Details of plans to overhaul the U.S. health care system released by late
June address some—though not all—of the issues critical to
psychiatrists and people with mental illness.
Congress began considering the three leading legislative proposals in June,
including plans by the Senate Finance and Health, Education, Labor, and
Pensions committees, as well as a unified House Democratic proposal. The
varying scopes of the plans mean that they will have to be reconciled before
Congress can clear legislation for President Obama's consideration. Obama said
he hopes to sign a bill by October.
The bill that has progressed most quickly is sponsored by Sen. Edward
Kennedy (D-Mass.), a longtime advocate of national health care reform and
better access to treatment. It would require all Americans to get medical
insurance, establish complex new insurance exchanges to facilitate
near-universal coverage, and dramatically increase regulatory oversight of the
insurance industry. Some drafts of the legislation include a government-run
insurance option and a mandate for businesses to insure employees—both
measures that are bitterly opposed by Republicans and some conservative
A second Senate bill hoped to attract bipartisan support in the Finance
Committee also would require that individuals have health care coverage and
would offer tax credits to help them afford it. It also would establish"
insurance exchanges" or marketplaces for people to buy various
levels of coverage.
The plan taking shape in the House has been carefully negotiated by the
chairs of the three committees with jurisdiction over health reform. It would
require all Americans to have insurance and all employers to provide coverage
or pay a penalty. The bill emphasizes preventive care but does not detail how
those costs would be covered. The House plan also would bar insurance
companies from denying coverage or charging higher premiums to people with
Among the most controversial aspects of the House bill is the option for
individuals to buy insurance through the federal government, which is the
so-called public option. Republicans have opposed any public option over
concerns it would undermine private insurers and lead to the creation of a
single-payer health care system, charges Obama and House Democrats reject.
Cost estimates by the nonpartisan Congressional Budget Office sapped some
of the momentum from the Senate bills, which are more expensive and provide
less coverage than some supporters hoped. The Kennedy bill would cost $647
billion in the first 10 years and would buy coverage for 20 million of
America's 47 million uninsured. The Senate Finance Committee's bill would
cover more than two-thirds of the uninsured but cost $1.6 trillion over 10
Supporters of the House bill expect it to cover 95 percent of the
uninsured, but its cost estimates were not completed by late June.
Mental health advocates said they have been repeatedly assured by
congressional supporters that the passage of the federal insurance parity law
(PL 110-343) in October 2008 created the assumption that coverage for
psychiatric conditions would be included in any health care overhaul. But
emerging legislative plans have added some uncertainty to that assumption.
These advocates have not seen evidence that reform proponents intend to
undermine parity; however, it remains unclear how insurance exchanges that
would be created by some of the proposals would incorporate parity. Advocates
want clarification of whether individuals who move to a government exchange
from employer-provided insurance would still have access to insurance that
offers parity for mental illness. Potentially complicating factors are that
the federal parity law applies only to employers with more than 50 employees
and doesn't apply to the individual insurance market.
"We're trying to figure out how parity would work with all of [these
proposals] because it is complicated," said Matt Sturm, an associate
director of APA's Department of Government Relations.
Numerous questions also surround the public insurance plan that may be
created under health care reform. The Kennedy bill, for instance, would
require physicians who voluntarily treat Medicare patients also to participate
in the new public plan. Physician reimbursement under the public option would
be at the standard Medicare rate plus 10 percent for all services. The
mandatory participation provision of the Kennedy bill has been opposed by the
AMA, however, and APA is waiting to receive input from more of its members
before taking a position.
The House bill's provisions "to ensure that mental health and
substance use services are available to all individuals included in the new
program to cover the uninsured is absolutely critical," said David
Shern, Ph.D., president and CEO of Mental Health America, in testimony before
a House panel in June.
Mental health advocates also have sought to include mental illness under
the various plans' definitions of chronic illnesses that insurers cannot
refuse to cover as preexisting conditions (see
MH Care Called Integral to Health
System Reform). The Finance
Committee plan is the only proposal to explicitly include mental illness as a
One clearly positive step for many people with mental illness is the
Kennedy plan's requirement that insurers offer coverage to beneficiaries'
children up to age 27, instead of the common cut-off of 22 or the end of
The need for strong mental health care for young people was highlighted by
Shern, who cited research showing that half of people with a psychiatric
diagnosis become ill by age 14 but do not receive treatment until age 24 on
"This 10-year delay in treatment and early age of onset interfere
with a young person's ability to succeed in school and gain employment, thus
increasing the likelihood of developing a costly disability," he
Psychiatrists also may be affected by quality reporting requirements. Some
proposals have included requirements for physicians to participate in the
Physician Quality Reporting Initiative (PQRI) or face penalties beginning in
2012. Physician advocates have urged a delay in PQRI penalties to avoid
consequences such as physicians, who are already in short supply in general
medicine and some specialties, retiring to avoid additional paperwork