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Trampling Our Values

Cash on Delivery
Looking for Love in All the Wrong Places
by Mae Bunagan

Page Inflation
The Rising Cost of Textbooks
by Lily Huang

Democrats' Dilemma
Finding a Message in Opposition
by Eli Sprecher with Danny Schlozman

Courting Disaster
The Case of Rehnquist v. Liberties
by Patrick Taylor Smith

Starving for Treatment
Inadequate Coverage for Eating Disorders
by Leah Litman

Introspective
Deconstructing the T
by Danny Schlozman

Salmagundi

The Back Page
Moore Strikes Again
by Brendan Connors

Today, we are bombarded with statistics and news stories about eating disorders. But the media have paid little attention to the treatment of eating disorders, despite the potential for significant national change in the upcoming months. The Mental Health Equitable Treatment Act (MHETA) stands before the next session of Congress. While MHETA takes the important first step of equating the seriousness of mental and physical illnesses, provisions in MHETA fail to adequately address the needs of eating disorder patients. While MHETA deals with all mental illnesses, it fails to adequately address the ambiguous place of eating disorders, which carry not only mental, but also physical and behavioral symptoms.

Eating disorders are among the most prevalent and insidious mental illnesses. The Alliance for Eating Disorders Awareness has found that more than five million people in the United States suffer from either anorexia or bulimia. Medical data set the fatality rate of anorexia nervosa (intentional starvation accompanied by extreme weight loss) at ten percent, above that of any other psychological disorder. Anorexia contributes to cardiovascular diseases, which can lead to cardiac arrest; hematological illnesses, such as anemia; skeletal damage; and other medical complications. Other related eating disorders such as bulimia result in numerous gastrointestinal complications as extreme as stomach rupture. Not all eating disorders involve excessive weight loss. The American Obesity Association (AOA) has classified 60 million Americans as obese. Like other eating disorders, obesity carries severe health risks. AOA studies have linked obesity to high blood pressure, type II diabetes, heart disease, stroke, and gallbladder disease. Responding to these statistics, the Bush administration has undertaken publicity campaigns urging Americans to exercise. Because obesity has only recently been classified as an eating disorder, few improvements have been made in treating the psychological components of the disease.

Because social values promote dieting and thinness, eating disorders are difficult to diagnose. Moreover, these illnesses often remain undetected since many sufferers effectively conceal their symptoms. Eating disorders are also dangerous since the underlying psychological factors involved become progressively harder to address. But despite such well-established information, treatment for eating disorders is still difficult to obtain.

MINIMAL COVERAGE IN MOST CASES

Regulations at the federal and state level allow insurance providers to deny or provide only minimal coverage for eating-disorder patients. Before the Mental Health Parity Act of 1996 (MHPA), insurance companies were not bound to provide any treatment for mental illnesses. MHPA required coverage of mental illnesses but permitted insurance providers to cap the amount of coverage they would provide. MHPA also allowed insurance providers-not medical professionals-to determine how much coverage was necessary. Unfortunately, this assessment often leaves eating-disorder patients without adequate professional care. Insurance providers often determine the severity of the eating disorder based on the recurrence of the disease. However, research compiled by the Eating Disorders Coalition for Research Policy and Action indicates that the absence of early treatment often leads to relapses. Thus, by the time insurance companies decide to grant coverage, patients are often at a stage where they need the most intensive and expensive treatments with the lowest rates of success. Startling statistics-collected from insurance claims by Ruth Striegel-Moore, a psychologist at Wesleyan University-indicate that insurance companies only provide coverage for ten percent of people diagnosed with eating disorders. Despite diagnoses by health care professionals, insurance companies do not pay for their treatment.

The minimum coverage required under MHPA fails to encompass the range of treatment necessary for recovery. Hospitalization costs, which can run into the tens of thousands of dollars per month, are a primary component of treatment, and include nutritional rehabilitation and medical attention to many of the physical complications of eating disorders. Hospitalization must be supplemented by various forms of therapy including nutritional and emotional counseling. Often, family members find counseling helpful in aiding their own understanding of eating disorders and in helping the patient's recovery.

Insurance companies fail to cover all the necessary components of a successful treatment program. The Eating Disorders Coalition for Research Policy and Action gathered data showing that insurance companies typically cover ten to fifteen sessions of outpatient treatment, while the American Psychiatric Association (APA) recommends forty sessions for patients identified even in the earlier stages of anorexia. Sometimes, insurance companies deny claims because patients have exceeded their authorized number of treatments-even after the patient was initially approved for care and later hospitalized for relapse. The fiscal stipulations given to patients also fall short of estimated costs for treatment plans. The Ohio Department of Health estimates that the cost of outpatient treatment is around $30,000 and that inpatient treatment costs around $100,000 per incidence of the disease. Insurance providers often cap their coverage at $10,000 for outpatient care and $40,000 for inpatient care. This inadequate coverage forces patients either to forego treatment or to pay the difference themselves, or to find other kinds of care. However, free services such as community-based support groups run by untrained caregivers are often inadequate. Several activist organizations have compiled stories of families that have bankrupted themselves to obtain the best care for family members.

Other insurance companies simply provide coverage for the physical aspects of the treatment and refuse to cover behavioral or psychological treatments. The patients are treated for physical complications such as malnutrition and dehydration, but coverage is not provided for nutritional counseling; psychopharmacology, such as antidepressants; or cognitive behavioral therapy. The patients then leave the hospital with only the symptoms and not the disease treated. According to the APA, those patients who only receive treatment for physical problems are just as likely to relapse as those who receive neither physical nor psychological treatment.

Insurance companies have also been reluctant to cover weight-loss treatments for obese patients. Many insurance providers still classify obesity as a behavioral disorder-suggesting that the patient has complete personal responsibility for it-and therefore refuse to cover even the minimal treatment provided for in MHPA. However, even though certain behaviors do correlate to obesity, insurers cover other diseases associated with high-risk behavior. Smoking contributes to lung cancer, tanning contributes to skin cancer, and unprotected sex can lead to STIs, and yet insurance companies cover all of these diseases. The role of personal responsibility in eating disorders is overstated and should not be an obstacle to insurance coverage. The treatments that insurance companies provide for obesity are usually limited to a few therapy sessions that are largely ineffective. However, other treatments may be more effective. In 1998, the National Institutes of Health (NIH) published recommendations for treating obese patients. These recommendations included physical treatments, such as surgery or pharmacology, in conjunction with therapy sessions to promote healthier lifestyles. The NIH guidelines also emphasize the importance of early intervention in treatment. Untreated patients are more likely to experience medical complications associated with obesity and their long-term psychological problems are more difficult to treat.

CHANGES IN COVERAGE

The mental health parity outlined in MHETA is a first step toward achieving obtainable care for eating disorders. Under MHETA, several barriers in the way of treatment are to be removed. MHETA mandates that insurance companies remove co-payment requirements for mental illnesses. MHETA also eliminates the predetermined limits set on treatments. The fact that MHETA provides for equal insurance coverage for mental and physical illnesses would also be illnesses and their devastating effects on patients and their friends and family.

Unfortunately, many of the shortcomings of MHPA have found their way into MHETA, which still allows insurance companies a large amount of discretion to determine who is truly “mentally ill” and eligible for coverage. In concessions to the insurance industry, policymakers have allowed arbitrary exclusions and treatment limitations to be incorporated into MHETA. For instance, MHETA explicitly says that insurance companies make the final treatment decisions.

The potential failures of the act are evident in several state parity laws that have already been enacted. Thirty-four states have passed parity laws similar to the pending Congressional legislation. However, the National Association for Anorexia Nervosa and Associated Disorders points to the fact that even in these states, eating disorders are not covered because insurance companies claim that eating disorders are not exclusively a mental illness. Insurance companies refuse to provide coverage for eating disorders on the grounds that they are behavioral illnesses, which do not fall under mental health parity guidelines.

The federal legislation provides one additional loophole for insurance companies. Unlike the many state laws, MHETA does not require insurance companies to provide mental health care. Even though it removes co-payment requirements and arbitrary limits on the number of therapy sessions, patients only reap those benefits if the insurance company decides to cover treatment, effectively nullifying any positive effect of MHETA. Moreover, MHETA does not address whether eating disorders are mental illnesses or behavioral diseases brought on by the patient's lifestyle. Therefore, insurance companies can continue to deny coverage by making this arbitrary distinction.

CAMPUS COVERAGE

While many insurance companies provide minimal coverage, others have instituted a degree of parity even in the absence of such a legal requirement. The insurance coverage offered through Harvard University Health Services (UHS) offers unlimited care from physicians, nutritionists, and psychologists. Services offered through Harvard also include numerous counseling and support groups for patients suffering from eating disorders and for those who are close to them. The Bureau of Study Counsel also offers individual and group counseling for those with eating concerns. Although long-term medical treatment can be limited by availability, insurance coverage for care provided by UHS is unlimited. The elective Blue Cross Blue Shield plan also covers twelve mental health visits to doctors outside of UHS and three other medical visits to doctors not affiliated with UHS who specialize in non-mental illnesses.

Because adolescents and young adults are at high risk for eating disorders, coverage for college students is incredibly important. A 1987 study at George Mason University reports that five to twenty percent of college women are either anorexic or bulimic. Although the level of coverage at Harvard is not available at all schools, many universities have been making efforts to improve health care for eating disorders. For instance, Wellesley recently increased its coverage so group therapy sessions are now covered under the university health insurance program.

Every person deserves to have access to quality care, especially in a time of need. Even the proposed changes to mental health's status under insurance guidelines are inadequate to help those suffering from eating disorders. Instead, they allow insurance companies to deny sufficient care rather than providing patients with the full range of treatment options that can help them overcome an eating disorder.

Questions? Comments? Please contact perspy@hcs.harvard.edu