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End remaining discrimination

June 1, 2010
by Mark Covall
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Concerted advocacy has led to fundamental reform, including parity. Now, let's finish the job

The fight for equality-what many have called the civil rights fight for our field-is now coming to fruition. Parity in insurance coverage for mental and addictive disorders has become law. In 2009, the State Children's Health Insurance Program (SCHIP) was reauthorized with mental health parity. This year federal parity regulations were issued that are both pro-provider and pro-consumer. After years of debate and discussion, healthcare reform is also now law (P.L. 111-148, P.L.111-152), with strong provisions that build on the federal parity law. For example, health exchanges will be required to provide behavioral health benefits at parity.

As we've made strides in putting behavioral health where it belongs-as a routine part of health-we need to build on this momentum to remove remaining vestiges of discrimination. For individuals coping with some of the most severe disorders who may need hospitalization, there are two particular areas that a group of national associations are now working to change within Medicare and Medicaid:

  • Elimination of the Medicare 190-day lifetime limit

  • Implementation of the Medicaid Emergency Psychiatric Care Demonstration Project Act of 2009, or IMD/EMTALA Demonstration

End Medicare's 190-day lifetime limit

When people are seriously ill and at their most vulnerable, there is no time for them to be worrying about their health insurance coverage. But if you are a Medicare beneficiary experiencing a severe mental disorder, you may find your coverage disappears just when you need it the most. A little-known provision in the Medicare law limits Medicare beneficiaries to 190 days of inpatient psychiatric hospital care during their lifetime. This restriction is applied only to individuals with mental illnesses who receive care in a psychiatric hospital (the limit does not apply to psychiatric units in general hospitals). There is no such lifetime limit for any other Medicare specialty inpatient hospital service. Congressional action is needed to address this limitation, since it was not addressed in recent healthcare reform legislation.

More and more Americans facing complex, chronic, and disabling mental illnesses are hitting this Medicare lifetime limit and losing access to essential crisis hospital stabilization services when they are most needed. Like other diseases such as diabetes, mental illnesses can be chronic and require brief, but recurring, hospital visits for stabilization and medication management. For Medicare beneficiaries, these short stays help them to remain active in their communities, but can quickly add up to 190 days-a worry that people with chronic physical disorders never have to think about.

The impact of the arbitrary 190-day lifetime limit (which was put into law decades ago) is particularly painful because Medicare beneficiaries include not just the elderly, but also the disabled. Over eight million Medicare beneficiaries, or about 17 percent, are under age 65 and disabled.1 More than a quarter of Medicare beneficiaries (29 percent) have a cognitive/mental impairment.1

Low-income seniors and younger persons with disabilities who are enrolled in both Medicare and Medicaid (“dual eligibles”)-accounting for some 8.8 million Medicaid beneficiaries-have substantial health needs. Over half are in fair or poor health (twice the rate of others on Medicare). Dually eligible individuals are also more likely to have mental health needs compared to other Medicare beneficiaries.2 Medicare is a critical safety net for those who have long-term mental disabilities, yet retain the ability to participate in the community throughout their lives given adequate support.

“This arbitrary cap on benefits is discriminatory to the mentally ill,” wrote Sens. John Kerry (D-M.A.) and Olympia Snowe (R-M.E.) in a letter to colleagues announcing their introduction of a bill this spring (S.3028) to fix the problem. The Medicare Mental Health Inpatient Equity Act would repeal the 190-day lifetime limit for patients receiving care in a psychiatric hospital. A total of 48 national organizations of all types have endorsed S.3028, including the AARP, American Hospital Association, American Nurses Association, American Psychiatric Association, Federation of American Hospitals, National Alliance on Mental Illness (NAMI), National Association of Psychiatric Health Systems, National Council on Aging, and Mental Health America, among others. Eliminating the Medicare 190-day lifetime limit, these groups believe, will:

  • Equalize Medicare mental health coverage with private health insurance coverage;

  • Expand beneficiary choice of inpatient psychiatric care providers;

  • Increase access for the most seriously ill;

  • Improve continuity of care; and

  • Create a more cost-effective Medicare program.

Implement the Medicaid Emergency Psychiatric Care Demonstration Project Act of 2009

Emergency psychiatric care, delivered in general hospitals and freestanding psychiatric hospitals, is an integral component of community-based care for persons with severe mental illnesses. Yet, a 30 percent decline in inpatient psychiatric beds over the past two decades makes it hard to find beds for these people. As a result, people who have mental health emergencies are often diverted to already overcrowded emergency rooms or forced to travel long distances for care.3