Jewish World Review April 12, 2002 / Rosh Chodesh Iyar, 5762
Drs. Michael A. Glueck & Robert J. Cihak
http://www.NewsAndOpinion.com | Sometime toward the end of the last millennium, we Americans developed a curious notion. Everything that's good should be a right. We forgot that how we manufacture and provide these endless new "rights" can be just as important as the rights themselves.
Several weeks ago, the Medicine Men column dealt with the issue of "parity" for mental health in health-insurance coverage (" Too many beautiful minds to waste") The column reported that "some states have begun to require that mental health treatment be covered in the same way as other medical care." In contrast to that article, which expressed mainly Dr. Glueck's viewpoint, today's column expresses an alternate opinion from Dr. Cihak.
As used here, "parity" is the idea that insurance companies be required to provide coverage for some mental problems to the same degree they provide coverage for physical problems. In other political contexts, "parity" conjures up images of that wasteful world of farm price supports, where production of certain goods is subsidized one year and penalized the next. Yet who, save the scroogiest of Scrooges, could possibly object to keeping family farms together -- or, in the present instance, helping out people with mental illness?
We need to review a few of the problems encountered or created by mandates and subsidies. We'll look at three kinds: historical, personal, and political.
First, there's only a rough medical consensus, and no social or political agreement, on what mental illness is or how it should be defined, much less treated. The census of 1840 was the first to try to count America's crazies. It enumerated just two categories: alcoholism and dementia. The latest edition of the Diagnostic and Statistical Manual put out by the American Psychiatric Association lists over 400 separate ways to go bonkers. More are forthcoming. In a world where, the shrinks assure us, everybody's got some sort of dysfunction, shall they all be covered? For how long? And who decides?
Yes, many of the most severe and debilitating mental illnesses have been shown to be chemically based. I'm willing to believe that some kinds of therapy and treatment do immense good for many such patients, and for others less savagely afflicted, too. But at what point does a passing spell of the blues segue into mental illness, or mere ineptitude, laziness, or cowardice into "dysfunction"? Who is to say? And who is to pay?
Mandating parity also hurts others. Some people lobbying for mental-health parity have family members suffering from mental disorders. Their individual situations may be difficult, even tragic. But in essence they're demanding that the government coerce others into paying for their misfortunes. As a result, those other families will have fewer resources left to deal with their own problems and might not be able to afford their own health insurance.
Even if a relatively benign program to benefit mental-illness sufferers were instituted, it would still be true that almost all government programs have unfortunate consequences in time. Medicare was touted as a way to help older Americans get health care. It has turned into more of an obstacle than a help, as demand spirals out of control and government gradually imposes more and more regulations and restrictions, to the point where some doctors, instead of being paid for their work, are forced to provide services and essentially become slaves to the system.
To paraphrase the comments of a psychiatrist friend: "We psychiatrists have spent years trying to help our patients become independent. Now the government wants us all to become dependent."
So who might object to enforced mental-health parity? Everyone who understands these facts of life. But what's the alternative?
By definition, insurance is the pooling of similar risk. It is not, as politicians like to misinterpret it, prepayment of a specified amount in return for unlimited services. True insurance pools are formed when people pay relatively small amounts against the possibility of an uncommon and unpredictable event in the future. You don't buy boat insurance if you don't own a boat, and you know what you'd say to your nautical neighbor if he demanded that you do so in order to help him out. Why then, for example, if you're older than 60, should you subsidize somebody else's contraceptives or pregnancies or abortions? The "reason" is that all those services are bundled together into packages you, your employer, or your politician buys on what is, pretty much, a take-it-or-leave-it basis.
The solution is not more bundling and packaging, and
certainly not more governmental coercion and regulation.
It's the creation of specialized insurance pools and service-
prepayment plans for those who wish to insure against the
possibility that they might suffer mental
04/09/02: No Time for Litmus Tests: In War We Need a Surgeon General and NIH, CDC, and FDA Directors