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Mental health and health-care reform

Mental-health advocates are "almost giddy" about the Affordable Care Act. That, plus last year's passage of "the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act" could really end up revolutionizing mental-health care in this country.

By Ezra Klein  |  March 30, 2010; 5:07 PM ET
Categories:  Health Reform  
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What that piece doesn't quite address is the extent to which mental health services are heavily dependent upon either state government or private services operating under state contracts, and the state budgetary crunch has brought hiring/wage freezes.

(The VA is doing fairly well, after a recruitment drive to deal with the surge in PTSD and other cases among returning vets, but anyone working in state mental health is scanning the VA hiring pages on a regular basis right now.)

Posted by: pseudonymousinnc | March 30, 2010 5:44 PM | Report abuse

eh. I support Mental Health Parity but it feels like a very separate-but-equal thing to me. Given all the advances in psychiatry and neuroscience, the understanding of the genetic components of mental health issues, it seems very arbitrary and outdated to have two buckets of benefits. I'd prefer they just stopped making any distinction whatsoever.

Posted by: ThomasEN | March 30, 2010 6:13 PM | Report abuse


From what I read in this article Mental coverage must be equal too Physical coverage. The problem is equal is still a raw deal in the way it has been implemented in my state.

Under my plan if I have a $1500 deductible for physical health, I have ANOTHER $1500 deductible for mental health. This is better than not having coverage at all, but it still seems like one of the "Worst practices" talked about by Pres. Obama.

Has this changed?

Posted by: chrynoble | March 30, 2010 6:33 PM | Report abuse

I'm all for parity, but mental health talk therapists needs to step up their game. They need to start being better about distinguishing between therapies that work and those that don't. Right now what is emphasized is the practicioner, not the practice.

Posted by: inkadu | March 31, 2010 12:24 AM | Report abuse

Translation: quack, quack, quack.

Posted by: ostap666 | March 31, 2010 8:34 AM | Report abuse

I agree that we need to distinguish between therapies that work and ones that do not have a high success rate. But when it comes to mental health issues there are so many different and competing ideas about what works since there are so many different illnesses. My daughter has anorexia nervosa and nearly died several years ago because our insurance company's standards and those of her treatment providers clashed. In the meantime she became very, very ill, finally receiving out of state residential treatment. She is now doing well but many patients languish (and their families go broke) because eating disorders are unfairly and unevenly covered, if at all.

For example, I am concerned over the use of “medical necessity” clauses to authorize treatments and control costs for mental health coverage. This may be a loophole used by insurance companies to refuse to pay for mental health services. From what I understand that determination will be left to insurance companies to make, and not your doctor or therapist.

So, my question is where does this idea of "medical necessity" fit into insurance coverage for mental illness, specifically eating disorders? If a person has anxiety or depression, are the standards still medical necessity? EDs are mental illnesses that manifest themselves in disordered eating and it is often the case that a person can achieve a weight within the low to normal boundaries but still suffer from the mental illness and therefore be denied treatment if a strictly physical criteria is used.

I understand, of course, that my insurance company needs to use a criteria to approve treatments of any sort. But shouldn't that criteria be left to the mental health professionals to determine?

Another point is access to services. Anthem gives a list of providers. But try and find a provider in your state trained in eating disorders that accepts new patients on insurance and provides a range of services - it is extremely difficult if not impossible.

Anthem refuses to cover nutritional counseling of any sort for eating disorders. Yet every professional recommends it. It is a cornerstone of treatment - this is from the National Institute of Mental Health:

"TREATING ANOREXIA involves three components:

1. restoring the person to a healthy weight;
2. treating the psychological issues related to the eating disorder; and
3. reducing or eliminating behaviors or thoughts that lead to disordered eating, and preventing relapse."

To get from 1 to 2, you need nutritional counseling - which is not covered. So while parity is laudable and necessary, I am afraid that there are enough loopholes in the law to continue to make it extremely difficult to get comprehensive mental health treatment.

Posted by: laurap2 | March 31, 2010 9:02 AM | Report abuse

excellent example LauraP2. That's one of the things I was thinking of when I made my comment.

On a somewhat related note, in Jersey Aetna settled a class action lawsuit because they refused to give eating disorders parity of any kind, claiming there was no biological basis, despite ample evidence to the contrary.

More reasons why I think the distinction is meaningless. We're only just now understanding the biological basis of eating disorders, 20 years ago no one knew anything about the biological basis of depression, and so on. As science advances it it worthwhile to hold on to these distinctions?

Posted by: ThomasEN | March 31, 2010 11:10 AM | Report abuse

That's a good point, ThomasEN but I sincerely doubt that will ever happen. If we look at the history of mental health services, it is only in the last few decades that it has improved to the point where sufferers (including from EDs) can hope for relief. In addition, there is still a strong stigma attached to getting treatment. I remember saying to my daughter that there should be no more shame in getting help for what is essentially a brain disorder than there should be if she had a broken leg or diabetes. I can hope for a time when that shame doesn't stop people from getting help and where insurers do not discriminate but I think it may be a long ways off. Plus there is always a question with mental health issues of how biology intersects with environment. I think the next hurdle is the one of stigma and access to services. The community mental health system is disjointed and difficult to navigate. But I agree with your points.

Posted by: laurap2 | March 31, 2010 7:20 PM | Report abuse

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