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DJ Jaffe


Health Care Reform Keeps Mentally Ill Uninsured

Posted: 09/24/09 10:54 AM ET

In answer to a question in Portsmouth, New Hampshire, President Obama publicly unequivocally asserted his desire to include treatment for mental illness as part of healthcare reform. And he has mobilized public opinion against the discriminatory practices of private insurers.  But when it comes to discrimination against the mentally ill, the federal government’s own program puts private insurers to shame. And Obama has yet to support the one bill, H.R. 619, that could fix it.

 Hello, Mr. President,…(M)y question is if every American who needed it has access to good mental health care, what do you think the impact would be on our society?

A: THE PRESIDENT: Well, (applause), mental health has always been undervalued in the health insurance market. And what we now know is, is that somebody who has severe depression has a more debilitating and dangerous illness than somebody who's got a broken leg. But a broken leg, nobody argues that's covered. Severe depression, unfortunately, oftentimes isn't even under existing insurance policies.

So I think -- I've been a strong believer in mental health parity, recognizing that those are serious illnesses. (Applause.) And I would like to see a mental health component as part of a package that people are covered under, under our plan. Okay? (Applause.)

I wish it were “Okay”.  Private insurers have largely ended discrimination against the mentally ill due to the passage of the Mental Health Parity Act of 2007. It forbids large group health plans from imposing treatment or financial limitations on mental health benefits that are different from those applied to medical or surgical services. That’s parity.

But for individuals with serious and persistent mental illnesses like schizophrenia, employer based insurance is largely irrelevant because employment is often impossible due to the severity of their illness.  

For the severely mentally ill, unable to get employment--and the insurance that comes with it; or afford private insurance that would discriminate against them anyway, Medicaid remains their only safety net. And it’s a shameful failure.

Medicaid, with some technical exceptions, refuses to cover long-term treatment for the mentally ill ages 18 to 64. If you have a disease or illness in any organ other than the brain, and need long-term care, Medicaid pays. But if the illness is in your brain, Medicaid does not. It’s an obscure provision called the “Institutes for Mental Disease (IMD) Exclusion.”

This is government-sanctioned discrimination against the mentally ill. The effects of refusing to reimburse for long term care have been horrendous and Obama should eliminate the IMD Exclusion now.

According to  “The Shortage of Hospital Beds for Mentally Ill Persons,” in 1955 (ten years before Medicaid) there were 340 public psychiatric beds available per 100,000 U.S. citizens. By 2005, the number plummeted to a staggering 17 beds per 100,000 persons. Some of that is due to improved treatments, but much of it is due to states kicking patients out of long-term care—where they were Medicaid ineligible—and forcing them into communities, where states could get federal reimbursement for half the cost of their care. (Disclosure: I am on the board of Directors of the Treatment Advocacy Center, which underwrote the report, and I assisted Dr. E. Fuller Torrey, the report’s author and the world's leading voice on mental illness research and reform.)

Where did the mentally ill who were kicked out of hospitals go? Today, over 150,000 live on the streets, 231,000 individuals with severe psychiatric disorders live in jail or prison.  5,000 take their own lives every year.  Think of the money that could be saved if they were given treatment rather than the boot.

To write this wrong, and force the federal government to do what they forced private insurers to do--cover the mentally ill--Congresswoman Eddie Johnson and Representative Raj Grijalva introduced H.R. 619, which would eliminate the IMD exclusion and thereby let the government provide long-term care for those with mental illness the same way they provide long-term care for those with other illnesses. Elimination is supported by the National Association of State Mental Health Program Directors, the National Alliance for the Mentally Ill, and almost all who know the issue.

The largest and neediest group of uninsured Americans could very well be those with mental illness. If President Obama really believes in equal health care for all, he should eliminate the IMD exclusion in Medicaid law now by incorporating HR 619 in health care reform. That’s reform I can believe in.


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