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April 10, 2002

Misperceptions Behind Mental Health Policy

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JAMA. 2002;287(14):1858. doi:10.1001/jama.287.14.1858-JMS0410-4-1

According to the 1999 Surgeon General's Report on Mental Health (SGRMH), about 20% of the US population is affected by mental disorders at any given time.1 However, the SGRMH goes on to say that "there is an enormous disparity in insurance coverage for mental disorders in contrast to other illnesses." People with mental illness thus often go without adequate care and suffer needlessly.1

There is a longstanding concern that coverage for mental illness treatment would result in an upsurge in health care costs. At the Medicare amendment hearings before the Senate Finance Committee in 1965, Robert W. Gibson, on behalf of the American Psychiatric Association, pointed out that "no doubt much of the discriminatory conditions set forth in this legislation concerning mental illness derive from a concern that if the mentally ill are treated like all the rest, that it will ‘break the treasury.'" Senator Russell Long of Louisiana responded, "I agree with you that largely we have not done more for the mentally ill because the argument has been made that when we get into this field it is going to cost a lot of money."2

Senator Long's argument, however, turns out to be unsupported. One recent study by the GAO estimated the cost increase for full parity to be between 2% and 4%.3 In the 35 states where parity meets or exceeds federal parity laws, parity had only a small effect on premiums, increasing cost by 3.4%.4 Additionally, the study showed that cost increases were lowest in systems with tightly managed care and generous baseline benefits. This implies that when coverage is present and restrictions that force patients to accept other "covered" solutions are removed, the inadequate care created by the patchwork of treatments ceases to be an issue, freeing up otherwise dedicated resources and consequently reducing overall costs.5

Congress took a step toward improving access to mental health care by passing the Mental Health Parity Act (MHPA) of 1996, which took effect on January 1, 1998, and recently sunset on September 30, 2001.6 This law established parity between the annual and lifetime benefits for mental health illnesses and those for medical and surgical care. Although this act did not require employers to offer mental health care benefits, it did require parity if such benefits existed.

Despite the legal mandate of parity, however, reimbursement for mental health services is often so low that many providers still refuse to treat patients with such coverage. In the private sector it appears that many employers are able to comply with the MHPA while subverting its spirit. The General Accounting Office (GAO) reported that 87% of employers surveyed claimed compliance with the requirements of the MHPA while using cost-sharing mechanisms allowed by the law.3 This effectively imposed new restrictions on mental health benefits by permitting strategies such as reducing the number of covered outpatient visits and hospital days, modifying the definition of "medical necessity," or imposing higher copayments and/or deductibles.3

Policies that limit reimbursement for mental health services may also reflect a misperception that most psychiatric diseases lack effective treatments.2 The SGRMH asserts that the current criteria for the diagnosis of mental disorders are as reliable as those for general medical disorders and a range of treatments of well-documented efficacy exists for most mental disorders.1 A study from the National Institute of Mental Health7 has shown that success rates of treatment for disorders such as schizophrenia (60%), depression (60%-65%) and panic disorder (80%) surpass those of some common medical procedures such as angioplasty (40%) or atherectomy (50%), when success is defined as a substantial reduction or remission in symptoms of the illness.

Misperceptions about the costs and effectiveness of mental health care prevent legislative action needed to help people with mental illness. A 1998 survey of 1300 randomly selected adults found that 69% supported expansions of mental health benefits, but that this number decreased to 34% if they might be asked to pay for it in increased taxes or insurance costs.8 This attitude may translate into sluggish legislative action if politicians perceive that their constituents view such initiatives unfavorably. It is imperative for our society to stop devaluing the treatment of mental illness based simply on this lack of understanding.

US Surgeon General Office, Mental Health: A Report of the Surgeon General.  December1999;Available at: http://www.surgeongeneral.gov/library/mentalhealth/pdfs/.C2.pdf. Accessed December 7, 2001.
Senate Committee on Finance, Not Available (1965, May) Social Security, Part 2. CIS-NO: 89 S1680-0-B, DOC-TYPE: Published Hearing, SESSION-DATE: 1965, SUDOC: Y4.F49:So1/8/965/pt.2, CIS/Historical Index.
US General Accounting Office, Mental Health Parity Act: Despite New Federal Standards, Mental Health Benefits Remain Limited.  May2000;Available at: http://americ20.temp.veriohosting.com/web/Mental Health Parity Act.pdf. Accessed December 7, 2001.
Sing  MHill  SSmolkin  SHeiser  N The Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits (DHHS Publication (SMA) 98-3205).  Rockville, Md Substance Abuse and Mental Health Services Administration1998;
American Psychiatric Association, Mental Health Parity—Its Time Has Come.  April1999;Available at: http://apaweb.psych.org/pub_pol_adv/fac-parity.cfm. Accessed November 14, 2001.
Health Care Financing Administration, The Mental Health Parity Act of 1996 . 1996;Available at: http://www.hcfa.gov/medicaid/hipaa/content/mhpa.asp. Accessed October 24, 2001.
National Mental Health Advisory Council, Health care reform for Americans with severe mental illnesses.  Am J Psychiatry. 1993;1501450- 1452Google Scholar
Hanson  KW Public opinion and the mental health parity debate.  Psychiatr Serv. 1998;491059- 1066Google Scholar