"Equity" and "parity" are important concepts for mental health professionals generally, and psychiatrists in particular, as the debateabout the future of mental health care continues. Yet, the concepts of both "equity" and "parity" are neither well understood nor clearly differentiated.
Most often, those advocating equity affirm thereby that health service should be accessible, available and utilized by patients according to illness and need, not according to income, insurance coverage, race, geographic locale, age, sex, education or other characteristics unrelated to need.'
Parity means that mental health service should be as accessible and available to patients as general health services. There should be no additional barrier (financial or otherwise) to the utilization of mental health services.
Thus defined, parity will lead to increased equity. A problem arises however, if we expand the concept of equity to include not only access, availability and utilization but also equitable distribution of the cost of care across all of society. Now we find that parity may not lead to equity.
Evidence suggests that accessibility, availability and utilization of psychiatric services continue to be determined by social status, income and third-party coverage.2 Continued disparity between support for general health as compared to mental health services appears to contribute, in part, to the persistence of inequities in psychiatric care. However, further analysis is required before complete parity can be advocated as a way to achieve equity. This article will briefly examine the history of equity and parity in mental health services, review selective data on these issues, and explore the relationship between equity and parity.
THE EMERGENCE OF A TWO-CLASS SYSTEM OF CARE
In the United States, the search for an equitable distribution of mental health services dates to the social reform movements of the early 19th century. Initially, "moral treatment" was an egalitarian approach to psychiatric care. However, the early flower of moral treatment in private and public asylums wilted quickly, giving way to a two-class system of mental health care. The failure of private institutions to serve the poor, the immigration of "foreign insane paupers," and the shift of large numbers of patients from local facilities to state-operated asylums all burdened the public sector beyond its capacity to provide quality service.4
Furthermore, throughout the 19th and early 20th centuries, expenditures per patient week in public mental hospitals remained low in comparison to patient expenditures in private asylums or in general hospitals, such as the Massachusetts General Hospital.5
During this period in history, virtually all formal, specialized mental health care was institutional and health insurance was essentially non-existent. The mental health care system was segregated from the general healthcare system and private asylums were separated from public asylums. Inadequately funded public institutions served the poor and well-endowed private institutions served the rich. Although this two-class system of mental health care mirrored the inequities of the general healthcare system, disparity between levels of funding for general health and mental health services exaggerated these inequities in the mental health care system. A poor patient suffering from "dropsy" on the charity wards of the Pennsylvania Hospital or Massachusetts General Hospital probably fared better than his indigent relation plagued by "moral insanity" and cared for in the state asylum.
THE PERSISTENCE OF A TWO-CLASS SYSTEM OF CARE
Inequities in mental health services, documented in the classic studies of Paris and Dun ham6 and Hollingshead and Redlich,7 persisted into the mid 20th century. By 1950, outpatient treatment had become a measurable component of mental health services, and like inpatient care, it too was inequitably distributed. High intensity treatments, like psychotherapy, were primarily available to the rich; the poor received low intensity treatment in public dispensaries and state and county mental hospitals.7
Furthermore, prevailing opinion suggested that psychotherapy was suitable only for the well-to-do, articulate client. Numerous studies confirm this self-fulfilling prophesy.8-11 However, as we shall see, "all the evidence is not in" on this issue.
The advent of insurance coverage for inpatient healthcare in the 1930s ignored mental health services. It seems likely that the lack of parity in insurance benefits helped to perpetuate the polar two-class system of mental health services. The expansion of general hospital service for the insured middle classes did not include psychiatric care until the early 1950s, when inpatient mental health benefits were first made available in insurance policies. Only then was there some erosion of the sharp division between public and private hospitals. However, the poor were still served predominantly by the public sector in public general hospitals, in state mental hospitals and in VA facilities. Some have argued that general hospital psychiatry only reinforced the two-class system.12
ATTEMPTS TO ELIMINATE THE TWO-CLASS SYSTEM OF CARE
Several Federal programs of the new social reform movement of the 1960s tried to further erode the inequities in mental health care. The Community Mental Health Centers (CM HC) Program was one such attempt to bring psychiatric treatment to the majority of Americans. Yet this program, despite ambitious goals, was modestly funded. Federal dollars were provided as "seed money" and as this funding declined, CM HCs were expected to find other financial resources. Therefore, as CMHCs approached their last year of federal support, they looked to patients with higher incomes and better third-party coverage. As a result, poor patients often revert to care in public hospitals, a trend undermining the attempt to redirect services from the institution to the community. Too often "deinstitutionalizatton" has resulted in the transfer of the support of patients from state dollars to federal funds with little provision for community support and clinical services.13.14
At the same time that the CMHC Program was initiated, Medicare and Medicaid appropriations put purchasing power in the hands of the elderly and the poor. In general, these programs have succeeded in redistributing healthcare more equitably.15 However, disparity between health and mental health coverage continues. Medicare outlays for mental illness in 1979 were estimated at just over $500 million, or 1.8% of total expenditures. Medicaid outlays (federal and state) total nearly $1.9 billion, or9.6% of total expenditures (Health Care Financing Administration, 1979). Total federal expenditures for mental health account for only 4% of total federal healthcare expenditures, while recent estimates indicate that the cost of direct mental health care alone amounts to roughly 15% of all direct health expenditures in the US.16 In addition, private insurance coverage accounts for 12% of total psychiatric costs, compared to 25% of general medical costs. State "categorical" dollars account for over 30% of mental health care costs, compared to 12% of general medical costs.8
A combination of factors, including the lack of insurance coverage, have perpetuated the two-class system of mental health care. Data reported in 1975 to the Division of Biometry and Epidemiology of the National Institute of Mental Health suggest that inequities still characterize the pattern of utilization of mental health services. Uninsured, non-white patients with chronic and more severe diagnoses (organic brain syndromes, schizophrenia, alcoholism) predominate in public institutions (state and county mental hospitals, VA hospitals, and CMHCs) when compared to private institutions serving a better insured, white population with less severe, acute disorders. Numerous local studies of utilization of mental health services echo these national trends.2 Inequities exist with respect to distribution to facility type and the availability of particular services.
PSYCHOTHERAPY AND THIRD-PARTY FUNDING
It is clear that lack of insurance coverage for the disadvantaged is a barrier to equity in mental health services. It also seems certain, especially in the area of inpatient care, that disparity between health and mental health insurance coverage has contributed to the perpetuation of the two-class system of care. However, lack of insurance is not the only hurdle on the road to equity. Nor is parity necessarily the best or only solution.
A case in point is the controversy over third-party funding of psychotherapy. If coverage of psychotherapy on par with other ambulatory medical services results in the redistribution of resources from the poor to the rich, then parity does not imply equity. This argument, discussed in detail by several authors,11,17,18 raises a number of critical issues:
* Pattern of utilization - to what extent do the duration, quality, and effectiveness of treatment depend on the extent of coverage?
* Need - is need dependent on various sociodemographic and economic variables? Do the rich have a "greater need" for psychotherapy?
* Demand - will the rich claim greater benefits than they contribute to the insurance system through taxes?
Given a limited supply of resources for psychotherapy or for inpatient care, even an increase in demand produced by increasing insurance coverage may not result in equity. Other barriers have been and could be established to limit access to and utilization of scarce services. Geographic locale, age, educational level, race, appearance, and religion have ail been shown to discriminate between patients, independent of income and/or insurance.1 In addition, service utilization patterns are difficult to change, as Liptzin demonstated in his study of the health insurance experience in Canada.19 Populations which traditionally have used public hospitals in Ontario continue to use these faculties even after the initiation of the National Health Service.
Thus, the dilemma for policy makers and researchers alike lies in the possibility that providing equal access to all care for all individuals will force the poor to assume an unfair portion of the total cost of care since they apparently use fewer services.
In order to identify areas for future research and to create a framework for analyzing models for the future organization of mental health care, let us examine more closely the distributive component of equity. In the most general sense, inequity arises because of a mismatch between what is needed and what is demanded in the marketplace. Need (in a strict sense) is not a matter of individual choice, whereas demand is discretionary. Demand depends on a combination of economic conditions and characteristics of the individual. Thus, only in the rare circumstance where economic conditions and the mix of individuals in a market produce a demand that equals need, will there be no potential conflict between equity and parity.
This raises the question as to whether all mental health services are equally open to discretionary behavior. In other words, does the same discrepancy exist between need and demand for all mental health services? This does not seem to be the case.
For example, the decision to seek inpatient psychiatric care for severe disorders can be viewed as offering relatively little discretion. Empirically, rates of treatment (especially hospitalizaron) of severe disorders are remarkably stable. It is expected that virtually all actively, severely disordered individuals are "under care." In such cases, need and demand are practically identical.
In contrast, visits for outpatient treatment are much more a matter of individual choice. An example is the enormous expansion of ambulatory episodes of care between 1955 and 1975, during which period inpatient episodes of care changed very little.20 Patients may seek this type of care for a wide range of services (eg, psychotherapy, medication, evaluation) for a variety of problems (eg, neuroses, chronic psychoses, "problems in living"). The choice of services will depend upon a number of factors, including the individual's ability to pay. In this case, demand and need may diverge significantly. The extent of this potential divergence remains to be measured.
In "National Health Insurance, Psychotherapy and the Poor," Edwards and his colleagues review the evidence on patterns of demand and utilization of psychotherapy." Based on results which indicate that the poor will use ambulatory mental health services and that they are not always discriminated against by providers, they concluded that "National Health Insurance coverage for psychotherapy need not be a subsidy from the poor to the rich." McGuire21 has come to a similar conclusion. Clearly, if this is the case for the most discretionary of services, then parity and equity are compatible for other, less discretionary services.
However, the controversy continues. It is interesting to note how similar our problem is to the controversy which raged in days past about public subsidies for secondary education. History finally proved wrong those who argued that public education would only serve the interests of the rich at the expense of the poor.
As far as our problem is concerned, we hold that patterns of provider and patient behavior can change. Certainly, further research is necessary to clarify some of the important questions which remain. However, beyond the need for data, there is a need for a continuing commitment to the pursuit of equity in mental health services.
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