Senate Mental Health Reform Act (S2680): Legislation sans Appropriation.

The Senate Committee on Health, Education, Labor, and Pensions (HELP Committee) unanimously, and therefore with full bipartisan support, passed legislation to reform the provision of “mental health” care.
Goals of the legislation: The goals include efforts to increase access to “mental health” care; improve training for those who care for people with “mental illness”; and promote better enforcement of existing “mental health” parity laws—making insurance companies reimburse for “mental health” treatment the same as for “physical health” treatment. The bill is composed of six titles. For example, Title III proposes support for state responses to “mental health” and substance abuse disorder needs. Title IV promotes access to “mental health” and substance abuse care, and Title V does the same explicitly for children and adolescents. The bill authorizes (not appropriates—do you understand the difference) block grants to states for “mental health” services and for prevention and treatment of substance abuse disorders.
Limitations: Foremost is the fact that the HELP committee lacks jurisdiction over funding. Stated differently, the committee that passed the legislation cannot actually appropriate funds to support implementation of the legislation. The Congressional Budget Office (CBO) scored the bill and estimates that it would cost between $40 to $80 billion dollars over 10 years—a new appropriation that would have to be offset with cuts elsewhere to maintain overall budget neutrality. Nonetheless, the bill could move to the Senate floor as early as next week to debate funding and to entertain any amendments.
Amendments on the Senate floor: What happens next is not readily predictable. For example, Senator Collins lamented that “exclusions of reimbursement for certain residential mental health services is a concern.” The Senator might offer amendments to repeal the current prohibition on Medicaid paying for inpatient care for anyone over age 21years or under age 65 who resides in an institution for “mental disease” (IMD). Removal of this so-called IMD exclusion would be very costly even though it would remove a major barrier to treatment of “mental illnesses”. Other Senators are “concerned also about Medicaid’s prohibition against reimbursements to hospitals and facilities larger than 16 beds for mental health and substance abuse treatment.” These are difficult issues, especially concerning funding decisions. Given the harsh reality of the current budget deficit crisis, this bill may fail to gain any appropriations in the ensuing Senate debates.
Does all this make sense to you? One additional comment from Senator Collins caught my attention. She lamented, “It is stunning to me that in this day and age we do not treat mental illness in the same way that we treat physical illness.” Her observation has veracity, of course. However, physical diseases are never lumped under a label of “physical illness” the way that we lump diseases of the mind under a label of “mental illness.” I remain puzzled by the labeling of some diseases that affect the mind as “mental illnesses” while others are labelled as diseases of the brain. (Feussner JR. When diseases of the brain become diseases of the mind: A new frontier for clinical research. US Medicine 39:9, November 2000.) For example, Alzheimer’s disease has devastating effects on personality, cognition, and memory. Is Alzheimer’s disease a disease of the brain or a “mental illness”? A brain tumor, or a temporal lobe seizure disorder, can affect one’s cognition or personality—are these diseases of the brain or “mental illnesses”? Alternatively, depression is likely to be labeled as a “mental illness” despite studies demonstrating a neuro-chemical basis for depression. Are schizophrenia or bipolar disorder diseases of the brain or “mental illnesses”? Does our profession inadvertently contribute to the lack of equitable reimbursement for “mental” as opposed to “physical” illnesses in part because of our labelling practices? Perhaps all those treating these patients can change our nomenclature in the future–just stop labelling patients as “mentally ill” and stop using the catch-all phrase “mental illness” altogether. Stay tuned!
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