Michael M. Miller: Bailout plan included historic moment for mental health parity

Michael M. Miller  —  10/09/2008 10:26 am

On Oct. 3, 2008, President Bush signed into law H.R. 1424. Most people know that as the financial rescue ("Wall Street bailout") plan. In fact, the president signed the mental health and addiction parity bill, H.R. 1424, to which two huge amendments were attached: the financial rescue plan, and the tax extenders bill.

Few pieces of legislation, if any, compare to the "bailout" bill -- in dollars appropriated, in the extent of "nationalization" of investment instruments from the private sector. But in their own way, the parity provisions of H.R. 1424 are no less earthshaking.

Ever since health insurance was developed and woven into employee fringe benefits packages, psychiatric conditions and substance use disorders were treated differently. At one time, "conditions of the mind" or "behavioral disorders" were considered unworthy of full insurance coverage. These conditions (but not heart disease, obesity or lung cancer) were considered "self-imposed conditions." Psychiatric care was equated with psychotherapy, which in turn was viewed as an option, a luxury often pursued by the "worried well."

But current medical science has revealed the facts. Addiction and anorexia nervosa are not desired states. People have clinical depression or manic depression because they have a problem of functioning in their brains. The seizures of epilepsy, the hallucinations and delusions of schizophrenia, the forgetfulness and agitation of Alzheimer's dementia, the rigidity and tremor of Parkinson's disease, all happen because of dysfunction in the brain. Even the pathological preoccupation with drug use, the powerful cravings triggered by conditioned cues, and the defects in inhibiting use seen in persons with nicotine, cocaine and alcohol addiction, are traceable to the reality that the brains of persons with addiction differ from the brains of non-addicts, even those who regularly use drugs and alcohol.

There is no rational basis to discriminate (in all meanings of the word) between persons whose emotions, thoughts and actions differ from others' due to one kind of structural or chemical defect in their brains, versus another such defect in the brain. The editorial board of The Capital Times has consistently advocated for parity in insurance coverage for mental illness and addiction. Freelance columnist Mary Conroy has poignantly written about the need for employer-based insurance to cover treatment of psychiatric and addictive disorders -- for the benefit of patients and families and the benefit of the employer as well.

With enactment of H.R. 1424, if an insurance plan covers mental health and addiction (virtually none exclude such coverage), there can be no limits placed on such coverage that differ from limits placed on medical/surgical/obstetrical care. Hospital days, outpatient visits, total dollars of coverage per year and per lifetime, all must be the same for mental health and addiction, and all other covered conditions. If there are out-of-network provisions in a plan, they must apply equally to mental health and addiction care and to medical/surgical care. No discrimination is allowed.

There have been many champions of parity in Wisconsin -- former Sens. Mary Panzer and Carol Roessler, current Sens. Spencer Black, Jon Erpenbach, Dave Hansen and Fred Risser, and Assembly members like Sheryl Albers. Members of the Coalition for Fairness, including Catherine Beilman from NAMI-Wisconsin, Sheldon Gross from MHA-Wisconsin, Bill Stone from the Wisconsin Association on Alcohol and Other Drug Abuse, Sarah Bowen from the Wisconsin Psychological Association, and myself from the Wisconsin Medical Society, have pushed this issue in session after session of our Legislature.

In Washington, D.C., Rep. Tammy Baldwin was instrumental in ushering H.R. 1424 through various subcommittees and committees as well as the legislative maneuverings of last week. Patients and families are indebted to the original authors of the H.R. 1424, Reps. Jim Ramstad and Patrick Kennedy, and to Sens. Pete Domenici, Ted Kennedy, Christopher Dodd and others who found a way last week to get this historic legislation to the president's desk.

The American Society of Addiction Medicine and the American Psychiatric Association have fought for years to make parity a reality. The American Medical Association and the Wisconsin Medical Society have advocated for parity as well -- not because the psychiatrists and addictionologists in their membership called for it, but because family physicians, pediatricians, general internists and emergency medicine doctors want their patients to be able to receive needed services without arbitrarily capped insurance benefits. What ER physician wants to see a suicidal patient and have to release him or her back home solely because the patient has had a psychiatric admission earlier in the year and their "caps" for allowable days of hospitalization have been met?

Thank you to the Wisconsin State Journal for putting the New York Times story on mental health and addiction parity on the front page of the paper Monday. This is a historical watershed: the recognition that mental health and addiction conditions are disorders of the brain, a realization akin to accepting that epilepsy isn't due to demons or spirits. This legislation says that persons with addiction and psychiatric disorders are not bad people, they are people with bad diseases, who deserve compassion and equal consideration in health insurance benefit design. The world will look back to this event one day, when America led the way in aligning its health policies with scientific knowledge and moving beyond ignorance and stigma to help people recover from these very common afflictions.

Michael M. Miller, M.D., who practices at Meriter Hospital in Madison, is president of the American Society of Addiction Medicine.

Michael M. Miller  —  10/09/2008 10:26 am