The Federal Employees Health Benefit Plan provides health insurance for 9.5 million persons, making it about nine times as large as the biggest private plan, A.T.&T., and about thirty times as large as General Motors' plan. Until January 1, 1982, Federal employees, could obtain insurance coverage through Blue Cross-Blue Shield for 70 percent of unlimited outpatient visits up to a lifetime maximum of $50,000.
When Blue Cross, with Office of Personnel Management encouragement, cut back to a limit of 50 outpatient visits per year, this option was effectively foreclosed. Whereas Blue Cross spread the risk over 6 million people, smaller plans would be overloaded if all patients in intensive treatment had to switch to them.
The emergency legislative effort, sponsored by Senator D'Amato in the fall, received much support, thanks to hard work by many American Psychoanalytic Association members who alerted interested people. In the confusion over the budget, the Amendment itself never came to a vote; but the demonstrated support led to a Senate floor colloquy wherein Senator Stevens, the Senate leader on Federal employee issues, agreed to include “adequate coverage for mental health benefits” in revising the Federal plan. He stated, “Mental health care should be treated the same as other forms of health care. If reductions … become necessary, no form, including the mental health benefit, should be forced to bear a greater share of reductions.”
Meanwhile, in the House, Congresswoman Oakar and her Subcommittee on Compensation and Benefits set to work on legislation to revise the Federal Employees Plan with requirements for nondiscriminatory coverage for mental illness.
Lawsuits were initiated by a group of patients, the American Psychiatric Association, the Washington Psychiatric Society, and national groups of social workers and psychologists to block the cutback. Though it was agreed by the U.S. Court of Appeals that the Federal Employees Benefit Act required catastrophic coverage (that is, the insurance pays expenses after the employee pays a certain amount out of pocket) and that the cut in mental coverage violated this provision, the courts have so far allowed the cut to stand, rather than complicate the administration of contracts now in effect.
For patients who had begun treatment in 1981 under the Blue Cross contract, a suit on behalf of inpatients was settled, giving those patients 365 days of hospital coverage in place of the 60 days limit in the new contract. A suit is now pending on behalf of outpatients who had understood that the treatment they undertook for their illness in 1981 was covered.
The general support for the D'Amato Amendment has now helped to mobilize a coalition of sixteen organizations related to mental health, alcoholism, and drug abuse to back Representative Ottinger's “Federal Employees Health Benefits Plan Amendment of 1982” (H.R. 5995), requiring nondiscriminatory mental health benefits for Federal employees and reaffirming catastrophic coverage for mental illness. As of May 11, early in the campaign, the Bill had 50 cosponsors.
It is hoped that, with the efforts of the sponsoring groups, enough mail, telegrams, and direct communications to Congressmen in support of this Bill will activate 100 cosponsors. Such support can win inclusion for these provisions in the revision of the Federal Employees Plan being prepared by Congress-woman Oakar for proposal in the Senate. The bill, however, faces stiff opposition, especially from Blue Cross, which threatens to pull out of the Federal program if required to offer more benefits for mental illness.
Though the payout for psychiatric benefits has been stable for seven years at 7.7 percent of the total payout in their Federal Employees Plan, Blue Cross has singled out this coverage as a primary reason for their financial difficulties. Their own figures, however, show that a disproportionate number of retirees who use much care of all types is the main drain on their financial resources. In singling out analysis and intensive psychotherapy for cutbacks, the essential principle of insurance, namely to spread among many the risk of large costs to a few, is thereby vitiated.
Recognizing this trend, several American Psychiatric Association District Branches, including Virginia, Washington, D.C., Ohio, North Carolina, Michigan, two branches in California, and Houston, have begun, through consultants, to go directly to employers to educate them on the need for good employee mental health coverage.
Such educational campaigns emphasize not only the need for rational, humane medical care, but also the economic benefits derived through increased productivity and more efficient medical utilization. The American Psychiatric Association has formed the Psychiatric Benefits Marketing Project to gather information on psychiatric coverages nationally and to approach employers and insurance companies on the national level to improve benefits.
At the May meeting in Boston the Executive Council voted to join the coalition sponsoring the Ottinger Bill and to contribute $500 toward the cost of the lobbying effort. It appears that the psychoanalytic community must forcefully advocate the place of psychoanalysis as a necessary and vital treatment method and thus a necessarily included item in health insurance. The alternative is to see psychoanalysis limited by financial constraints to the wealthy or to low-fee clinic settings.
L. David Levi, M.D.
Washington, D.C.