August 6, 1999

As Senate Democrats regrouped after losing their battle to pass comprehensive patient protection legislation last month, Senator Edward M. Kennedy assured a group of advocates for the homeless meeting in Washington, D.C., that the Democrats had lost a battle but would win the war.

Kennedy (D-Mass.) made his remarks on July 16 in a speech to the National Alliance to End Homelessness, only hours before his nephew, John F. Kennedy Jr., died in a plane crash en route to Martha's Vineyard. In his speech, Kennedy interwove mental health issues and the need for federal protection of patients subjected to managed care.

The "problem of homelessness in our society stems in large part from our failure to provide adequately for the needs of persons with serious mental illness," said Kennedy. But a convergence of events, including growing understanding of the biological basis of mental disorders and greater sophistication in public attitudes, has provided "a rare opportunity in Congress and across the country to achieve major gains" in providing better care and access to care for those with psychiatric disorders, he added.

The Senate debate over managed care reform and the Patients' Bill of Rights is an important aspect of improving care for the mentally ill, said Kennedy. The Democrats' version of that bill, which was defeated in the Senate, would have protected patients and returned medical decision making to physicians and patients, said Kennedy. But the Republican majority's "Bill of Wrongs" supports "the excessive profits of HMOs and leaves patients out in the cold," he asserted.

APA President Allan Tasman, M.D., commended Kennedy's positions. "He clearly supports an end to unwarranted discrimination against those with psychiatric illnesses, and we will do all we can to ensure his message gets out to the public," Tasman told Psychiatric News. "It is only stigmatization that allows continued deprivation of care for psychiatric illness. Our diagnoses are accurate, our treatments are effective, and it is a national disgrace that people with mental illness can't get the care they need."

Since there are "good data that show the cost of untreated psychiatric illness is over $150 billion a year, it is unfathomable to me why anyone would not agree with Senator Kennedy, especially those who are concerned about the costs of untreated illness to business and society," Tasman said.

The Democrats' bill would have guaranteed access to appropriate specialists, including psychologists and psychiatrists, whenever a patient required that care, said Kennedy. It also would have ensured continuity of care if an employee's physician were dropped by the patient's health plan or if the employer changed plans.

Primary care physicians see many patients with a wide range of psychiatric problems and are often able to help. "Too often, however, primary care physicians do not recognize the mental health problems of their patients," said Kennedy. HMOs have been putting pressure on primary care physicians to "take care of the mental health problems of their patients without referring them to specialists," he added. "We have to do more."

Another provision of particular importance to psychiatry would have given patients access to necessary medications even if those medications were not on a health plan's formulary. For some psychiatric patients, new medications are "genuine medical miracles," said Kennedy, giving people "opportunities to resume lives, relationships, and work that have all been devastated by these cruel illnesses." But managed care plans or pharmacy benefit managers have limited access to new medications because they are more expensive than drugs that have been around long enough to be available generically.

This is both bad medicine and bad economics, Kennedy said. Depriving patients of needed medications or other necessary care leads to "increased hospitalizations and other unnecessary medical services, and increased social costs from lost productivity," Kennedy asserted. "We need to guarantee that no patient with mental illness is subjected to this kind of abuse."

Mentally ill persons in prisons and jails also need protection, said Kennedy, pointing to a Department of Justice report released earlier that week that found far more mentally ill persons in jails and prisons than in psychiatric facilities. Most of those people receive "little or no mental health treatment," he noted.

Despite the Democrats' setback on the Patients' Bill of Rights, there has been progress on mental health, Kennedy observed. The Clinton administration's budget for the new fiscal year contains a 24 percent increase in the federal mental health block grant to the states, the "first major increase in many years for federal funding for core services for community mental health programs," Kennedy noted.

There has been meaningful progress on mental health parity, although certain loopholes need to be closed, he observed. The 1996 Mental Health Parity Act guaranteed that lifetime and annual dollar limits in insurance coverage for mental health care must be equal to benefits for physical illness. The spirit of that law, however, has been violated by employers and health plans imposing restrictive limits on treatment and setting copayments for mental health services higher than those for other medical services, he added.

"It makes no sense to restrict effective treatments for people who can genuinely benefit from them," said Kennedy. "Full parity is essential for mental health care and care for physical conditions" and would improve health care, lower overall costs, and result in only a 2 percent to 3 percent increase in insurance premiums, he contended. Yet "for-profit insurance companies reject greater parity because they know that some of the savings will not go into their pockets or flow to their stockholders."

Surveys have shown that the general public supports access to mental health services, and Congress is "finally catching up with the people," Kennedy said. "Mental illness does not respect party affiliation or race or age. It is an equal opportunity destroyer, but it doesn't have to destroy at all." It is "long past time" to enact full parity into law.