“Mental Health May Be Stormiest Battle of Clinton Plan,” read a headline on a November 5, 1993, story in the Wall Street Journal. And indeed it is becoming so. Led by Tipper Gore, the Mental Health Task Force proposed “parity” between mental-health problems and physical illnesses under Clinton’s health reform. However, when the actuaries calculated the costs of “parity,” they recognized it as a fiscal space odyssey and, appropriately, delayed its full implementation until 2001.
This induced outrage among many mental-health organizations. Former First Ladies Rosalynn Carter and Betty Ford were brought to Washington to defend parity, and the National Institute of Mental Health dusted off its studies demonstrating the widespread prevalence of mental disorders. Meanwhile, the American Association of Manufacturers was suggesting that the benefits be scaled back radically.
The main source of contention is that “mental health problems” include an extraordinary melange of conditions which can be categorized into four groups. The first group includes conditions such as schizophrenia, manic-depressive illness, severe recurrent depression, and obsessive-compulsive disorder. There is now strong evidence that conditions such as these are brain diseases in the same way as multiple sclerosis, Parkinson’s, and Alzheimer’s are. But the Clinton health proposal includes limits of sixty hospital days and thirty outpatient visits per year plus higher co-payments for the brain diseases of schizophrenia, et al., but no such limits for brain diseases such as multiple sclerosis, et al. The Clinton plan has thus established a hierarchy of brain diseases, claiming that some are more worthy of coverage than others.
If Clinton’s proposal had established a similar hierarchy for heart diseases or liver diseases, there would be public and professional outrage. The additional costs of covering brain diseases such as schizophrenia at parity with other brain diseases would be modest, especially since considerable Medicaid and state mental-health funds are already being spent on them. The Equitable Health Care for Severe Mental Illnesses Act, introduced by Senator Pete Domenici (R., N.M.), proposes such coverage with no discrimination against any brain disease. Appropriate treatment for schizophrenia and manic-depressive illness would substantially reduce the number of mentally ill homeless persons on the streets and in jails.
The second group includes mental conditions that probably aren’t brain diseases but are officially classified as mental disorders by the American Psychiatric Association (APA). This group includes addictions to alcohol or drugs, personality disorders, the condition previously called “neurosis,” and other conditions ranging from “nicotine dependence” to “post-traumatic stress disorder” to “adjustment disorder with work inhibition.” The official definitions of many such conditions are so broad and vague that almost anyone can be fitted into one condition or another.
Mental-health advocates have argued that this group should be included at full parity with physical illnesses (it isn’t in the Clinton plan). Citing statistics from various studies, they even claim that such coverage would not be too expensive. But the credibility of these numbers is suspect: it was precisely such studies that predicted that Medicare would cost only $500 million – yet today it costs $150 billion. In fact, the National Comorbidity Survey, published in January 1994, reported that each year 30 per cent of all adults experience a psychiatric disorder. Multiply these 65 million people by their proposed annual eligibility for sixty hospital days and thirty outpatient visits, and the string of zeros stretches halfway around the Beltway and rapidly bankrupts the Treasury.
Many individuals in this group are unhappy and functioning at a lower level than they should. But there is no evidence that these conditions are brain diseases and no reason, therefore, to cover them under a health plan. Social services at the state or local level may elect to provide counseling for some of these individuals, but funding of such services should not be under a health budget.
A special word should be added concerning alcohol and drug abusers. Although it has become politically correct to say they have a mental illness, there is no evidence that they have a brain disease. There is evidence that they have a genetic predisposition to their addictions, but genetic predispositions are not diseases. There is also a volitional aspect to alcohol and drug addictions which distinguishes them from brain diseases – there is no addiction unless someone purchases and ingests or injects the addicting substance. The Clinton Administration could do more to combat alcohol and drug abuse by imposing conditions, such as sobriety and abstinence, on the more than 250,000 alcoholics and drug addicts who, according to the General Accounting Office, received $1.4 billion in cash payments from Social Security programs last year. Currently federal entitlement programs are supporting addicts.
The third group of “mental-health problems” includes problems inherent in the human condition and not officially classified as mental disorders” by the APA. These include problems with interpersonal relationships, low self-esteem, and mid-life crises. In the past these problems were handled by having a talk with your hairdresser, bartender, clergy-man, or friend, but now have been redefined as the result of co-dependency, victimhood, and dysfunctional families. In New York, Woody Allen has become a parody of his films after 33 years of psychotherapy. In Boston, Harvard psychoanalyst John Mack makes a career of treating individuals who have been “abducted” by “extra-terrestrials” – close encounters of the psychiatric kind.
Officially such activities would not be covered by the Clinton proposal, but unofficially many of them would be. Mental-health professionals are remarkably creative in redefining problems to fit reimbursable diagnostic categories. Surely, an encounter with E.T. qualifies a person for having a “post-traumatic stress disorder.” Almost all life’s crises can be viewed for reimbursement purposes as “adjustment disorders,” defined by the APA as “a maladaptive reaction to an identifiable psychosocial stressor, or stressors, that occurs within three months after onset of the stressor, and has persisted for no longer than six months.” If coverage of the second group of “mental-health problems” does not bankrupt the nation, redefining problems of the third group surely would.
Finally there is the fourth group of “mental-health problems.” These are social conditions such as poverty, racism, and sexism which are said to cause psychiatric disorders. The “prevention” of “mental-health problems” through social engineering lies just beneath the surface of Clinton’s proposals. Dr. Bryant Welch, former executive director of APA, argued that “you cannot treat an inner-city youth who has had multiple traumas” with only thirty outpatient visits per year. Therefore more visits should be covered. Rosalynn Carter, promoting “equitable mental-health benefits,” recommended that the Clinton plan “promote mental-health practices as well as provide for prevention.”
So, should the Mad Hatter’s madness be covered under the Clinton health plan? The answer is yes, because the “madness” of nineteenth-century hatters was caused by poisoning from the mercury used in the process of making hats. The Mad Hatter therefore had a brain disease which should qualify him for coverage. The March Hare, on the other hand, was merely neurotic, while the Dormouse came from a dysfunctional family. Neither should be covered. Finally Alice, well meaning and intently desirous of helping others, would try to solve the social problems of the world and “prevent” mental problems if given an opportunity under a health plan. The Clinton Administration should simply return her resume with a polite note of thanks.