By Janet Singleton

For the Insured: Better Insurance Coverage for Psychotherapy and Meds

For the Uninsured: Take Two Wellbutrin and Go Away or …

Traditionally, humane mental health treatment has been a luxury partial to the affluent. Mental illness has no such bias.

As of January 1, 2010, the federal Mental Health Parity and Addiction Act will mandate that insurance coverage for mental health be comparable to that for other medical interventions, for group plans of companies employing 50 or more. What it means, for those who are sheltered beneath its modest umbrella, is that reimbursements, number of visits, annual and lifetime caps, co-payments, and any out-of-pocket costs for psychotherapy and related medications should be in line with, for example, treatment for diabetes.

Generally speaking, nearly six in ten Americans will have a serious emotional problem, in the form of anxiety disorders, clinical depression, or substance abuse, before age 32, according to a new study out of Duke University. Millions more will experience mental ailments, have a family member who does, or both, experts say. Psychological illness may be no scarcer than physical illness, just more stigmatized.

Wellstone-Domenici beefs up a standing federal law. Forty-two states, according to the National Alliance on Mental Illness (NAMI), already provide parity to varying degrees. If a state has no rules for equity, like Florida, the federal law imposes them. If a state has a weaker law than Wellstone-Domenici, the new legislation picks up the slack.

“Discriminatory Limits No Longer Allowed”

The legislation reflects a decades-long political movement toward parity. In the past, insurance companies could place strict limits on coverage of visits to a psychotherapist, require higher co-payments for antidepressants like Prozac and Wellbutrin, and allow fewer reimbursed days for mental health hospitalization, says Andrew Sperling, director of federal legislative advocacy for the NAMI. “Those types of discriminatory limits are no longer allowed. We believe this law is going to help a lot of people.”

Though Wellstone-Domenici does not apply to self-insured plans and programs that cover groups of less than 50, Sperling, whose organization has long fought for mental health parity, says that he believes some businesses and providers will comply voluntarily. That will not be out of the goodness of their hearts, he says, but a matter of pragmatism. Purchasers buying insurance plans in which parity is already incorporated may find adjustments may not be possible.

No Insurance, No Gain

Still, the law comes with a big silent “if.”

“You have to have some insurance to begin with,” says James Flowers, MD, a Nevada-based internist who previously worked in Milwaukee’s inner-city. For many African Americans, the new legislation means nothing, because nearly 20 percent have no medical coverage, compared to 16 percent of the nation as a whole, reports a recent Gallup Poll,

Yet Flowers believes that Wellstone-Domenici represents a bit of progress. “My belief is that any ‘nationalization’ like this is an essential first step to ensure better access and services for blacks in general, but is not sufficient to achieve the goal of equal access and quality of services across the board,” Flowers said. “These laws will benefit those who already have the better insurances and are paying out of pocket. In my working at a majority drug treatment center, I encountered no blacks who came and paid for their mental health/AODA (Alcohol and other Drug Abuse) services, I did encounter many whites who did so. “

Another factor that may stunt the law’s effects: psychiatry and psychology continue to be inexact arts. Studies show that a combination of “talk therapy” and medication is more effective than either approach alone. Yet, watchdogs charge that “meds” have taken the place of verbal therapy.

“A lot of psychiatrists these days are on short leashes,” says Joe Graedon, pharmacologist and author of The People’s Pharmacy. They are pressured by an impatient, bottom-line culture, he says. “Three months of cognitive behavioral therapy may be better than putting everybody on pills.”

Graedon offers a caveat about parity. “We won’t know what reform looks like until it gets here.”

“My concern,” Flowers says, “is that the increase in premiums will not be 0.4 percent as predicted. What you will see is an increase in the number of fly-by-night providers of mental health services arise to take advantage of this act. This will push up utilization and will force the insurance companies to do one of two things: 1) raise premiums significantly, 2) just eliminate mental health services from that company, start a totally new company that offers only mental health services and then avoid the law altogether.”

And parity in insurance does not mean parity in priority. “When someone comes in with a heart attack, we’re going to talk to you once a week,” says Eric Burns, MD, cognitive therapist and author of Feeling Good. “But depression has the same morbidity rate.”

Uninsured Have an Option

His experience in a lower-income area in Philadelphia showed him that underserved and overstressed communities respond to intensive cognitive (thought-based) group therapy, he says. Studies using Burns book Feeling Good point to an additional resource for those with limited resources. Participants in the research who read the book and followed its instructions reported getting more relief from depression that did members of a control group.

Still, in a nation where 43 percent polled by the National Mental Health Association view mental illness as a “moral weakness” and black mental health professionals lament the reluctance of affected blacks to seek help, shame may dwarf lack of insurance as a barricade to treatment. “Is this law going to eradicate the stigma?” Sperling says. “No. But having these laws recognize (psychological disorders) as legitimate illnesses is absolutely critical for ending long-term stigma.”

Burns says change is sorely needed. “I am looking for a revolution in the way that we look at and understand therapy,” he says.

Janet Singleton is a freelance writer.