Will health insurance once again pay for long-term,
psychodynamic psychotherapy? On October 3, President Bush signed the financial bailout bill, which is
also the Mental Health Parity and Equity Act. Two days earlier, the prestigious journal JAMA published an
analysis that found extended individual therapy, with a minimum duration of one year or 50 sessions, to be an especially effective treatment for chronic mental illnesses, including personality disorders and mood disorders. In one study in the survey, patients with treatment-refractory depression and
anxiety were seen for a mean of 310 sessions over three-and-a-half years. So: are we there yet?
I have always been a strong proponent of parity. Opponents contend that insurance mandates distort competitive economic incentiives - that mandates lead insurers to drop out of markets, cause employers to cut coverage, and raise prices for everyone. But those arguments never made much sense.
The health insurance industry is nothing like a free market. All aspects of insurance are regulated, and public hospitals, along with private hospitals via required charity care, act in effect as "insurers" of last resort. You can't sell comprehensive health insurance, in any state (or under ERISA), and not cover heart disease. The differential coverage of mental illness is a historical anomaly, based on the time course of the development of evidence that the common mental illnesses are ordinary diseases. Besides, once we know that depression is a risk factor for heart disease, the only question is whether parity will come via lawsuits or legislation; the segregation of mental illness coverage ought to be illegal under existing rules. And the bulk of evidence suggests that mental illness treatment lowers costs or is cost-neutral; the issue of coverage concerns cost-shifting, not overall health care expenditures. (The Congressional Budget Office estimates that the parity act will raise premiums by 0.2%, but such figures never fully account for cost-offsets and omit cost-shifting entirely.) Because of a chain of reasoning along these lines, in the end, insurers favored the parity act, as an orderly route to an inevitable outcome.
The act has it problems. The biggest is that it allows plans to exclude mental health coverage altogether. For reasons of self-interest, most large employers and most large unions will not agree to those cuts, and in the case of some (but by no means all) retirees, classes of benefits are fixed going into the future. According to the New York Times, the Federal government estimates that the law, which goes into effect in 2010, will improve coverage for 113 million people.
To my mind, the real fight is over the long term. It's not certain - and ever less certain in the current economic environment - that non-portable, job-related plans will survive as the standard model for health insurance in this country. The fight over parity is finally a fight over the scope of universal or near-universal coverage when it arrives, in whatever form.
Of course, we don't know what full or equal mental health coverage means. It should be clear that insurers cannot arbitrarily restrict psychotherapy sessions - unless a plan also explicitly restricts visits for diabetes care, chemotherapy administration, angina palliation, and the like. It is yet clearer that insurers will still try to control the duration of mental health treatments. What will happen in practice is hard to predict. Bad insurers deny care first and accept regulatory penalties or lawsuits later. But in theory, the battleground should be research evidence or professional consensus about efficacy. If chronic mental illness is covered, and if long-term psychotherapy is the best modality for a given condition, then insurance should help pay for the treatment.
In part two of this posting, I will look at the evidence: Does the JAMA study demonstrate the need for traditional weekly sessions spread out over years?
