditionally steeped with shame and stigma, while those who suffered from them were seen as crazy or weak. And, despite new research showing many mental illnesses are biologically based, opinion polls show large numbers of individuals still do not believe such disorders are true illnesses.
By including mental health prominently in his health plan, advocates say, the President has done much to advance the understanding of these disorders. Some even exhort that the plan is the best that can be achieved, given cost restraints facing the President.
But others, while praising the President’s efforts, say they are disappointed with some shortcomings in the plan.
“What I’m encouraged about is mental-health treatment is covered in the basic benefits package. What I’m disappointed about is the benefit does not have full parity with other illnesses,” says Dr. Michael Freeman, president of the Institute for Behavioral Healthcare, a San Francisco-based think tank concerned with the mental-health industry.
An estimated 60%-70% of the mentally ill have inadequate insurance. Almost 24 million American adults and 12 million American children have a serious mental disorder, according to the National Assn. of Psychiatric Health Systems.
But, if Clinton’s plan is enacted by Congress, everyone gets something.
“It’s an incredible improvement for those (underinsured) people,” Freeman says. “For the rest, it’s pretty similar to what a lot of the Fortune 500 companies offer or better.”
There are other praiseworthy aspects of the plan. Clinton has avowed that no one should be refused medical insurance because of a pre-existing condition. Increasingly, people who have needed mental-health services have been refused any type of medical insurance.
“We are enormously pleased with the prohibition against pre-existing condition exclusions,” says Wade Horn, executive director of Children and Adults with Attention Deficit Disorders, a parent-based organization with more than 400 chapters nationwide.
“We have been seeing a lot of people being refused treatment for ADD because insurers say, ‘You were born with it. It’s a pre-existing condition.’ ”
Clinton’s plan also removes lifetime cost caps, such as the common $50,000 limit that is grossly inadequate for the treatment of most severe, long-term illnesses, such as schizophrenia or autism.
Those who criticize the President’s mental benefit say they had hoped for more.
Clinton should have seized the moment to give mental health parity with other illnesses, Freeman says. The plan promises parity by 2001, but by not doing so now: “It perpetuates the stigma and second-class status of mental health,” Freeman says.
But, according to Arons, it is impractical to think that full mental-health benefits could be introduced at one time without breaking the bank.
“That’s a big jump,” he says. “People know that (parity) is right morally and even clinically. But it’s still a big jump in the service system.”
Arons says that he expects some states to introduce parity gradually. For example, Maine has already legislated a phase-in of full coverage for several major mental-health disorders, such as bipolar depression, obsessive-compulsive disorder and autism.
But even if major mental illnesses achieve full parity in short order, many mental-health experts are concerned that people with more mild or moderate disorders will be handicapped by the limitations on outpatient services.
Under Clinton’s proposal, people who need regular medication for a disorder, such as lithium for bipolar depression, would have unlimited outpatient visits for medical management. But someone not on a psychotropic medication would be limited to 30 psychotherapy visits.
“The problem with the outpatient benefit is it does nothing for the person in need of serious outpatient therapy,” said Dr. Bryant Welch, senior policy adviser of the American Psychological Assn.
“Thirty outpatient visits is fine for an adult going through a psychological crisis. But for children, trauma victims, adults with severe anxiety disorders or depression, it forces them to turn to (drug therapy), whether appropriate or not, or forces them into expensive inpatient or residential-based treatment.”
The APA, whose members provide a majority of non-medical, outpatient treatments, argue that 70%-80% of all mental-health dollars are already spent on inpatient care and that savings could be achieved by providing incentives to use outpatient services instead.
Some consumers also fear that limits on outpatient services will leave them with inadequate care.
Mary Riley, a San Diego woman whose son has attention deficit disorder, says ADD children often need long-term therapy, while the family requires services to learn how to manage the child.
“There are some things, like social skills training, which are vital to parents. And some children require more than one type of intervention. For example, some have auditory or motor-skill problems. So 30 visits may not be enough,” says Riley, whose son Michael is 8.
Like other people with mental disorders, intense therapy for children with ADD can prevent later problems and the need for future, costly treatment, says Horn, of Children and Adults with Attention Deficit Disorders.
“It seems to us, if we put more into outpatient, it will be cheaper in the long run and will prevent our kids (from) developing more serious secondary problems that will require hospitalization,” he says. “But this plan unfairly balances away from outpatient management.”
Arons says Administration officials simply feared that people would overuse a larger or open-ended psychotherapy benefit, which would lead to out-of-control costs.
But, he says, a “major accomplishment” of the Clinton plan is the inclusion of 120 days of “hospital alternatives,” which can be used by people in need of more outpatient services. “Hospital alternatives” means day-treatment programs, non-residential halfway houses or any program that falls between overnight hospitalization and a one-hour-per-week therapy session.
“The non-residential alternative benefit will be extremely helpful to control costs,” Arons says.
Bryan Jones, director of public policy at the Mental Health Assn. in Los Angeles County, also praised the benefit for hospital alternatives, saying it will be a godsend to people who now have no mental-health coverage.
During the summer, says Jones, rumors leaked from Washington that the mental-health portion of the Clinton plan was being whittled away, including the greatly hoped-for hospital alternatives benefit. The response by the mental-health community was overwhelming.
“There was a massive letter-writing campaign . . . and they began to put things back in, including the piece concerning 120 days of alternative care,” he says. “Now, the California mental-health community is organizing visits to every congressional district over the next few months to make sure we can hang on to this and that it doesn’t get lost in Congress.”
Despite criticisms of the plan, says Jones: “This is a great first step.”
Comparing Mental Health Benefits
President Clinton’s low-cost and high-cost mental health benefits vs. standard Blue Cross and typical Fortune 500 company benefits: * INPATIENT
Deductible Clinton low-cost sharing plan (HMO): None High-cost sharing plan: One day’s cost Blue Cross: $250 per admission Fortune 500: Not specified
Coinsurance Clinton low-cost sharing plan (HMO): None High-cost sharing plan: 20% Blue Cross: 40% Fortune 500: 20%
Time limit Clinton low-cost sharing plan (HMO): 30 days per stay; 60 days annual High-cost sharing plan: 30 days per stay; 60 days annual Blue Cross: Unlimited Fortune 500: Limits on substance abuse
Cost Limit Clinton low-cost sharing plan (HMO): None High-cost sharing plan: None Blue Cross: $50,000 lifetime maximum Fortune 500: None
Coinsurance Clinton low-cost sharing plan (HMO): $10 per visit; $25 per visit for psychotherapy High-cost sharing plan: 20% except for psychotherapy; 50% for psychotherapy Blue Cross: 40% Fortune 500: 20% for employee; 50% dependent
Time limit Clinton low-cost sharing plan (HMO): Psychotherapy: 30 visits High-cost sharing plan: Psychotherapy: 30 visits Blue Cross: 25 visits Fortune 500: Limits on substance abuse
Hospital Alternatives Clinton low-cost sharing plan (HMO): 120-day annual maximum High-cost sharing plan: 1-day deductible; 20% coinsurance; 120-day annual maximum Blue Cross: 25 visits includes hospital alternatives Fortune 500: Not specific