Wednesday, August 20, 2008

So What Did We Win?: Legislation and Children's Mental Health

It's all over but the shouting.  The Children's Mental Health Omnibus Bill has passed, albeit in two pieces:  "An Act Relative to Mental Health Parity" and "An Act Relative to Children's Mental Health".  As one would expect, we did not get everything that went out in the original "ask".  It probably makes sense to spend a little time thinking about what we did get, and what work still needs to be done.  I hope that others who better understand how the system actually works will correct my misunderstandings, and that through this process, we can better understand the path that stretches before us.

Today, let's look at Mental Health Parity;  that seems more straightforward.  Mental Health Parity seems a simple concept: illness is illness, and the brain gets sick as frequently as the body.  So, it makes little sense to treat mental illness differently than physical illness.  Since treatment seems to follow payment, and we don't let insurance companies opt out of treating particular "physical illnesses" (i.e. you are insured for all illnesses except diabetes- not allowed), why should we allow them to say that they won't pay for mental illnesses. Why is this complex?

The complexity, it seems, comes from the definition of "illness".  In 2000, Masachusetts passed a law that created Mental Health Parity for nine "biologically-based" illnesses:   Schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, delirium and dementia, and affective disorders (note to self:  all mental health takes place in the brain, which is a biological computer.  Why only those nine disorders?).  There was a way to add to the list, but involved the intervention of the Commissioner of Mental Health AND the Commissioner of Insurance.  Two Commissioners makes it hard to do.  For children, there was one extra clause:  
For non-biologically-based mental, behavioral, or emotional disorders that substantially interfere with or substantially limit functioning and social interactions, where:
  1. The child’s primary care physician, pediatrician, or a licensed mental health professional has made the referral for diagnosis and treatment of the disorder, and has documented the substantial interference or limitation,
  1. The substantial interference or limitation is evidenced by conduct, including, but not limited to (1) an inability to attend school, (2) the need for hospitalization, or (3) a pattern of conduct or behavior that poses a serious danger to self or others.
This language, in practice, led to the widespread exclusion of treatment for children with eating disorders, Asperger's syndrome, conduct disorder, oppositional defiant disorder and anxiety disorder until they became "end-stage" conditions, such as Kenny, of whom I blogged earlier in the year.  So, what did we win?

First, we won a new list:  
(1) schizophrenia; (2) schizoaffective disorder; (3) major depressive disorder; (4) bipolar disorder; (5) paranoia and other psychotic disorders; (6) obsessive-compulsive disorder; (7) panic disorder; (8) delirium and dementia; (9) affective disorders; (10) eating disorders; (11) post traumatic stress disorders; (12) substance abuse disorders; and (13) autism.
This is a victory for children, because of the inclusion of eating disorders and autism on the list.  There is room for improvement:  ADHD, ODD and anxiety disorder, the three most prevalent forms of mental illness in children, are not on the list.  In our original bill, we, like Patrick Kennedy, asked to have the whole DSM-IV added to the list.  We didn't get that.  But this is definitely an improvement.
Second, we won an easier process to add to the list.  Under the new Bill, the Commissioner of Mental Health can expand the list.  I see no language about the Commissioner of Insurance (please correct me, someone, if I have missed something).   Given that the Omnibus bill calls for the formation of a Behavioral Health Council to advise the Commissioner on Children's Behavioral Health issues, this power may prove more useful than having to go back to the legislature every time we change the bill.

What didn't we win?  For kids, I see a few things:  First, language that recognizes that kids don't always fit diagnostic boxes, and that we can do a lot for families BEFORE a diagnosis is finalized.  EI has shown us that, and we need to make that part of the future.  I think that the restrictive "medical necessity" language regarding children is still in play, which means that children will still have to wait for intensive intervention until they are really badly off.  We should think about changing the standard for requiring coverage:  for example, why wait until they are "substantially unable to attend school", when intensive intervention earlier on could prevent that breakdown in a child's life.  And, if we are still working off of a list, anxiety disorder and oppositional defiant disorder should be on it.  So we still have some work to do.

On the other hand, not a bad change.  Not bad at all.  I'll keep working on understanding the longer and more complicated bill in the future.

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