Coverage Only for the Most Severe Conditions

RICHARD E. VATZ and LEE S. WEINBERG

June 08, 1993|By RICHARD E. VATZ and LEE S. WEINBERG

The Clinton administration has given mixed signals about whether mental health would be included in its evolving health-care package. Some weeks ago, the New York Times quoted a confidential report proposing broad coverage for mental health on the grounds that ''the division of diseases into medical and mental types becomes more arbitrary with every new study.''

More recently, the administration has appeared to retreat. The Jackson Hole Group of business and health advisers is recommending stringent cuts in psychotherapy visitations to cut mental-health care costs. And Hillary Rodham Clinton recently warned mental-health interest groups: ''I won't lie to you and say that mental illness will be covered at parity [with physical illness]. . . . You have to understand that some have argued whether mental illness should be in the package at all.''

Hard decisions will have to be made. Advocates for parity for all mental illness must confront the economic reality that such a program is simply too costly; those who oppose virtually all medical coverage for mental disorders must face the political reality that a compassionate American public favors coverage for individuals with the most severe problems. A mental-health policy that covers most treatment for ''severe mental illness'' (schizophrenia, bipolar disorder and major depression), but mandates very limited coverage for treatment of lesser psychological problems might be the Solomonic solution -- and one which might get through Congress.

Most ''mental illnesses,'' as psychiatrist Thomas Szasz and the former American Psychological Association president George Albee have argued, are problems in living and not real illnesses; thus, they cannot be conclusively confirmed by any medical tests, and leading mental-health professionals are virtually unconstrained in their claim that mental illness is pandemic.

The National Institute of Mental Health claims that it has determined from interviews by ''lay interviewers'' that more than 25 percent of adults in America have at least one ''psychiatric disorder'' within any one-year period (and they warn that this may be an underestimate), and that there is a 29 to 38 percent lifetime prevalence. Their Division of Epidemiology and Services Research claims that 52 million American adults have a diagnosable mental illness.

But inasmuch as the institute claims that only about 4.5 percent of Americans have severe mental illness, it concedes that more than 95 percent do not. To oppose full coverage for the 95 percent does not deny that these individuals have emotional problems, but no health-care package should be expected to take on all the psychological stresses of a complex, industrial society.

One estimate of the current cost of outpatient psychotherapy alone in America puts it at 2.5 percent of the total health-care expenditures, which exceed $700 billion, while mental health costs altogether constitute 10 percent. And studies show that increased coverage of psychotherapy will lead to significantly increased utilization.

Some psychologists feel some guilt about accepting medical insurance payments for doing psychotherapy for psychological problems which they regard as not severe and certainly not medical. One psychologist confided to us, ''You will be proud of me. As soon as my children finish college, I will no longer use insurance to subsidize my marriage counseling.''

Others feel no guilt. Psychologist Stanton Peele, whose ''Diseasing of America'' made him famous for his decrying of ''mislabeling all of our problems as medical ones,'' surprised us on a videotaped panel by referring to the ''third-party payments I get as a licensed psychologist.''

When we asked how he could claim that mental health was a category error, but use that category for financial reimbursement, his response was, ''How do you make a living, buddy? . . . I have to make a living.'' When another therapist on the panel said that he refused to accept insurance payments for therapy, Dr. Peele retorted, ''You can't get a house in Morris County [a well-to-do area in New Jersey] that way.''

Surprisingly, limitations on mental-health coverage are supported not only by mental-health skeptics. Sufferers of ''severe mental illnesses'' and those who love them are often at the forefront of criticism of coverage for the ''non-severe'' mentally ill, arguing that expansive coverage, including coverage for arguably willful behavior such as substance abuse and excessive gambling, dilutes compassion and resources needed elsewhere. The mental health field's incredibly expansive claims of behaviors and problems as medically treatable illnesses has cost it credibility.

The Clinton administration should do what many employers have done with mental-health benefits: guarantee coverage on a parity or near-parity basis only for ''severe mental disorders.'' Other conditions should receive limited or no coverage. Finally, any plan must ensure that ''severe'' and other mental illnesses are not so loosely defined as to permit practitioners to broadly apply such diagnoses.

Richard E. Vatz teaches rhetoric at Towson State University. Lee S. Weinberg teaches in the Graduate School of Public and International Affairs at the University of Pittsburgh.

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