More news on the Affordable Care Act (ACA) in the New York Times today. I certainly want to applaud the New York Times for including another article that is fairly positive in terms of content regarding psychiatry and mental illness. On the other hand it is probably not a realistic appraisal of the impact the ACA will have on increasing the quality and availability of mental health services in the United States.
As I posted a couple of days ago the predominant business paradigm in healthcare is the main obstacle to reform, not the laws regulating healthcare or the payment mechanism. As long as the health care system is run by people who have no expertise and are making essentially business decisions we can expect the ongoing triple whammy of more health care inflation, poorer healthcare quality, and a lack of innovation.
This opinion piece is interesting because it includes a comment about what was supposed to be the great leveler of the healthcare landscape - the Mental Health Parity and Addiction Equity Act of 2008. Similar opinion pieces were written about this law as soon as it came out in 2008. It was a cause for celebration among psychiatrists and advocacy groups. And then slowly over time it became clear that reality did not match the enthusiasm, even by a long shot.
The same process is occurring as I write this about the ACA. Through a process of being favored by politicians and regulation, managed care companies have always been able to use purely subjective guidelines often under the rubric of "medical necessity" to deny care to people with mental illness or addictions. There is absolutely no reason to expect that will not continue to happen.
Let me be clear about the types of problems I am referring to. I am referring to people with significant disability due to major mood disorders, psychotic disorders, and addictions who have life-threatening problems and no real access to solutions other than spending a few days in a hospital ward that is poorly equipped to help them and the hope that they can make it to a 10 or 15 minute equally meaningless outpatient appointment anywhere from one to four weeks down the road. These people frequently have associated medical problems and no resources like a stable income or housing.
The proponents of the ACA will tell you that these people will now be seen in integrated outpatient primary care clinics and the quality of their care will improve. The logical question is why have the resources to help them been denied for the past 20 years and what is the likelihood that dynamic will change with an additional 15 to 20 million people in the system?
Psychiatric illness on a par with all other medical disorders? I don't think so. Not as long as a faceless managed care bureaucrat with no accountability can throw you out on the street, deny a medication that you need for an "equivalent" medication, or tell you that the treatment for your problem involves an endless series of "medication checks" with a "prescriber".
George Dawson, MD, DFAPA
Richard Friedman. Good News for Mental Illness in Health Care Law. New York Times July 9, 2012.