Although Americans have long kept depression and other psychological disorders as dirty secrets, a growing popular movement hopes that politicians, insurance companies, and ordinary citizens will soon view mental illness as they would any other health affliction, such as a toothache, that could qualify an individual for insurance coverage.
Analysts say the work of activists such as Tipper Gore and mental health advocacy groups, along with a generation of baby boomers less hesitant to talk about issues formerly considered too personal, has led to the de-stigmatization of psychological illness.
The result has been a popular mental health movement that, among other things, has politicized mental health care coverage.
"Formerly, mental health was pushed off into a different realm which people did not want to talk about. Until recently, mental illness was not considered a legitimate health issue," said Denise Anthony, Adjunct Professor of Community and Family Medicine.
Anthony said part of the new attention on mental illness is commercial in origin. The expansion of the pharmaceutical industry into the area of mental health has pushed the issue into the public spotlight, she said.
"People want prescriptions like Paxil and Prozac covered by insurance, and the companies want them covered too, so people will buy more of them," she said.
Heightened awareness has politicized mental health.
"One of the top healthcare issues during the 2000 election campaign was the establishment of an outpatient prescription-drug benefit in the Medicare program," said Laurie Flynn, executive director of the National Alliance for the Mentally Ill.
NAMI, "a grassroots organization of individuals with brain disorders and their family members," according to the official website, works through research, community outreach and education projects, and lobbies at the local, national, and state levels "to eradicate brain disorders and improve the quality of life of persons of all ages who are affected by them."
Responding to such pressure, Democratic presidential nominee and then Vice President Al Gore called early in his campaign for legislation that would require health insurance companies to provide children with mental health coverage comparable to that given for physical ailments.
Additionally, as part of a larger package of mental health measures, Gore proposed the creation of a $3,000 tax credit for families to pay for health care services such as stays in mental institutions.
Prior to the campaign, the wife of the vice president, Tipper Gore, had already worked to bring the issue of mental illness onto the public agenda. In 1999 she wrote an editorial in USA Today disclosing that in her 40s she had received treatment and medication for what she called "situational depression."
In the editorial, she specifically called for reforms in health care that would provide counseling at affordable prices and not overlook "how our minds affect our bodies."
During the presidential campaign, leading mental health organizations such as the NAMI and the American Psychological Association applauded the proposals of the Gore camp as a step toward what the movement for equal rights for the mentally ill calls "parity," coverage for mental health comparable to insurance benefits for physical maladies.
However, as the campaign progressed, said Flynn, the issue of health care insurance "was most commonly framed as 'coverage of prescription drug benefits for seniors.'" According to Flynn, few candidates for federal office discussed the issue "in terms of providing such coverage for the 1.3 million non-elderly people with disabilities who are eligible for Medicare by virtue of having been on Social Security Disability Insurance for a minimum of two years."
Nonetheless, Flynn said that "efforts are underway in Congress" to achieve "full parity." She called the 1996 Domenici-Wellstone Mental Health Parity Act a "first step" toward doing so, but said, "compromises that were necessary to pass this legislation meant that many important measures for truly equal coverage had to be surrendered."
For example, she said, "the law does not apply to companies of fewer than 50 employees, and no company has to meet this standard if they opt out of offering mental health coverage altogether."
"It is still perfectly legal to charge onerous co-pays for all services for mental illnesses and to restrict the number of hospital days and outpatient visits without regard to the patient's condition," she said.
However, she praised a new Mental Health Equitable Treatment Act introduced last March by Senators Domenici and Wellstone that proposes parity coverage to all insured Americans. The plan is similar to that in the Federal Employees Health Benefit Plan and would lower small business exemption to firms of 25 or fewer workers. The bill, if passed, would expand parity coverage to an additional 15 million people, Flynn said.
But Anthony said that once on the legislative agenda, parity coverage will face its largest obstacle in determining the institutional structure and implementation of any proposed plan.
"The people who would benefit from mental health coverage, such as the homeless population, usually do not go to mental health professionals, and would have a hard time getting into the system," she said. "And the regular health care providers at the bottom of the system usually do not have the training necessary to refer a patient with a mental health issue," she said.
Dartmouth Professor of Anthropology Hoyt Alverson, who has extensively studied the mental health care system in Connecticut, brought an anthropological perspective to the issue, warning against responses to mental health coverage that would not take account of each patient's individuality.
"Mental health care must be tailored to each individual and his or her cultural background," Alverson said. "When designing any type of program, we cannot treat everybody alike."
He criticized previous attempts at public mental health coverage, with potential patient's facing great hurdles to be characterized as mentally ill.
"Purchasing power directly determines the quality of care that an individual will get. The best care is for those who are financially capable. As in most things, you get what you can pay for in mental health care," he said.
