Andrew Solomon

"When I met with Senator Domenici, joint sponsor of the Mental Health Parity Act, I laid out for him the anecdotal and statistical information I had collated, and then I proposed fully documenting the tendencies that seemed so obviously implied by these stories. “Suppose,” I said, “that we could put together incontrovertible data, and that the questions of bias, inadequate information, and partisanship could all be fully resolved. Suppose we could say that sound mental health treatment for the severely depressed indigent population served the advantage of the U.S. economy, of the bureau of Veterans Affairs, of the social good—of the taxpayers who now pay cripplingly high prices for the consequences of untreated depression, and of the recipients of that investment, who live at the brink of despair. What, then, would be the path to reform?”

“If you’re asking whether we can expect much change simply because that change would serve everyone’s advantage in both economic and human terms,” said Domenici, “I regret to tell you that the answer is no.” Four factors block the development of federal programs to achieve care for the indigent. The first, and perhaps the most formidable, is simply the structure of the national budget. “We are now niched with programs and program costs,” Domenici said. “The question we must confront is whether the program you’re describing is going to grow and require new funds, not whether there’ll be some overall savings for the Treasury of the United States.” You can’t immediately reduce other costs: you can’t in one year take the money out of the prison system and out of welfare to pay for a new mental health outreach service, because the economic advantages of that service are slow to accrue. “Our evaluation of medical delivery systems is simply not outcome-oriented,” Domenici confirmed. Second is that the Republican leadership of the U.S. Congress does not like to give directives to the health care industry. “It would be a mandate,” Domenici said. “There are people who would support this kind of legislation at every level but who are ideologically opposed to mandating states, mandating insurance companies, mandating anyone.” Federal law, the McCarran-Ferguson Act, makes the administration of health insurance a states’ issue. Third is that it is difficult to get people elected for limited terms to focus on long-range improvement of the social infrastructure rather than on the quick spectacle of immediately visible effects on the lives of voters. And fourth is that, in the sad and ironic words of Senator Wellstone, “This is a representative democracy we’re living in. People defend the causes their voters care about. Indigent, depressed people are at home in bed on Election Day with the covers over their heads—and that means they don’t have much representation up here. The indigent depressed are not what you’d call an empowered group.”