The Clinton administration recently announced two initiatives relating to mental health. One is called “mental health parity” which would require insurers to provide the same annual and lifetime benefits for mental health care as for standard care. The other is an extension of the law prohibiting discrimination against the disabled to cover discrimination against those disabled by mental illness.
Both of these initiatives are highly questionable. They are based on arguments by analogy. First, mental health is like physical health. Therefore, the same insurance practices should apply to both areas. Second, being disabled by mental illness is like being disabled in other ways. Therefore discrimination against either type of disabled person should be prohibited.
Neither of these analogies works.
First, consider the extension of medical insurance rules into the mental health area. The problem is that people who aren't really very sick can use the mental health benefits of most insurance plans. Some years ago, my husband and I sought marriage counseling from a psychologist that our insurance company generously paid for. We weren't really sick. We could have been served just as well, or maybe even better, by a clergyman or a self-help group.
More recently, we adopted a little Romanian boy who has a variety of psychological problems stemming from his years in a minimum-care orphanage. He is really sick. He needs specialized care from very experienced professionals. His therapy is time intensive and requires specific knowledge. For these reasons, his care is also intrinsically expensive.
Unfortunately, the average insurer can't tell the difference between these two cases. The qualifications of helping professionals for both cases might be the same: “Marriage, Family and Child Counselor.” However, to discourage frivolous use, insurers come up with limits on the number of visits they will pay for per year — frequently 20. But we aren't being realistic to think that an incest survivor or an attachment-disordered child can be treated adequately in 20 visits. The insurers are trying to break even by lumping unlike cases together. Requiring “mental health parity” increases every-body's coverage and everybody's costs, but does nothing to overcome the basic problem of distinguishing the frivolous from the truly needy.
One plan at the state level attempts to sort out such problems. A bill recently introduced in the California legislature lists nine serious mental illnesses and requires insurance parity for these specific illnesses. By increasing coverage, this plan offers the relief that families of the seriously mentally ill are looking for.
Even this plan is not without problems, however. We still have to hope that no one will seek a false diagnosis of schizophrenia, for example, in order to qualify for increased coverage. But that's not entirely likely. Our experience with the Americans with Disabilities Act shows that people can become pretty creative when a lot of money is at stake. People (with the help of their attorneys) have had an almost irresistible urge to define themselves as disabled in order to qualify for the protection of the act.
On the other hand, the good thing about the California plan is that it is a plan for California only. If its plan has too many loopholes and attracts unforeseen clients, racking up unforeseen costs, still no other state is penalized. In fact, other states might learn from the experience. The odds are that the 50 states trying different approaches will come up with some workable solutions. The odds of the federal government hitting the nail on the head with the first try are close to zero.
Now consider the second problem of treating mental disability like other disabilities under discrimination law. The problem here is that people who are mentally ill need others to make adjustments for them. Employers should be aware of such conditions in making job assignments. The more disabled the person is, the more it is truly necessary to “discriminate” in this sense. A person with bipolar disorder should not be expected to function well in a high-stress position. An employer who does not assign someone a particular position because the worker has a serious mental illness should not be treated like an employer who will only hire blacks as custodians.
Again, the confusion arises from lumping together very different kinds of people who have sought mental health assistance.
Tipper Gore is passionate about mental health because she herself had the experience of depression after her son had a serious accident. She sought care from the mental health community and she was right to do so. Certainly, she should not face any discrimination from the fact that she sought counseling.
But she was not chronically sick in the way that people with more serious disorders are. Schizophrenics, psychotics — these are people who require long-term care. It is not compassion to prevent employers from acknowledging the limitations flowing from the condition of the mentally ill.
The mentally ill present particular challenges. They demand time-intensive, specialized care, sometimes for a lifetime. They challenge our notions of who we are and what our freedom means. Sometimes, we would prefer not to look too closely at them and the demands they place on us.
At the same time, they deserve better than to be swept into categories we already have in place, categories meant to address different problems. They deserve for us to think through their unique set of needs and capabilities. Our common humanity demands that we see them for who they are, rather than evading them.
Jennifer Roback Morse, a research fellow at the Hoover Institution, welcomes e-mail at firstname.lastname@example.org.