Health Affairs, 25, no. 3 (2006): 706 doi: 10.1377/hlthaff.25.3.706 © 2006 by Project HOPE	New Online   New Issue: China & India   Obesity In China   Pay Cuts For Medicare Docs   Access To Care Woes

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Regulation & Policy

PROLOGUE

Regulation And Policy In Mental Health

The papers and Perspectives show how debates over policy and regulation have interacted and reemerged to shape policies, regulations, and definitions. In different ways they portray how complex and fragmented mental health care and policy have become. To begin, Julie Donohue’s paper anchors us in the present-day debate over Medicare Part D and Medicare’s mandate to pay for and thus regulate psychotropic medications. Donohue notes that once the decision was made to provide coverage, a host of regulations and procedures ensued to counteract problems with adverse selection and insurers’ countervailing tendency to underinsure.

Next, Nancy Tomes looks at a different side of the regulatory picture. Her paper chronicles the conflict about who should regulate. She highlights the rise of the consumer/survivor movement in mental health. Born out of the radical restructuring of the mental health system in the 1950s, the movement inspired ex-patients to demand a seat at the policy forum as people who possessed unique insight into mental illness. Some found this development empowering; others viewed it warily. To Tomes, the movement is a consequence of broader fragmentation and politicization of the mental health system, in which many stakeholders, not always successfully, navigate a system broken into pieces.

Tomes’s piece evoked differing reactions. Robert Bernstein applauds the rise of the consumer movement and urges it to continue its vigilance and not fall victim to marginalization in a fractured health care system. Steven Sharfstein and Faith Dickerson concur with Tomes’s findings but take issue with her definitions, finding important political and historical differences between consumers and survivors.

Finally, Howard Goldman and Gerald Grob remind us that definitions and history matter. The history of mental health policy is also the history of definitions of mental health, and, particularly in contemporary parlance, severity of impairment. Expansive definitions of disease and impairment led to the inclusion of Alzheimer’s disease coverage in Medicare, which then led to expansion of coverage for all mental disorders. Defining what impairment is, how severe it is, who is impaired, and who is qualified to decide continues to roil doctors, patients, and policymakers, with enduring ramifications for our society and ourselves.

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