MINDS OVER MONEY

WASHINGTON -- To many, the idea that neuroses or depression could be
diagnosed as precisely or treated as effectively as a broken leg or a burst
appendix seems counterintuitive, even preposterous.

To the layperson, symptoms of psychological ills often seem vaguer, more
diffuse than physiological ones. Diagnoses seem more subjective, and many
people suspect that a patient has more control over a mental illness than a
physical one. But the medical model of mental illness has gained ground in
recent years as scientists discover biological, chemical and even genetic
explanations for mental disorders. With these discoveries have come a
citizens' movement for equivalence, or parity, in the insurance coverage of
mental and physical illnesses.

That movement has galvanized Congress. Senators Pete V. Domenici,
Republican of New Mexico, and Paul Wellstone, Democrat of Minnesota, have,
for more than five years, led a campaign to translate the idea of parity
into law. In October, the Senate approved the proposal as an amendment to a
spending bill for the Departments of Labor and Health and Human Services.
But the proposal was dropped this month by a House-Senate conference
committee because of opposition from House Republicans, who shared the
concerns of employers and insurers that it would drive up costs.

Mr. Wellstone said the White House had been of no help. President Bush said
he favored "quality insurance coverage" for mental health care, but worried
that the legislation would prompt employers to scale back benefits or raise
premiums, so people would lose coverage.

Just as critics of "mental health parity" tend to describe the costs as
prohibitive, so proponents tend to minimize or deny the differences between
physical and mental illnesses.

Dr. Steven E. Hyman, who was director of the National Institute of Mental
Health for the last five years, acknowledged that "we do not have objective
diagnostic tests for mental disorders." But he insisted: "The most serious
disorders are very well defined in clinical terms. There are very typical
symptoms. They run a typical course through the lifetime. They run in
families in ways that clearly implicate a role for genes."

Moreover, doctors said, many physical illnesses, like multiple sclerosis
and some forms of arthritis, can also be difficult to diagnose. And in an
aging society, doctors and patients are increasingly confronted with
chronic illnesses whose inception, course and outcome are uncertain. So too
with mental illness: some are curable, some are not, and patients with the
same condition may progress at different rates.

Popular stereotypes suggest that a physical illness can be cured in a
fixed, predictable time, whereas treatment for mental illness goes on
indefinitely. The clinical truth is far different. Many chronic physical
illnesses, like heart disease, can continue indefinitely, and some mental
illnesses can be cured or controlled in a limited time.

Advocates of parity describe their campaign as a struggle for civil rights,
an attempt to end what they see as discrimination against people with
mental illness. Congress adopted a limited form of parity in 1996, when it
decreed that group health plans could not set more restrictive annual or
lifetime dollar limits on mental health care than they had for physical
illnesses.

But many employers got around the law by setting other limits. Andrew
Sperling, director of public policy at the National Alliance for the
Mentally Ill, said it was still common for health plans to set annual
limits of 15 hospital days and 20 outpatient visits for mental illness,
when they had no such limits for the treatment of cancer or heart disease.
Likewise, he said, some health plans charge a $5 co-payment for a drug to
treat diabetes or high blood pressure, but $30 for an antidepressant.

Psychiatrists resent managed care even more than most other doctors. They
complain that health plans set arbitrary limits on care, demand quick
results, pressure them to use drug therapy rather than other types of
treatment, and infringe on the privacy of the doctor-patient relationship.

But parity would be unaffordable without the cost-control techniques of
managed care. A small number of specialized companies, like Magellan Health
Services, use those techniques in coordinating mental health benefits for
tens of millions of Americans. Dr. Henry T. Harbin, chairman of Magellan,
said these companies supported parity legislation and believed, from
experience with state laws, that total health care premiums would rise less
than 1 percent.

THAT is consistent with an estimate by the Congressional Budget Office,
which said that premiums would rise an average of 0.9 percent as a result
of the Domenici-Wellstone bill. The cost seems more significant when stated
in absolute terms: $23 billion over five years.

Even large employers who provide generous mental health benefits oppose a
federal requirement for strict parity. "We promote investment in mental
health care as a way to improve productivity," said Helen Darling,
president of the Washington Business Group on Health, which represents 160
companies. "But large employers don't like mandates because they eliminate
the flexibility that's so important to them."

House Republicans promised to hold hearings on parity proposals next year.
One question sure to arise is whether the requirement should apply to all
mental problems or just the more serious illnesses. The Domenici-Wellstone
legislation applies to "all categories of mental health conditions" listed
in the diagnostic manual of the American Psychiatric Association, with the
exception of drug and alcohol addiction.

Even Dr. Hyman, a supporter of parity, said, "There are many, many
diagnoses in that book for which there is no certainty, no empirical
validation." As an example, he cited histrionic personality disorder,
defined as "excessive emotionality and attention-seeking behavior." By
contrast, Dr. Hyman said, "we have 150 years of good empirical information
about schizophrenia, manic-depressive illness and major depression, and 70
years of good empirical information about autism."

Parity is no panacea. A parity requirement would not guarantee treatment
for every mental ailment, but would mean that mental disorders could no
longer be set aside in a separate class, to be treated differently, with
less coverage.