Creating Oregon's advance directive for health care in1989 was one of the first issues I worked on in the Oregon legislature.  My role was to assure protection of people with disabilities and mental illness in "surrogate decision-making."  The bill finally passed after many, many hearings, some contentious and emotional. 

Talking about death in public, I learned, is not an easy thing.

Four years later, Disability Rights Oregon (then Oregon Advocacy Center) played a central role in drafting a bill to create an advance directive for psychiatric care.  This bill did not touch upon end-of-life decision-making, yet fears still ran high among many consumers of mental health services that an advance directive would be used to force them into treatment and institutionalization.  Many, many safeguards were put into place to allay those fears.

Since then, I've followed discussions and studies about advance directives.  In Oregon, psychiatric advance directives are hardly ever used because doctors won't accept them.  Nationally, doctors accept health care directives less than half the time.  Studies show that white, middle and upper-middle class people are far more likely to use advance directives.  One explanation is that minority and low-income individuals are less likely to trust doctors to treat them fairly and are more likely (particularly immigrants) to believe in miracle cures.

I'm sure you know where this is leading: to the present health insurance reform debate.  I'm not going to talk about the "death panel" thing.  What more can one say?  I'm more interested in the trust thing.  Why are so many people convinced that expanding health coverage through government action is a scary proposition?  Many of these folks must have had the experience of being turned down for coverage or payment by their private insurer.  Most must have had a friend or family member denied.  Why are they not upset about that?

Perhaps one answer hearkens back to those studies of advance directive usage.  Remember that minorities and low-income folks are less trusting of professionals who they feel may devalue them.  But what if the tables were turned?  What if the main proponent for changing how health decisions are funded is an African-American with a Harvard education?  Private insurance companies, in contrast, seem to have no ethnic identities or motives other than making money.  Does health insurance reform seem like just one more threat to people who are used to being in the majority but whose complacency is being eroded by increased national diversity?

People with disabilities have always been concerned that their lives are devalued by medical personnel.  The evidence to support this fear is plentiful.  In an earlier posting, I discussed the work of philosopher Peter Singer and his proposal to treat a quadriplegic's life as half as valuable as an able-bodied person's life.  (Consider the similarity with the US Constitution that originally designated slaves as 3/5 of a human being.)  The demand of any minority population is not to be judged according to standards that dismiss its equal value.  Perhaps the demand of a majority population is to retain its perceived  advantage.

Advance directives are specifically designed to give people more personal choice in how decisions are made about their health care.  But many people who came to the legislature back in the day thought that directives would do just the opposite.  In the health insurance debate, some people feel that having more choices of coverage will eventually take away their choices.  In both cases, some feel that being given a choice means that one's choice may be coerced.  They may feel that it is better to leave these decisions to some other realm.  But that is also a choice.

It took over 10 years to get a mental health parity bill through the Oregon legislature.  But it happened. 

In 2005, Gov. Kulongoski signed into law Senate Bill 1, which said that beginning on January 1, 2007 state-regulated group health insurance policies must cover mental health and chemical dependency treatment at the same level as physical health services.  

In the years leading up to the parity law, private insurers and business interests insisted that it would cause insurance rates to skyrocket, leaving business owners no choice but to drop all insurance coverage for their employees. Advocates countered that parity would in fact save money. 

How so? Because untreated mental illness and addictions result in physical health ailments, parity advocates predicted that providing treatment in a timely manner, before costly hospitalization became necessary, would be cost-effective.

Who was right?  Although it might be too soon to say for sure, a recent report from the Oregon Department of Consumer and Business Services is making the advocates look pretty good.

The report compares claims from 2006 (before parity) and 2008.  The data show that claims for outpatient mental health visits went up 17.9% while claims for inpatient mental health treatment went down 6.2% and claims for residential mental health went down 30%.  Claims for both outpatient and residential chemical dependency treatment went up but had very little impact on the overall cost of health insurance. 

According to the report, “there appears to be relatively little impact to total healthcare claims costs.  Mental health costs remained at a little over 3.1% of insurers’ total healthcare claims costs, and insureds actually saw a small decrease in the relative percentage of overall costs attributable to mental health claims.”

So the data show more outpatient visits, fewer hospitalizations and cost neutrality.  Yay, advocates!  The fears promoted by businesses and the insurance industry have, so far, proved baseless.  This is a good example for us as the broader health insurance reform debate rages on.