The mental health parity law, enacted in 2008, states that health insurance companies cannot subject their customers to different treatment based on a diagnosis of mental illness or addiction. They cannot impose annual dollar limits or limits to the number of treatments per year as long as the same limits are in place for all other, medical illnesses. This was a long time coming as the brain is an organ of the body just like any other, is it not? Why should someone who has an illness located in his brain be treated differently than someone with an illness in his pancreas or lung? There is no good reason for this, and so came the mental health parity act to the rescue.
There is just one catch. The new, beloved, parity law still allows discrimination against people with mental illness when it comes to access to long-term care. This is the mental health system's dirty little secret and it affects the people who need treatment the most. Our mental health system delivers care in reverse proportion to the severity of the illness; it allows for the discrimination against people who are the most in need of care and least financially able to pay for it, the people on Medicaid. The health care reform bill, currently under heated negotiation, will do nothing to help them either.
Neither the mental health parity law nor the health care reform bill removes
the Medicaid Institutes for Mental Diseases (IMD) Exclusion which excludes all psychiatric hospitals from Medicaid subsidies. The
consequences for this discriminatory provision, in place since Medicaid was
enacted in the 1960's, are that nursing homes will not accept people disabled
by mental illness for fear they will become classified as an IMD. This happens
when the percentage of the nursing home's patients with mental illness hits the 51% mark. When that happens, all of their patients loose their Medicaid eligibility, no matter what their patients' individual diagnosis happens to be.
Secondly, the state hospitals no longer keep patients on a
long-term basis because state hospitals are already classified
as IMDs.Therefore, the people who need treatment the most have no place
to go. Following their logic, if the federal government won't help pay for a mentally ill person's long-term care, they don't really need it.
In my opinion, the state hospitals could keep the patients that need long-term care, if they really wanted to. They say they can't afford to pay for it, so they push their patients out into the community where the local police, hospitals, social services, and other community agencies' meager budgets are in no better shape, even with the Medicaid subsidies which are denied to the state by this discriminatory provision. Worse, the former patients are responsible for dealing with a maze of rules and regulations that some cannot handle. They are expected to manage their own treatment plan when many of them don't even recognize they are sick.
My brother, Paul, was committed to the state hospital system in 1977, after the IMD Exclusion was enacted. He was released over 20 years later, a year or so after my mother died; a decision I find suspect. I believe they took advantage of the confusion my siblings and I were under, in the beginning, over Paul's state of emancipation. After all, he was only 17 when he became a ward of the state. What made things change? They released him before we knew what hit us and led us to believe he would still be "taken care of". He wasn't any better then than he was when my mother was alive. It was all about money.
Some people mistake my call for the repeal of the IMD Exclusion as a call to re-hospitalize, or "lock up" all people with a mental illness. They don't realize how sick Paul was. All I ask is that each person be evaluated independently; that one set of criteria be used to discern the need for long-term care for all people, no matter what the illness is called or where in the body the illness is located. Medicaid eligibility should be determined by income level, not the type of hospital in which a person is treated.
That is also not to say I want to go back to "warehousing" people in large, cavernous state hospitals either. I think those days are over. Nursing home-like or group home facilities are more in line with what I envision. All I ask is that all people who need long-term care have access to it, and that we provide that care in the most humane and less restrictive way possible. I also know this is not as simple as it seems, believe me.
We deal with this situation today, with people who have Alzheimer's. Would we ask a person with a severe form of Alzheimer's to live on his own, or cook and clean for himself? No, I don't think so, yet that is what was asked of Paul in the beginning. He went without food for almost a month, in one instance, as a result. All because he had to be the one to fill out the forms to renew his food stamps forms. He was the one that needed to ask for help, when he was living in an "assisted" living apartment complex. He had to learn to live on his own, the case worker said to us afterwards.
Like other illnesses, mental illnesses have their severities. Some people with even the severest forms of mental illness such as schizophrenia and bipolar disorder can live independent and productive lives; I wish that were Paul's case. But Paul was not alone. We see people like Paul on our streets, they crowd our prisons, and they languish in adult homes.
After Paul was released from the state hospital, he spent 8 of the last 10 years of his life cycling in and out of psychotic events; he went from the local ER room and psych ward, and sometimes to the state hospital, only to be released again where the cycle would continue. At first, Paul lived in an "assisted" living apartment, but when that became too difficult he was placed in an Adult Home. He spent the last year of his life in a nursing home due to chronic lung disease.
Ironically, I am thankful for that last year. Paul's mental state improved
to the point where we could actually have a somewhat normal life with him, like
anyone else with a family member in a nursing home, that is. His delusions
had logic of their own that we learned to follow; we were able to speak his
language, in a sense. We could hold normal conversations about the weather,
what to eat, what movie to watch, football, etc. Invariably, some delusion
would sneak its way in, and that was OK.
Paul had actually been this way, on and off, after he was placed on a new medication a couple of years prior to his admittance to the nursing home, but it was inconsistent due to other factors involved with living in an adult home. That Paul had to get sick with chronic lung disease, then lung cancer, before he was deemed worthy for the level of care he should have received in the first place is bad enough; that it gave my family something of our brother back only to watch him die from lung cancer is a kick in the gut no one should have to go through.
The IMD Exclusion acts as a barrier to access to long-term care for the poor and the middle class, who have a mental illness. It is discriminatory and should be repealed. It is that simple.
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