Richard Frank, Ph.D., is Professor of Health Economics at Harvard Medical School where he studies the economics and financing of mental health care.
Can you give us an overview of the mental health care system — how do people currently pay for mental health treatment?
People pay for mental health treatment with standard private insurance or with Medicaid or Medicare if they rely primarily on the public mental health system. People who are on supplemental security income or disability insurance very often rely on Medicaid to pay for a good part of their mental health services.
One aspect that is important to understand about the mental health care system is the availability of clinicians, because even if you have coverage, you may still have a lot of difficulty finding clinicians. The supply of mental health providers or clinicians is very uneven in two ways. First, it really varies geographically. If you're in a in a larger city and you're an adult, generally you have a reasonably good chance of finding a psychiatrist — and finding a psychiatrist who would even specialize in a particular problem that you have. As you move down in age, for example to children and adolescents, there's a shortage of clinicians almost everywhere. Child psychiatrists are difficult to come by and they command top dollar. Therefore very often, they don't feel that they need to participate in insurance networks. This can make securing the services of child psychiatrists very difficult everywhere, and especially tough in places that don't have a lot of professionals to begin with.
On the Medicaid side, fees are very low to outpatient psychiatrists. The consequence is that that a low percentage of psychiatrists, about 30 percent, participate in Medicaid, the lowest of any medical specialty.
What are the issues mental health parity addresses?
The main effect of parity is to offer anybody who has health insurance much better financial protection if they have a mental health problem. Historically most health insurance policies cap coverage after 30 in hospital days and 20 outpatient visits. The idea of insurance is that it is supposed to protect you when you are very ill. But mental health coverage historically has not done that. It had pretty decent up-front coverage for routine doctor visits for example, but if you got really sick, you were on your own.
Parity eliminates the caps on both outpatient and inpatient care, which means that the people who have the greatest needs are going to get the lion's share of new coverage. For example, right now if you're hospitalized for bipolar disorder, you'll run up a bill easily of 12 to 15 thousand dollars in a year. With mental healthy parity, you will have a lot more of that hospitalization cost covered by insurance than you used to. Parity will make the largest difference to people who are the sickest because it restores what insurance is supposed to really do for people with mental disorders.
What will mental health parity NOT fix?
Mental health parity does not address people who do not have insurance. The mentally ill are disproportionately represented among the uninsured in this country. So, if we expand insurance to those who are uninsured, it will greatly benefit people with mental health problems.
Parity does not apply to companies with less than 50 employees. Also, if a company opts out of mental health coverage they are not bound by parity. We hope this will not be the case because there will only be a minor increase for mental health insurance, a four tenth toone percent increase on insurance premiums is projected.
What do we need to do to make mental health coverage better?
Patients and families have to be not only advocates with the clinician, but also advocates with the financial and the delivery systems (e.g., their insurance companies). Generally, these insurers will not turn down people who are persistent. They may get a somewhat different level of care than they were seeking, but they usually walk away with something that's reasonable.