Mental health professionals have hailed the prospect of federal legislation mandating parity of mental health with other health services. Our enthusiasm should not obscure awareness of the sadly inadequate methods of financing health care in general in this country. If mental health achieves parity, we must ask, "Parity with what?"
Since major health care reform legislation died in Congress, the emphasis has been on "incremental reforms," such as the Kennedy-Kassebaum portability bill, the President's proposal to extend eligibility for Medicare, and a proposed Patients' Bill of Rights. Since 1993 the growth of health care costs in the U.S. has slowed, but the number of uninsured Americans has risen. The debate on health care tends to focus on tangible details, such as lengths of hospital stay for new mothers. Also since 1993, fundamental conceptual issues have largely been avoided. One reason is the annoying reality that it is not possible to simultaneously maximize access to care and quality of service and minimize costs. Second, we must acknowledge that, de facto, society regards some health care services, such as obstetrical services, as social goods or inherent primary rights, and others, such as liposuction or psychoanalysis, as discretionary commodities.
If we want to keep a lid on costs and do not want to compromise quality, access to discretionary health care products has to be managed—or, put bluntly, rationed. Services perceived as discretionary are most efficiently managed and distributed through market forces. It follows that services perceived as essential rights should not be subjected to the "invisible hand" of the market. Free, universal access should be guaranteed to the latter services, not the former.
The debate then shifts to which services fall into which category. The Oregon Medicaid project of the late 1980s has provided a useful blueprint. Subsequent to such classification, the services delineated as essential must be removed from the fragmented payer structure of a competitive market and, instead, treated like police services and fire protection—provided without question. At the same time, elective services should continue to be subjected to the supply-and-demand dynamics of the free market to achieve efficient distribution at an equilibrium price.
Inherent in such a restructuring would be abandonment of the historical nexus between employment and health insurance. We would need to replace the current mosaic of taxes, insurance premiums, deductibles, and copayments by one revenue flow for essential health services. Such a revenue flow would most likely be generated through a progressive user-fee assessment on income.
