Americans were startled in late 1999 when Surgeon General David Satcher presented a
report claiming that more than 50 million Americans - nearly one-fifth of our population -
suffer from some kind of mental illness each year. Like the famed 1964 surgeon general's
report on the perils of smoking, this first-ever report on mental health focussed debate
on one of the great unresolved areas of health care reform.
The Satcher report's most sobering finding was that nearly half of those afflicted with
a mental disorder fail to get treatment, though adequate and affordable therapies may be
readily available. The barriers are often social stigma and cost.
By laying the mental health issue squarely on the policy agenda, Satcher directly
engaged one of the central issues of the current debate: mental health parity.
Should insurers be required to treat mental illness just like any other disease, with
ample coverages and reasonable rates? Satcher, backed by Health and Human Services
Secretary Donna Shalala, says yes. "There's no scientific reason to differentiate
between mental health and other kinds of health. Mental illnesses are physical
illnesses."
Lines of disagreement on parity, however, are deeply drawn. Insurers worry that putting
mental health coverage on a par with physical health will rapidly accelerate claims.
Employers in turn fear a sudden leap in their insurance premiums - a very high cost for
what they consider a minor need. Parity proponents argue the opposite: that giving mental
health parity with other health issues will meet a great need while only marginally
raising costs.
A host of other controversies surround mental health coverage, including:
Confidentiality: Questions range from whether psychiatric notes are
privileged to how much information should be shared with families who provide care.
Restrictive pharmaceutical formularies: Existing lists of approved and
insurance-covered drugs tend to be outdated and don't include new medicines that show
great promise but are also expensive.
Criminalization: Too many disturbed people are in jail rather than in
treatment, where they belong.
Like so many other areas, mental health care is a field where our skills in finding
solutions - through advanced drug therapies, for instance - have far outrun our capacity
to deliver. Secretary Shalala says that mental illness is the second-leading cause of
disability and premature death in the United States and that we face "a public health
crisis."
Clearly, while continuing research is needed into what works best for patients, mental
health care must be integrated into our overall attempts at reform. The parity issue, for
example, should be seen as part of the larger question of universal coverage. How hollow
would the promise of coverage for everyone be if it excluded, say, heart disease? While we
can't cover everything - and costs must be considered - we should acknowledge that many
mental health care services are in fact cost-effective, especially compared to the price
(in crime and social services) of leaving mental illness untreated.
Our challenge in mental health as in all other fields is to level the playing field,
make choice and access available to everyone, and to empower Americans to remove
themselves from the roster of 50 million who need help every year. We must also overcome
lingering prejudices against psychological treatment by taking charge of our own mental
health the same way we take charge of a cold or seek treatment for the flu. Emotional
health is an important contributor to general health and longevity, and the sooner we can
develop collaborative strategies among patients, providers and payers for identifying and
treating such disturbances, the better off we will be as a nation.
