Just days after a young man massacred a group of first-graders at an elementary school in Connecticut, Dr. Leonard Rappaport sat down with a mother who had brought her 7-year-old son in for an appointment at Children's Hospital in Boston.
The woman spread some notes out as they prepared to talk about her son, a nice boy who has struggled with behavioral issues. Rappaport, chief of developmental medicine at Children's, noticed that one of the sheets of paper had names on it, listed in three separate columns, with a line drawn through each of them.
"That's impressive," Rappaport told her. "You've got all your Christmas shopping done."
The woman looked at him and shook her head. It wasn't a gift list, she explained. It was a list of the mental health professionals she had called to no avail: Either they weren't taking new patients, or they wouldn't accept her insurance.
The list contained 66 names.
Rappaport was so taken aback that he asked to make a copy of the list. He scanned it onto his computer, and keeps it there as a reminder, an indictment of a health care system that is supposed to treat physical and mental illnesses with parity.
"Consider how much time this woman spent trying to find a therapist for her son," Rappaport said. "Think about the stress on that family. If you need a pediatrician, you might have to make three phone calls. You don't have to make 60phone calls."
The mayor of Boston declared a public health emergency Wednesday because of the flu. On the same day, Lenny Rappaport sat in his office, explaining that there is a public health emergency facing this city, this state, this country, and it has nothing to do with the flu. It has to do with the pitifully poor access to good mental health care, especially when compared to the care available for physical illness.
"There is a law that requires parity, but there is no parity," Rappaport said. "Like everything else, it's economics." Insurance providers outsource their mental health coverage to companies that are better at saying no.
"They don't outsource their cardiac coverage," Rappaport said.
But it's beyond insurance companies.
"There's no parity out there," Rappaport said, pointing his finger toward a window. "There's stigma. People with mental illness are openly discriminated against."
Congress passed and President George W. Bush signed the Mental Health Parity and Addiction Equity Act in 2008, requiring Medicaid plans and group health plans to cover mental health and substance abuse the same way they would other illnesses. But the final regulations that would enforce that law have not been issued, so confusion reigns and insurance companies often say what they say best: no. Massachusetts law guarantees only limited parity.
Confusion and inequity on reimbursements, meanwhile, feed the other side of the equation, making it less attractive for professionals to go into the field, while creating a disincentive for established mental health care professionals to take on patients covered by insurance.
Lenny Rappaport reveals the worst kept secret in town when he says, "The best therapists and psychiatrists in the Boston area are fee for service."
Out of pocket, or you're out of luck.