Mental Health Reform Movement Loses Steam

DALLAS - On a spring day last year, President Bush blew into Albuquerque on the winds of change.

His mission: to help propel the movement to reform mental health care. The president was clear and emphatic.

"We are determined to confront the hidden suffering of Americans with mental illness," he told a gathering at the University of New Mexico. "These illnesses affect individuals, they affect families, and they affect our country.

"Remarkable treatments exist," he said. "Yet too many people remain untreated."

That day, the president announced his New Freedom Commission on Mental Health, charged with evaluating the nation's system of psychiatric care. And he pledged support for equalizing insurance coverage between traditionally physical illnesses and severe mental ones. Americans with mental illness, he said, "deserve a health care system that treats their illness with the same urgency as a physical illness."

More than a year later, as patients and advocates await the commission's final report, much has happened to take the wind out of the movement's sails.

Statehouses are struggling with mental health funding. A federal effort to address the insurance inequity - a concept known as mental health parity - appears for now, at least, dead in the Washington waters. One of the movement's chief advocates, U.S. Sen. Paul Wellstone, died in a plane crash last fall.

All along, reams of authoritative reports, including an interim one by the president's panel, have detailed the mental health system's myriad ills. A recent American Psychiatric Association report laments that although psychiatric treatments are better than ever, they are reaching few people.

Another, by the General Accounting Office, said many parents give up custody of their children because needed mental health services are unattainable. Still another, by the National Mental Health Association, evaluated investment in mental health services nationwide and flunked all 50 states.

Meanwhile, the nation has been fighting its demons abroad, in the war against terrorism and in Iraq.

The president's support has helped put mental health issues on the national agenda, said Bob Carolla, news director for the National Alliance for the Mentally Ill, or NAMI. "But . . . what's been happening internationally ends up overshadowing everything."

As priorities have shifted, so has potential funding, said Melanie Gantt, public policy director for the Mental Health Association in Texas. "Any money that could have gone to improve the mental health system has gone into homeland security," she said.

"We're watching state budgets hemorrhage," Carolla said. "That goes to some fundamental revenue decisions that aren't . . . going to be solved by the New Freedom Commission."

Because the hemorrhaging is state by state, "it's not necessarily being seen from the national perspective," he said. "If you put the national perspective together, it looms as this horrible, powerful tidal wave that's not only swamping everyone but is also building to crest again a year from now."

In a typical year, about 6 percent of U.S. adults will have a mental illness. Dallas resident Cliff Gay believes that without full insurance support, many of those people can't afford effective treatment.

He speaks from experience. "Having come from a padded cell with `snakes' coming out of a drain," he said, "I know that treatment works."

After more than a decade of misdiagnosis, Gay was found in 1985 to have bipolar disorder, or manic depression.

"The older I got, the more severe the episodes became and the closer together they came," he said. "So the quicker you can get to the doctor and get yourself into treatment, chances of your having to go through what I had to go through are not as intense."

Yet at 62, even with other health ills, Gay said bipolar disorder is his No. 1 health issue. "No question about it.

"Some of the other physical things I have are tied to that; if I let myself get into an episode my other conditions start to exacerbate."

He said that if he had suffered heart attacks instead of bipolar ones, he'd have more insurance coverage.

Patients and advocates still believe strongly in federal legislation mandating employer-based insurance parity, said Gay, a board member for the Dallas chapter of NAMI. But "I think we've lost a little bit of faith that the bill will really become law."

Last year, a parity law from Congress appeared to be a likely and far-reaching victory for advocates. But the effort has become mired in the political process.

The current parity legislation, the Senator Paul Wellstone Mental Health Equitable Treatment Act, would bar certain employer health plans with medical and mental health benefits from imposing unequal limits on mental benefits. Chief sponsors are Rep. Patrick Kennedy, D-R.I., and Sen. Pete Domenici, R-N.M.

Kennedy believes parity is the "silver bullet in the legislative arsenal," said Ernesto Anguilla, the lawmaker's press secretary. "If you can pass parity, you'll have immense improvements across the board, because insurance companies will no longer be able to apply arbitrary limits to care."

Although advocates expect eventual approval in the Senate, they accuse the House Republican leadership of repeatedly obstructing the popular legislation.

"After the president made those remarks," Anguilla said, "we thought, finally, with the president on our side, that would open up the House leadership and allow this bill to get a fair hearing."

Aides to House Speaker Dennis Hastert, R-Ill., as well as to Domenici, did not reply to repeated requests for comment.

Kennedy's bill has 234 co-sponsors among the 435 House members; Domenici's has 62 co-sponsors in the 100-member Senate. Yet those legislative forces haven't been formidable enough to overcome other political powers, the business and insurance lobby, said Gantt.

"They are very strong lobbies, both in Texas and in D.C., and especially the business community does not want any mandates . . . on what they have to cover in insurance," she said. Business leaders have voiced concern that such mandates may make it impossible for them to offer any health benefits at all for their employees.

"What is not said in that," Gantt said, "is the costs that get shifted to communities because people don't have (mental health) insurance."

The bid to address insurance inequity was dealt a dramatic blow with the death of Sen. Wellstone, D-Minn., in October. "We lost a true champion," Mr. Gay said.

Although Mr. Domenici has been a staunch supporter of insurance parity for major mental illnesses, such as bipolar disorder and schizophrenia, "it was really Wellstone who had been pushing so hard with Domenici for full parity including substance abuse, which is so important, because it so often goes hand in hand with mental illness," Gantt said.

Stigma against mental illness - particularly a tendency to see it as a character weakness rather than a physiological one - has long hampered the parity movement, Anguilla said. "Sen. Wellstone was an icon when it came to ripping through those stigmas," he said. "When the bill does pass . . . it will be in Paul Wellstone's name."

Since the formation of the president's New Freedom panel, dire accounts of mental health care nationwide have stacked up. The panel itself has scrutinized such problem areas as providing services to children, minorities and the aged; addressing needs through schools; finding housing for the mentally ill; and delivering services in rural areas, all within the context of a fragmented safety net.

"It is becoming clear that the mental health services system does not adequately serve millions of people who need care," the commissioners wrote in their interim report last fall.

The GAO survey, saying that parents give up custody of thousands of children a year because of a lack of mental health insurance or services, has caught Congress' eye, Carolla said. "Already there's a strong emerging consensus that that's an area where something has to be done."

Far outside advocacy circles, public discourse on mental health is coming of age, Carolla said. For instance, in last fall's Miss America pageant, Arizona's Laura Lawless spoke candidly about her struggle with severe depression, a suicide attempt, and the benefits of therapy and medication. "She actually may be better remembered than whoever did win the Miss America title," he said. "It was a stigma-busting moment."

Another such moment came in the wake of the last Super Bowl, when Oakland Raiders teammates harangued center Barret Robbins for disappearing just before the big game, apparently amid a bipolar episode. "What was incredible - without the mental health community generating a press release at the time, it was really spontaneous - was that many of the sports writers and columnists turned on the Raiders . . . and came to Robbins' defense," Carolla said.

Such breakthroughs help lay a foundation for government action, Carolla said. "Those have been helping to set the stage and create a moment of opportunity for the president or whoever else wants to seize it."

The commission's final report, initially due out in April, has been working its way through internal White House reviews before formal presentation to the president, Carolla said.

While Bush's potential 2004 Democratic opponents have been discussing health care, "none of them are talking with this kind of specificity about the mental health system. So he is out there and has been leading," Carolla said.

Some advocates aren't optimistic that the final report will have a huge impact. "We've heard from the commission that they've been told to put things in the report that can be done by executive order" - not legislation that would require funding, Gantt said.

"It's not going to be a sweeping and radical set of recommendations," Carolla said, "but it certainly will probably be a first step down a road toward a series of comprehensive reforms."

Gay hopes the president will tackle mental illness with the same commitment he has shown for fighting AIDS in Africa. Such attention to mental health, Gay said, has the potential to affect not just those who are ill but their loved ones.

"I think it'll be a big motivator towards moving us away from all this stigma associated with mental illness," he said. "When our elected officials finally come out and acknowledge this and say we're going to give it equal footing, I think it will break down a lot of barriers."

Untreated mental illness is the scourge of jails, crisis systems, emergency rooms, homeless shelters and morgues, Gantt said.

"People with mental illnesses," she said, "you don't put them to bed like they have a cold and in a couple of days they'll be OK."

---

(c) 2003, The Dallas Morning News. Distributed by Knight Ridder/Tribune News Service.