8 years ago the Mental Health Parity and Addiction Equity Act of 2008 was heralded as a major victory against the stigma of mental illness. The law was supposed to eliminate (for the most part) financial and treatment inequities for mental health care. Co-pays, deductibles and treatment limits could no longer be more restrictive than for ‘regular’ medical care. The definition of parity is the state or condition of being equal, especially regarding status or pay.
There is no doubt that in many ways, the Parity Act has made a positive impact not just for my family but for many of the families I’ve worked with over the years. There is also no doubt that the current laws do NOT guarantee equal coverage or equal access. But in the span of a few short days, I feel like I’ve been hit front and center with the harsh reality of gaping holes in parity and equity.
The following two examples are real circumstances experienced by real individuals. Names and other details have been changed to maintain confidentiality. However, these two cases are anything but unique.
Example #1*: A 20-year old man, ‘Bryan’ walks into a local agency seeking mental health services. He shares that he has a history of deepening depression with frequent suicidal thoughts often accompanied by a plan. Although he doesn’t currently feel suicidal he recognizes that he is in a cycle that is getting worse. Bryan has insurance and saw a psychiatrist recently but stopped going after his insurance denied coverage. As a result, Bryan has run out of the medication he was prescribed. It turns out that Bryan’s insurance has a $4000 deductible. It is unlikely that even if he sees a psychiatrist and therapist regularly for a year he will not meet his deductible. Essentially he will be paying first dollar for every visit, every treatment. However, (and this is the part that really got me fuming), his insurance company shared that visits to a primary care doctor are exempt from the deductible. So as long as Bryan seeks treatment from a generalist rather than a specialist, his insurance will pay.
Example #2: ‘Conner’ was diagnosed with schizophrenia when he was 25 years old. Over the past 6 years he has been in and out of hospitals while his illness progressed to the point that he cannot live independently. Recently, Conner’s family learned that his Medicaid insurance was being switched to Medicare because of the length of time he has been deemed totally disabled. It turns out that Medicare puts a lifetime cap on inpatient mental health benefits. Coverage for inpatient treatment in a psychiatric hospital stops, forever, after 190 cumulative days. If, however, Conner is hospitalized in a general hospital (with or without a psychiatric unit) there are no limits on the covered number of days of inpatient care.
In both of these situations a huge double standard exists. Private and public insurance companies consider it cost effective to treat psychiatric illnesses utilizing clinicians with limited knowledge and training. And they are NOT willing to provide comparable access to care provided by those who have a deeper knowledge, specialized training and skill sets. To me that is analogous to saying that broken bones should be treated by a family practitioner rather than an orthopedic surgeon. Why don’t we have our car’s failing brakes repaired at an oil change franchise instead of by a mechanic trained in brake replacements? No matter that our car’s brakes may fail, plowing into a school bus or a crowd of bystanders. It seems to be primarily about saving dollars on the front end. Regardless of the rising costs on the back end.
I wish I could wrap up this blog with a nice, neat solution but I can’t. There is no one singular problem so how can we presume to have a singular resolution? Over the years many of the families I’ve worked with have limited resources and are grateful for any treatment they can obtain. But why, I keep asking myself, should they or anyone else have to ‘settle’? It’s not just about individuals, it’s about all of us. Who has the right to decide that the brain is less worthy of health care than any other part of the body? No one should have to settle.