Senator Pete V. Domenici (R-N.M.) has struggled for 17 years with the mental illness of his 34-year-old daughter, a victim of treatable schizophrenia. At meetings of family support groups, he has encountered similar travails. He recalls the mother whose 25-year-old son spent years in a catatonic stupor until a drug released him from the prison of mental illness, and the accountant whose two sons--both suffering from schizophrenia--simply disappeared one day. Only one ever returned.
Spurred by such tragedy, Domenici has done the seemingly impossible: Without any hearings, over the opposition of dozens of business and insurance-industry lobbyists, and in the midst of a corporate-friendly Republican Congress, he and his allies have imposed a new business mandate. After Jan. 1, 1998, health-insurance providers won't be able to impose lower spending limits for mental health coverage than for standard medical and surgical benefits. Typically, managed-care plans have a $1 million lifetime limit for medical care but a $50,000 limit for mental health (table).
LOST BENEFITS? Foes and backers of the measure, which was grafted onto an unrelated appropriations bill on Sept. 19, agree its passage is almost entirely due to the perseverance of the softspoken, 64-year-old father of eight. "Domenici is one of the few guys with the tenacity and the credibility on this issue, and the connections, to be able to call up the leadership of the Senate and the House and get this done," says Thomas A. Scully, a lobbyist with the Federation of American Health Systems, a hospital group.
After a failed attempt to add the provision to the Kassebaum-Kennedy health-insurance reform measure last August, Domenici regrouped. At a key meeting of top Republicans in the office of Senate Majority Leader Trent Lott (R-Miss.) on Sept. 18, Domenici offered to delay implementation for a year and to exempt businesses with fewer than 50 employees. He also agreed to an escape clause for companies whose overall health expenses increase more than 1% as a result of the mandate. "We have much less than we started with, but at least we can see the [eventual] effects" of expanded coverage, says Domenici.
Business lobbyists, with good reason, worry that Domenici's mild amendment doesn't preclude a broader crusade. Already, 32 states have enacted requirements for mental health coverage, according to the Blue Cross & Blue Shield Assn. Opponents say new mandates will only force companies to drop mental health benefits entirely or scale back on medical and surgical benefits to compensate for the new services. "We need flexibility in designing the best overall coverage, not more mandates," says National Association of Manufacturers lobbyist Julie Cantor-Weinberg.
Employer groups and insurance lobbyists were geared up to press their case at hearings on Sept. 12. But their appearances were canceled after Domenici short-circuited the usual legislative process by attaching his measure to a Senate spending bill a week earlier. Opponents had hoped to focus on the experience of Xerox Corp., which instituted parity in 1988 only to see mental health services capture 40% of its total benefit payout. The biggest growth in expenses turned out to be for "adjustment disorders" of employees coping with the stress of divorce or bereavement.
But Domenici insists that such transitory episodes aren't the crux of his amendment. Rather, he's concerned with severe mental illness--diseases of the brain with chemical and biological causes that respond favorably to new medications. The success rates for treatment range from 60% to 80%, as against just 41% to 52% for heart disease, according to the National Alliance for the Mentally Ill, a group of patients and families.
That's ammunition for Domenici's next goal: funding research to establish the physical basis of mental disorders. "If we're going to eliminate the stigma of mental illness, we'll have to start with an education process to show people these conditions are real and that they're treatable," he says. Increasing spending in deficit-obsessed Washington isn't easy, but Domenici has shown how a personal passion can beat the odds.