Paying for mental health care

After more than a decade of lobbying, a new federal law will transform the way large insurance plans pay for mental health care and addiction treatment. Advocates are celebrating the win, but say decades of discrimination in mental health care financing has set up an unequal system. From WHYY’s Behavioral Health Desk, Taunya English reports on the struggle to pay for care when a family member is diagnosed with a debilitating mental illness.

After more than a decade of lobbying, a new federal law will transform the way large insurance plans pay for mental health care and addiction treatment. Advocates are celebrating the win, but say decades of discrimination in mental health care financing has set up an unequal system. From WHYY’s Behavioral Health Desk, Taunya English reports on the struggle to pay for care when a family member is diagnosed with a debilitating mental illness.

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Transcript:

Doctors recently told Dave and Neen Davis their son has schizophrenia. Ben is 27 and developmentally disabled. The Davises helped Ben create a somewhat independent life away from their home in Harleysville, Montgomery County. But in recent years Ben started behaving in baffling ways.

Dave: He became just increasingly psychotic; he was seeing blood on the walls. He wouldn’t sit on a toilet because he thought lightening was coming up out of it. He basically stopped showering, wouldn’t go near the water, he thought the water was contaminated.

Getting to a schizophrenia diagnosis has taken months. In the meantime, Ben spent time in two different psychiatric hospitals. Neen says the bills are piling up.

Neen: Just can’t imagine, like Dave said, it’s six figures, and we don’t know if the first number is a one.

Because Ben is developmentally disabled, he’s covered by the Davises’ insurance plan, but his mental health benefits have run out for this year. Still, he needs to be in a secure facility with 24-hour observation. Like many health plans, the Davises’ mental illness coverage is more limited than the health insurance available for physical ailments. Debbie Plotnick says it’s an unfair distinction.

Plotnick: So whereas you would have 20 percent copays on a visit to a diabetes specialist. If you were to see a mental health specialist you might have a 50 percent copay.

Plotnick is Director of Advocacy for the Mental Health Association of Southeastern Pennsylvania.

Plotnick: And it would also limit the number of times you could visit that practitioner. So it is really a very different story.

Plotnick says that difference pushes many families to the financial edge as they try to pay for care out-of-pocket. The new Mental Health and Addiction Equity Act is designed to help.

The law won’t require insurance plans to add mental health care to the mix, but if they already pay for that treatment, benefit levels must equal the coverage offered for physical health care. Only employer-based health plans with more than 50 workers have to make the change. For most companies the law won’t go effect until 2010.

For now patients are left with the system as it is. Advocates say there aren’t enough affordable options.

Some patients abandon treatment when it gets too expensive. Others turn to government programs like the ones Joan Erney oversees. She leads Pennsylvania’s Office of Mental Health and Substance Abuse.

Erney: What has been incredibly challenging is the fact that the private insurers and the private industry has not carried their fair share. And so individuals default to the public sector, they default to our system really because of a lack of commitment and understanding and support for people with mental illness.

Plotnick says government programs provide a safety net, but many families are wary.

Plotnick: If you are moving into getting your child mental health coverage in the public system, then you don’t have as wide a range of practitioners, and you may have some longer waits and some other restrictions that go with it. But you are able to get services for your kids.

The Davises wanted a doctor with expertise in both mental illness and developmental disability. But that means paying more for an out-of-network therapist. When Ben’s benefits ran out, the Davises could have used Medicaid to have him treated in-state, but the care they trusted most was in Maryland.

Neen: Tell me what do families do who aren’t in a position to handle 90-some odd days of private pay in a hospital?

Dave: The answer to that is that they don’t go to Johns Hopkins, they go to a place where Medicaid will pay.

Dave is a partner in a law firm, but says he doesn’t have the money to just write a check when the medical bills arrive. The Davises may need to sell their home, and Dave says he realizes that many families aren’t able to take on the financial burden he and Neen have decided to shoulder.

Dave: I don’t think that it’s ever going to be a situation, at least in this country, where everyone gets the same level of service. I’m not opposed to parity, I think it’s wonderful, the point that I was just making is that other people are going to pay for it. It’s great that they are going to do it, but all that means is that premiums are going to go up anyway. People that don’t have any need for mental illness benefits are going to end up footing the bill.

Of course, staunch supporters of the parity law say that kind of cost sharing already happens. In traditional health plans, risk is spread out. Not everyone gets cancer, not everyone gets diabetes, but everyone pays.

Parity advocates say they shouldn’t suffer financially because the disease that runs in their family happens to be bipolar disorder or depression.

Neen says right now it’s clear that comprehensive mental health treatment is a privilege. Dave Davis is looking for more than a change to the insurance laws.

Dave: It’s a culture change that’s needed. Put aside the legislative issue because legislation only happens because certain interest groups force legislation to occur. When the larger public itself becomes aware then I think we will start to see the stuff that we really need.