National Alliance on Mental Illness
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Policy-makers: Points of View
In support of true parity: An interview with Edward M. Kennedy
NAMI: Passage of the Domenici-Wellstone Mental Illness Parity Amendment in 1996 was a major accomplishment for NAMI and longtime congressional advocates like you. How can we build on this success in the 105th Congress to further the goal of eliminating discrimination against persons with brain disorders in health insurance?
EMK: Continuing steps to achieve full parity are essential. Five million Americans suffer from serious mental illness every year. Few people do not have a family member, friend, or co-worker who has not been touched by these tragic illnesses. Too often in the past the occurrence of a serious mental illness was a double tragedy for a family: first they bore the pain of seeing a loved one suffer; then, lacking adequate insurance coverage, they found themselves facing financial ruin. The Domenici-Wellstone bill enacted by the last Congress was a matter of simple justice, and we need to build on that bipartisan breakthrough. The parity law prohibits disparities in financial caps, but does not address other serious parity issues such as number of visits or co-pays. Nor does it provide mental health coverage for those who do not already possess some level of coverage. True parity, which I strongly support, means equal access to high-quality, affordable care for those with mental illness.
NAMI: Both you and President Clinton have pledged to push for legislation in 1997 that would expand access to health coverage for uninsured children. Will you be working to ensure that any new program includes equitable coverage for brain disorders in children?
EMK: A high priority for me is to provide health insurance for the ten-and-a-half million American children who have no insurance today. These children have fallen through the cracks of the healthcare system. In the vast majority of cases, their families earn too much to qualify for Medicaid, but they don't get insurance on the job, nor can they afford to purchase it on their own. The problem is growing worse. More and more employers drop coverage for dependents to cut costs. I have introduced legislation to make health insurance coverage accessible and affordable for all children through age 18. Under this plan, federal subsidies will be available to all families with incomes under 300 percent of the poverty line--that's $39,000 a year for a family of three--to purchase health insurance for their children if they do not already receive coverage under an existing public program. Families with incomes under 185 percent of poverty--or $24,000--will receive a full subsidy. Families with incomes between 185 percent and 300 percent of poverty will receive assistance on a sliding scale. The program will be administered by states under federal guidelines. In general, states will contract with private insurance companies to offer coverage. The plan will be financed by raising the federal cigarette tax. The benefit requirements will guarantee that children get the care they need to grow up healthy, and it will include coverage for mental health and brain disorders.
NAMI: Another critical piece of legislation for NAMI families is the reauthorization of the National Institutes of Health (NIH) and the National Institute for Mental Health (NIMH). One of NAMI's major concerns continues to be the focus on the most severe brain disorders such as schizophrenia, major depression, and bipolar disorder (or manic-depressive illness). What can be done through the authorization process to ensure that proper resources are devoted to the most severe illnesses?
EMK: Congress must continue to fund basic medical science and clinical research; and these federal investments must be allocated fairly to all illnesses, including brain disorders. The National Institutes of Health is the premier biomedical research organization in the world. Its success is one of the great achievements of recent decades. Americans live longer and healthier lives as a result of NIH efforts to unlock the mysteries of illness and to identify effective ways to prevent, treat and cure disease.
NAMI: Just a few months ago, NAMI released a report on the state-federal vocational rehabilitation (VR) system that documented the difficulties people with brain disorders face when trying to access services in the current system. Is Congress planning any restructuring of the current program? What initiatives might be undertaken to make the VR system more responsive to the unique needs of people with serious mental illnesses?
EMK: NAMI's report raises very serious concerns. It documents how these rehabilitation services have failed Americans with brain disorders. The system designed to provide services for people with physical disabilities is inadequate for these individuals. The current programs are "time limited," functioning under the assumption that once placed, the individual will need no further assistance. Also, individuals who are the most disabled are not receiving the level of services they need, and available services are not co-ordinated with other entities in the mental healthcare system. Sadly, too many individuals who could be enjoying productive working lives are languishing within a system unresponsive to their needs. Vocational rehabilitation programs are scheduled for reauthorization by Congress this year, and I intend to do all I can to see that these concerns are fully addressed. Persons with brain disorders deserve vocational rehabilitation services appropriate to their needs.
NAMI: People with serious brain disorders view the movement toward managed care, both in the private and the public sector, as a mixed blessing. While managed care can offer increased access to treatment in the community, there is also the concern that for-profit managed care organizations may also have too much of a financial incentive to limit services for people with the most severe illnesses. Do you anticipate Congress taking up legislation to crack down on perceived abuses in the managed care industry, especially with respect to contracts between health plans and providers in the mental health system?
EMK: I'm very concerned about abuses in managed care. In recent years, the provision of services through managed mental healthcare plans has expanded enormously. Today some 142 million Americans receive some form of mental health coverage through managed care. Increasingly, states are choosing to contract with managed care organizations to provide services for their Medicaid-eligible citizens. The quality of services under these contracts is highly variable, and managed care too often leads to a decline in access to mental health services and the quality of these services. We need to strike a better balance between efficiency and quality in the managed care industry. Congress has a role to play. The challenge is to spell out the industry's obligations adequately, while avoiding micromanagement, especially at the level of clinical decision-making. I intend to introduce legislation to set federal standards for quality assurance and consumer protection in all aspects of managed care, including managed mental health care. A recent study funded by the Substance Abuse and Mental Health Services Administration and carried out by researchers at the George Washington University Health Policy Center reported what appear to be some very serious inadequacies in the Medicaid contracts between the states and managed care organizations and between the organizations and the service providers. These findings are a source of major concern, and they make it more likely that Congress will act.
NAMI: This year marks the 34th anniversary of President Kennedy's signing the Community Mental Health Center Act. Since that time we have seen dramatic changes in the publicly funded mental health system--through deinstitutionalization, advances in research on the brain, and most recently, managed care. As a longtime advocate for persons with severe mental illness, what do you see as the next set of issues that families and consumers will have to deal with?
EMK: We must continue to support research into the basic biology and epidemiology of mental illness. We must do more to ensure that the current trend toward managed care does not jeopardize quality. We must fight the stigmatization of mental illness and the prejudice and discrimination against Americans who have brain disorders. Health reform is a high priority for Congress, and our approach to mental illness in all its aspects will be a key part of the debate.