Like many structural shifts in public policy, it often takes a horrific tragedy to move us to do the right thing. Case in point-Timothy’s Law. Named after Timothy O’Clair, a 12-year old boy who committed suicide shortly before his thirteenth birthday, the law requires that insurance companies provide equal coverage for mental health treatment and treatment for physical ailments. This article will discuss the struggles of Timothy and his family and the ultimate passage of the law. Timothy’s story is important because it captures, in the most tragic and unfortunate manner, the difficulties families face in attempting to obtain mental health treatment for those they love. This article will also discuss the state of the law prior to the passage of Timothy’s Law and address the movement to broaden the coverage mandated in Timothy’s Law. Lastly, the article will discuss the nuts and bolts of Timothy’s law and what it requires in terms of insurance coverage.
Timothy O’Clair, born in Schenectady, New York on May 5, 1988, grew up as any normal little boy would, playing baseball, fishing, and bowling. As he continued to age, it became evident to his family that he was having difficulties. It started with problems staying focused and grew into a quick and ardent frustration that eventually developed into serious issues with his temper. The O’Clairs knew that they needed help for Timothy.
Although the O’Clairs had health insurance, they quickly learned that the coverage they received for the treatment of physical ailments was vastly different from the coverage provided for mental health issues. Timothy was allowed only 20 visits per year for psychiatrists and psychologists combined. And after only a few visits, the co-payment rose from $10 per visit to $35 per visit. The O’Clairs suffered significant financial difficulties trying to pay the medical bills, and worse, they were not able to obtain all of the treatment their young son needed. The cause of this was the fact that they used the allotted number of visits and further treatment was too costly for them.
Timothy’s difficulties began to escalate. In the 4th grade he refused to attend school. He had his first psychiatric admission in 1998 at Four Winds Hospital because he started engaging in seriously dangerous behavior like throwing rags in the furnace at his house. Although his treatment had not yet been completed, Timothy returned home when his parents’ insurance company would no longer pay for his stay.
Just a year later, with further behavioral disturbances and spotty treatment because of financial issues, Timothy was hospitalized yet again. Over the years, Timothy carried rather significant psychiatric diagnoses, such as Depression, Attention Deficit Disorder, and Oppositional Defiance Disorder.
Because the O’Clairs were rendered helpless in obtaining adequate treatment they were forced to make one of the most difficult decisions faced by a parent; relinquishing custody of their child. Once Timothy was in foster care, he would immediately become eligible for Medicaid, which would pay for the treatment he needed.
In foster care, Timothy bounced around the system. For the first few months he lived at a state-run residence in Albany, he then went to live with a foster family, whom the O’Clairs found completely unacceptable, and then to another state-run foster home. After a brief respite at home Timothy was finally sent to a residential placement center for about a year.
After what his treating clinicians thought was significant improvement, Timothy returned home. Unfortunately, within a short period of time, his condition deteriorated. On the day of his death, he started destroying his sports trophies, emptying the contents of his drawers, and threatening to take his own life, as he had many times before. When his parents returned home from work, they found Timothy in his bedroom where he had hanged himself in the closet. This horrific event caused Timothy’s family to become staunch advocates for a law that would guarantee parity for mental health insurance benefits within the State of New York.
The State of the Law Prior to Timothy’s Law
Prior to the passage of Timothy’s Law, the only protection for mental health insurance benefits was the rather slim Federal Mental Health Parity Act passed in 1996. This law requires large employers, defined as having 50 employees or more, to provide coverage for mental health treatment, although the treatment is capped at $5,000 per year and a total of $50,000 in one’s lifetime. Simply put, this is a paltry amount in comparison to the exorbitant costs of mental health care for an individual with a serious mental illness.
A few years prior to the passage of Timothy’s Law, a mental health advocacy group in New York City sued the New York State Insurance Department, contending that existing non-discrimination insurance laws demanded that mental health coverage be on par with coverage for physical illnesses. The case went to the Court of Appeals, the highest court in New York. The Court concluded that there was no discrimination where an insurance company provided less coverage for mental health benefits as compared to benefits for physical illnesses so long as the rules were the same for everyone. In other words, because everyone had unacceptable coverage for mental health benefits, regardless of whether or not you suffered from a mental illness, there was no discrimination.
At last, in the final days of 2006, the New York State Legislature passed, and the Governor signed, Timothy’s Law. Under Timothy’s Law there is a requirement for a base benefit for all employer-based insurance plans, regardless of the size of the employer. This benefit requires that the insurance plan provide a minimum of 20 out-patient mental health visits per year and 30 inpatient mental health days per year. Often this is referred to as the 20/30 base benefit. Most importantly, the co-payments for this mental health coverage must be equal to the co-payment for any other medical visit.
For larger employers, those with 50 or more employees, employers are required to provide insurance with unlimited mental health coverage for biologically based mental illnesses. These illnesses include, major depression, schizophrenia/psychotic disorders, bipolar disorder, delusional disorders, anorexia, bulimia, panic disorder, and obsessive-compulsive disorder. Additionally, small employers must provide their employees with the option to buy into this broader coverage.
Unquestionably, this change in the law is not only equitable, but cost effective as well. A 2002 study conducted by PricewaterhouseCoopers, based upon 34 states that already had mental health parity laws already in effect, concluded the total cost of implementing Timothy’s Law in New York would be $1.26 per insured individual per month. As further evidence of this point, major insurance providers in western New York have indicated that only 1% of the rise in insurance premiums in 2011 is due to Timothy’s Law as State funding for the law expires.
At such a limited cost it is difficult to understand why it took so many years for Timothy’s Law to become law. Moreover, when one considers that the American Medical Association estimates that more than $44 billion is lost annually in worker productivity as a result of depression alone, Timothy’s Law simply makes sense both morally and economically.
The Extension of Timothy’s Law
Presently, there is a push to extend Timothy’s Law’s coverage to those who suffer from Post-Traumatic Stress Disorder (PTSD). The amendment would include PTSD in the 20/30 base benefits. It would also include coverage during the acute phases of the illness including inpatient and out-patient treatment in order to bring the person to stability. Again, looking to the minimal cost and likely potential savings, it makes financial sense for this amendment to pass. Moreover, there is increased concern, and rightly so, for the mental health issues that many returning veterans must deal with after the impact of living in a war zone. Clearly, including PTSD within the ambit of coverage for Timothy’s Law would be of great assistance to this population of individuals. Unfortunately, as of the writing of this article, the amendment has not become law.
The enactment of Timothy’s Law has proven to be of immeasurable benefit to those in need of mental health treatment. As the readers of this article are surely familiar with the ravages of a chronic mental illness, we know that like any other illness, mental illness requires care and treatment from trained professionals on a regular and sustained basis. This care is costly and requires adequate coverage under existing health insurance benefits. Timothy’s law provides that coverage. The only sad point is that it took the tragic death of a young boy to force policy makers to recognize the right thing to do.