By Shankar Vedantam
The Washington Post
WASHINGTON — In his administration’s first major initiative on mental health, President Bush is expected to announce Monday his support for "parity," legislation that would require large employers to extend the same health benefits for mental illnesses that they do for physical ailments.
As word of the initiative broke on Thursday, it appeared that mental health advocates’ long fight for parity was finally nearing resolution.
But Bush’s involvement may portend a sharper debate, and mean difficult choices ahead for patients, doctors and advocates. The issues — how to define mental illness, how to treat it and who should pay — have been looming for years.
In the coming debate, the battleground will shift to a 941-page book — the American Psychiatric Association’s Diagnostic and Statistical Manual — a compendium of the diseases, disorders and distress that affect the human psyche. The primary issue is whether equal health benefits should be extended to every condition listed in the manual or limited to the most serious disorders, such as schizophrenia, bipolar disorder and major depression.
Psychiatrists, psychologists and patient groups want better coverage for all disorders, but a fault line runs between the groups: Patients and doctors dealing with the most severe mental illnesses say that if confronted with a choice between no parity and parity for only the most serious illnesses, they would settle for the limited benefit.
The Senate passed a parity bill last year, but it died after encountering strong opposition from the House Republican leadership. The bill has been reintroduced, and would offer equal coverage to all the disorders in the manual.
Insurance companies warn that opening the door to all the disorders would drive costs up steeply, making the proposal unacceptable to employers.
"The Senate bill will require coverage of a range of conditions, including caffeine addiction, jet lag, religious problems, occupation problems," said Karen Ignagni, president of the American Association of Health Plans, which represents insurers.
"When members of Congress think about mental health, they think about schizophrenia," she continued. "I don’t think they are aware of the generalities and terms used in the Senate legislation which could increase costs for conditions that are not supported by the scientific research."
The group said the cost of the measure was difficult to calculate, but it released projections and estimates from state experiments with parity that showed cost increases of up to 10 percent.
Advocates for full parity, however, cited a report by the Congressional Budget Office estimating that the Senate bill would raise costs by less than 1 percent. They have also argued that limited parity would shut out many patients with legitimate needs.
"If it only covers schizophrenia and bipolar illness, as important as that is, it would not cover many of the needs that people have as a result of trauma, terrorism and many other mental health problems," said Michael Faenza, president of the National Mental Health Association, the country’s oldest mental health advocacy group.
Fuller Torrey, a psychiatrist and longtime critic of the psychiatric establishment, said parity coverage should be limited to patients with disorders that have a biological basis, not to someone "who is being divorced by their third husband or second wife and is upset."
The American Psychiatric Association said critics were spreading misinformation about the validity of the group’s manual. Jay Cutler, special counsel for the association, said that diagnosis and treatment were separate issues, and that clinicians would offer treatment only to those people whose disorders significantly interfered with their lives.
"There would have to be clinically significant impairment" in order to be eligible for treatment, he said. "If I have a cold, it would be covered, but should it be treated? If you only sneeze once, you are not going to get coverage."
But those dealing with the more serious illnesses said they might be willing to compromise if backed into a corner. Cutler, for example, said, "I believe it’s better to begin the road to parity than never to set foot on it."
Groups like the American Psychological Association and the Bazelon Center for Mental Health Law will resist such a move.
It is unclear how many people would be affected by either proposal. Tens of millions are in such employer-covered plans, and many of those employees and their families would benefit from better mental health coverage. Employees with family members having the most serious disorders would especially benefit, but people with the most serious disorders are less likely to be employed themselves.
Chris Koyanagi, policy director at Bazelon, said 80 percent of people with schizophrenia were unemployed. "The more severe the disorder in adults, the less likely they are to be in this pool," she said.
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