Rethinking: Mind and Body

Stephen Wellstone was a promising college freshman in the mid-1950s when he suffered what was then referred to as a severe mental breakdown. After two years of in-patient psychiatric treatment, he returned to college and eventually graduated with honors. It’s a success story—except for the fact that his working-class parents spent the next 20 years paying off the accumulated medical bills.

The injustice of this extraordinary financial burden stayed with Stephen’s younger brother. Paul Wellstone would become a U.S. senator and lead a transformation in mental health care before his untimely death in 2002. Prior to his efforts, insurance benefits for mental health and addiction care were treated differently than physical health care. They often required much higher out-of-pocket payments, limits on the number of outpatient visits per year and maximum annual and lifetime dollar limits that were not required for other types of services. In Senator Wellstone’s view, this insurance discrimination contributed to severe undertreatment of mental illness and addiction in the U.S. 

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act in 2008 addressed these issues by requiring health insurance companies to offer mental health and addiction benefits equivalent to benefits for other medical conditions. (Senator Domenici, one of the Senate’s staunchest conservatives, joined his liberal counterpart on the legislation because of his own experience raising a daughter with schizophrenia.) Even with conservatives and liberals working together, it still took 15 years to pass the law.

The 2010 Affordable Care Act (ACA) built on the Wellstone-Domenici parity law in a critical way. The ACA mandated, for the first time, the inclusion of mental health and addiction care as essential health benefits for new insurance products offered under the law. 

Equally important, ACA’s health care delivery and payment reforms have the potential to break down longstanding barriers to health care that connects mind and body. Historically, general medical care and mental health and addiction care have suffered a profound lack of integration. Financial arrangements such as fee-for-service medicine reinforce this separation. This kind of fragmentation exacts an enormous toll. People with serious mental illnesses have higher rates of other illnesses. They die earlier, on average, than the general population—largely from treatable medical conditions associated with modifiable risk factors such as smoking, obesity and inadequate medical care. And, mental health and addiction disorders are often untreated in primary care. 

ACA includes important efforts to improve care integration. For example, the law created Medicaid “health homes” for people with multiple chronic conditions, including mental health and addiction disorders, that pay for care management and other coordination services not typically reimbursed. Other ACA reforms, including the development of accountable care organizations and new payment models, can foster integration. 

Taken together, the policy changes advanced under the Wellstone-Domenici law and the ACA have helped shift mental health and addiction care more fully into the health care mainstream. In doing so, these reforms have had an important, added benefit: combatting stigma. Despite major treatment advances in mental health and addiction disorders in recent decades, stigma remains extraordinarily high. Nearly half of American adults believe that people with serious mental illness are far more dangerous than the general public. And, three-quarters say they are unwilling to work closely with a person with mental illness. Stigma against individuals with substance use disorder is even higher. Stigma rates are remarkable given how common these conditions are in our society—nearly half of us experience symptoms that meet the criteria for mental illness at some point in our lives.

Why does the public have such negative attitudes? Part of the problem is that our news media is flooded with stories linking mental illness to violence. In a recent study, my colleagues and I found that 55 percent of all stories about mental illness appearing in major news outlets over the past 20 years referenced an act of violence by a person with a mental illness. This statistic is staggering and highly disproportionate to actual rates of violence. The focus on violence exacerbates stigma and decreases support for public policies that help people with mental illnesses. Conversely, media portrayals of people in successful mental health and addiction treatment lower stigma. An important takeaway from this research is that getting people into high-quality treatment can transform societal views. 

The goal of moving people into effective treatment to equally address the needs of a person’s mind and body is at the heart of Wellstone-Domenici and the ACA. Yet, just seven years after ACA’s passage, the question of whether mental health and addiction treatment should be essential components of every health insurance plan is once again under debate. The American Health Care Act—the “repeal and replace” proposal championed this spring by House Speaker Paul Ryan—would have eliminated the requirement that health plans cover mental health and addiction services as essential health benefits. The House passed the AHCA on May 4, but its final passage is uncertain.

It literally took decades for parity for mental health and addiction care to become the law of the land. This is the moment to build on the achievements of the last two decades, not to reverse course.

Colleen L. Barry, PhD, MPP, is the Fred and Julie Soper Professor and Chair of the Department of Health Policy and Management and co-director of the Johns Hopkins Center for Mental Health and Addiction Policy Research.