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TIPPER GORE and the Overreaching of Mental Health Coverage.

"Mrs. Gore's well-motivated, but not so well-thought out, expansion of mental health coverage to the point of actual parity [with physical illnesses] would represent an irresponsible and overly expensive change in the status quo."

IT WAS MAY, 1993, the year of the major health care battle that First Lady Hillary Clinton became famous (or infamous) for, and I had been invited to a party given by talk show host Larry King for Al and Tipper Gore at the late Duke Ziebert's restaurant in Washington, D.C. I was introduced to Mrs. Gore's aide, who, upon hearing the name of my university affiliation, said, "You know, Mrs. Gore was just infuriated by an article written by a colleague of yours in The Wall Street Journal." I asked if the article was about mental health insurance. Told that it was, I indicated that the aide was talking about an article written by me, and he asked if I would mind speaking to Mrs. Gore. After saying "no, not at all," I was confronted by a livid Mrs. Gore, who lambasted me for 15 minutes on the irresponsibility of my recommending that substantial changes be made in the Clinton-Gore mental health plan.

Tipper Gore is no newcomer to the battles over mental illness and the costs of health care for those who are seen as mentally ill. In fact, it is likely that organized psychiatry has never had as intrepid and important an advocate at such an advantageous time as it has in Tipper Gore, wife of Vice Pres. Al Gore, a candidate for the Democratic nomination for the presidency. Mrs. Gore majored in psychology at Boston College and received a Master's Degree in Psychology from George Peabody College in Nashville, Tenn. Her initial public work in psychology focused on aiding the homeless, and more than a decade ago she worked with the National Mental Health Association on an exhibit, "Homeless in America: A Photographic Project." Mrs. Gore's work for mental health issues earned her the title of Mental Health Policy Advisor to Pres. Clinton.

The first White House wife who engaged in major lobbying efforts on behalf of the interests of the mentally ill and those who care for them was Rosalynn Carter. Since 1970, when Jimmy Carter was campaigning to be Governor of Georgia, Mrs. Carter has been arguing for more money and sympathy for the mentally ill. During Carter's presidency, his wife was the honorary chair of the President's Commission on Mental Health. In the years subsequent to her husband's presidency, Mrs. Carter founded the Carter Center's Mental Health Task Force, of which she is chair. In recent years, Rosalynn Carter has been speaking out nationally on television shows like "Larry King Live" and emphasizing the view that psychiatric disorders are invariably biological disorders. Her book, Helping Someone with Mental Illness, which, according to Mrs. Carter, attempts to make the arcane language of psychiatric research understandable to the average reader, is the culmination of all of these efforts.

While Rosalynn Carter has been vigorously involved in the promotion of mental health issues, Tipper Gore has been at the forefront of the major issues confronting psychiatry in the past five years: stigma (see "Should We Destigmatize Mental Illness?," USA Today, May 1996), opposition to parity (see "Parity: The New Buzzword in Mental Health," USA Today, May 1997), and expanding health insurance for those who are labeled mentally ill. As the newsletter for The American Psychiatric Association, Psychiatric News, describes her work, Mrs. Gore "has worked tirelessly for many years" to advance the cause of quality, affordable care for the mentally ill. She has been particularly active in promoting the inclusion of mental health care in health care policy, as evidenced early on in her 1990 founding of Tennessee Voices for Children and by her later role in Children's Health Initiative, targeted toward including youngster's mental health care in Clinton Administration health care policy.

The most rigorous of her work in this area occurred in 1999. Mrs. Gore, along with the American Psychiatric Association, thought the time propitious to enact parity legislation, which a 1996 bill fell short of producing. Through her encouragement, Clinton ordered Federal mental health coverage to equal physical health benefits, effective in 2001, a change that can be enacted through presidential flat. This is meant to be a test case of the financial feasibility of parity, which Mrs. Gore complained was insufficiently affected by the 1996 Mental Health Parity Act that applied only to firms choosing to cover mental health services and exempted small businesses.

More recently, her influence has been evident in her husband's announcement of his proposals on health care. In what was heralded as a "major speech," the Vice President outlined his plans for shaping the nation's health care system. Within that speech was the unmistakable influence of his wife and her views as to the requirements for mental health coverage: "I want to make sure that a patient with depression is given access to care on terms no different from a patient who has diabetes," he said. "And I will begin by improving mental health services for those who receive Medicaid." In a proposal that echoed much of what the Administration had been proposing in health care, this point went significantly beyond its proposals for coverage of mental illness.

Early in 1999, in an unusual, but effective, persuasive maneuver, Tipper Gore announced that she had undergone counseling and had been treated with drugs for depression at some point following the recovery of her six-year-old son, Albert Ill, from injuries incurred in 1989 when he darted into the street and was struck by a car.

A short time after she revealed her bout with depression years before, Tipper Gore chaired the widely heralded first White House Conference on Mental Health, where the Clintons and Gores interviewed mentally ill citizens for more than two hours. The conference's agenda included most prominently what the Administration's 1993 health-care proposal was unable to deliver: parity for mental illness. This goal goes far beyond what mental health interests were able to accomplish in the Mental Health Parity Act of 1996. If successful, it would mean that the analogue to physical illness would finally be reached: Any insurance company that covered mental illness would be required to do so as they insure physical illness, with no limits on hospital stays or outpatient visits. Moreover, there could be no limits that would infringe on other health insurance coverage.

The American Psychiatric Association provides some idea of how many Americans should be seen as mentally ill or potentially mentally ill. The APA web site estimates that "between 15 and 25% of children evaluated in primary care settings have significant psychosocial disorders requiring some type of intervention." It also states unambiguously that "one in four adults will suffer from a mental illness or substance abuse disorder in any year." The APA and the National Institute of Mental Health have indicated that more than 50% of all Americans will suffer from mental illness in their lifetimes, and the NIMH's Division of Epidemiology estimated that 52,000,000 adults have a diagnosable mental illness, a figure that includes substance abuse.

One of the consequences of parity coverage could be an exponential rise in the use of psychoactive drug usage. In fact, the very drags that frighten parents of teenagers are recommended by parity supporters with reassuring, palliative language. Mrs. Gore, in her public disclosure of being treated for depression, quoted unnamed "social worker friends" as saying, "If Tipper Gore can take medication, I guess I can." When called "medication," drags don't seem so dangerous.

It is ironic to note that the APA and Mrs. Gore's call for parity includes "substance use disorders," a medicalized way of saying "people who abuse drags." The assumption that the use of drugs is not freely chosen behavior, some argue, is a virtual guarantor of the perpetuation of such activity. Nevertheless, she and the APA call the "drag abuse" label "stigmatizing" behavior, the most prominent bate noire of the mental health community. What they don't seem to acknowledge is that stigma may have a salutary value as well. Tipper Gore's own confrontation with "mental illness," which she related in the summer of 1999, is illustrative.

Mrs. Gore wrote of her "disease" of "situational depression" in a newspaper op-ed piece and discussed it in a variety of interviews on television, indicating that she allegedly suffered the condition pursuant to her son's life-threatening accident. There is no accepted mental illness recognized by the American Psychiatric Association called "situational depression," and depression following such a near-tragic occurrence, especially if one feels guilty regarding his or her child's experience, is hardly unusual. Mrs. Gore refused to provide any details at all regarding when exactly the depression struck, when it abated, or her symptomatology. Moreover, she declined to discuss the drag or drags she took as "therapy."

It is interesting to note the lack of criticism of Mrs. Gore's reluctance to provide details of her bout with depression while still decrying the existence of the stigma of mental illness. Abigail Trafford, editor of the "Health" section of The Washington Post and a Tipper Gore booster, articulated this stunning non sequitur regarding Mrs. Gore's selective revelations: "There are so many myths about mental illness that even Tipper Gore, long a public champion of addressing the issue, is reluctant to discuss the details of her own struggle with it." Still, the stigma that attends psychoactive drag therapy, which Mrs. Gore vigorously attacks, can serve as a disincentive to those who would take such serious, mind-altering drags for insufficient reasons.

Moreover, one perspective always absent from Tipper Gore's views on mental illness is the phenomenon well-known to rhetorical scholars and central to serious critics of parity for mental health care--that of a self-fulfilling prophecy. She has often spoken of her mother's severe depression, which caused Mrs. Aitcheson to be hospitalized at least twice. In one of her interviews, Mrs. Gore said that, due to her mother's history, she has scrutinized herself and her four children, looking for signs of mental illness. One could hardly find a more precise recipe for misperceiving the seriousness of sadness and problems, evident in virtually everyone's life, than such a debilitating and sensitizing "search."


The "parity" bill of Senators Pete Domenici (R.-N.M.) and Paul Wellstone (DFL-Minn.), the Mental Health Equitable Treatment Act of 1999, requires that limitations on the coverage of benefits for "severe biologically-based mental illnesses" may not be imposed unless comparable limitations are imposed on medical and surgical benefits. The National Alliance for the Mentally Ill claims that "the new bill provides full parity for people with serious brain disorders." That could well describe some cases of schizophrenia, but surely would not describe heretofore nonsevere mental illnesses, such as anorexia nervosa and attention deficit/hyperactivity disorder--both newly defined in the bill as "severe mental illnesses." The House bill even includes parity for substance abuse.

Through bait-and-switch labeling of the problems of the worded well plus expansion of the "severely mentally ill" category, the APA and Mrs. Gore's newly favored legislation creates an unjustified and unaffordable expansion of mental health benefits. The Employee Benefit Research Institute has determined that parity will lead eventually to increases in employer costs and possible elimination of other benefits in some cases, including health insurance coverage altogether. Moreover, the increased availability of cost-free psychiatric therapy poses the danger of a major increase in the population of people seen as mentally ill.

The NIMH estimates that 4.5% of Americans suffer from severe mental illness in a given year. Taking even that probably exaggerated figure seriously, one could come to an affordable national consensus on parity for mental disorders. In 1993, the Federal government announced a broad set of definitions through which states could define who is eligible for treatment in Federally funded state and local clinics wherein the cost to patients is minimal. At that time, Laurie Flynn, a lobbyist for the National Alliance for the Mentally Ill, said, regarding the expanding of the definition of severe mental illness: "This appears to make almost any condition a serious mental illness. Common sense tells you this isn't true. Serious mental illnesses are schizophrenia, manic depression, obsessive-compulsive disorder, depression and other severe conditions, and the definition should not include people who are merely adjusting to life's stresses."

Mrs. Gore's well-motivated, but not so well-thought out, expansion of mental health coverage to the point of actual parity would represent an irresponsible and overly expensive change in the status quo. Her own "situational depression," accompanied by possibly expansive psychotherapy and drag therapy, is just one example. If only correctly diagnosed (subject to utilization review), authentically severe mental illnesses--such as manic depression, schizophrenia, and major depression--were granted equal coverage status with physical illness, there would not be the precipitous rise in health insurance costs and additional uninsured Americans that will be the result if mental health coverage is expanded to full parity.

Richard E. Vatz, Associate Psychology Editor of USA Today, is professor of rhetoric and communication, Towson (Md.) University.
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Publication:USA Today (Magazine)
Date:Mar 1, 2000
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