Parity for Mental Health: History and Consequences
By Vallerie Propper and Ginger
L. Pomiecko
Introduction
The mental health care problem
Mental illness has been historically considered different than general
medical illness (those illness categorized by non-mental illness definitions)
Mental illness only recently been recognized as a disease/disorder equivalent
to general medical illnesses, and even
more recently have we been able to make strides in treatment strategies and
policy changes supporting the mental health consumer. . Perhaps due to our lack of knowledge,
our inability to understand and outright fear of the mentally ill, mental
disorders are still deeply rooted in social stigma. There are some people
even today who think some mental illnesses are just the result of character
flaws and should be overcome with sheer willpower. A recent survey of
Americans found that stereotypes of the of the mentally ill consumer have not
changed, and beliefs about this population from the general population are
similar to those of the 1950’s..[i]
Furthermore, doctors are often unable to treat mental disorders with a simple
one-time visit and
a prescription; but instead often require long-term and expensive care.
With this in mind, it is no surprise that coverage for mental health is often
not equal to that for traditional, physical illnesses otherwise known as
general healthcare.
This difference in coverage does not reflect a lack of need. The
National Advisory Mental Health Council reports that each year 22% of the adult
population in the
While it is unclear if mental illnesses are wholly biologically based, it
is thought that there are biological components which account for portions of
disease affliction. This should be
enough to require insurers to cover mental health costs. Unfortunately this is not often the
case.
In the last fifteen years both state and federal governments have tried to
address this through the enactment of mental health parity laws. Mental
health parity laws prevent health insurance plans from discriminating between
mental healthcare and general healthcare coverage.
Parity can take many forms; it may:
· Exclude substance abuse treatment
·
Only apply to annual or lifetime benefit limits, meaning that there may be
differences in the number of outpatient or inpatient visits allowed or amount
of co-pays.
·
Be limited to “biologically based illnesses” which usually include
schizophrenia, major depression, paranoia, developmental disorders like autism,
and others that are clearly linked to chemical or developmental irregularities[v]
·
Not apply to
employers who are self-insured (this will vary by state)
·
Include
exemptions for smaller businesses
Full parity (when discussing mental healthcare) refers to a law that does
not allow any discrimination based on mental healthcare versus general
healthcare.
The Roots of Parity
Treating mental illness.
Traditionally, mental healthcare coverage has been determined by each
individual state. In fact,
approximately 85% of mental health care costs in 1956 were paid for by the
state. Not only did this funding supply
treatment, but
also housing, food, and employment opportunities.[vi] Over the
years, however, financial support for mental health care started to come less
from the state and more from private sources.[vii]
In the 70’s and 80’s (before the growth of managed care) costs to employers
for treating mental illness and substance abuse of employees and their families
began to climb. According to some estimates, the cost of treating mental
health and substance abuse problems was rising at a rate almost double than the
rate of other kinds of healthcare.[viii]
Although very high priced services, like detoxification and long-term
psychotherapy were responsible for a large part of this rate increase, many
insurance plans began to cut benefits for all mental health and substance abuse
services. These benefit cuts were further rationalized by many
employers’ attitudes about mental illness.[ix]
There were several reasons in addition to cost that may have made it easier
for insurers to decrease mental health coverage. First,
it was thought that some people were taking
advantage of mental health services by getting long courses of therapy when
they may not have needed it. Secondly, others may have felt that chronic
mental health problems and addiction should be public health responsibilities
of the state. Thirdly, many did not think mental illness
was a real disease at all and could be overcome with willpower and a commitment
to lifestyle change. Lastly, still others may have thought not enough was
known to successfully treat mental illness, suggesting any care would be
wasteful.
The first parity laws
At the same time insurers
were reducing mental health coverage, more and more states were introducing
health insurance mandates. These
mandates placed certain restrictions and requirements on all employer health
plans (The mandates did notapply to self-insured
employers due to the federal Employee Retirement Income Security Act (ERISA) of
1974. This acti
prohibits a state’s regulation of self-insured companies). The growth of such
mandates, in conjunction with an increased advocacy for equal mental healthcare
coverage, these organizations were able to encourage various forms of parity in
several of states. By 1995,
Prior to these mandates, some employers began
to look into parity as a cost effective way to decrease productivity loss and
successfully treat both mental health and substance abuse disorders of both
employees and families of employees.
A Digital Equipment Company official says regarding its 54-page “Standards for
HMO Performance”, “We believe this provides real mental health parity.”[x]
However, most states and employers in the mid-1990’s still did not have any
form of mental health parity, and those state parity laws that did exist did
not apply to employers who were self-insured. Without federal action, many
people were left with diminishing benefits.
In 1994 the Clinton
Administration attempted to shift the burden from the consumer back to either
the public or private insurer sectors by introducing a mental health parity law
in its proposal for healthcare reform (Surgeon General 1999). The proposal never made it to fruition but
was instrumental in a trend toward mental health parity and the redistribution
of mental healthcare provided by HMO’s.
The intended goal of introducing a mental health parity law was to
provide equal funding for both general and mental health services within the
managed care setting. The goal would be
to eliminate lifetime limits on mental health benefits or match lifetime limits
of mental health benefits with general health lifetime limits.
The MHPA
Federal Legislation
In April 1996, Senators Pete Domenici (R-MN) and Paul Wellstone (D-MN)
first introduced the forerunner of the Mental Health Parity Act (MHPA) as an
amendment to the Kassebaum-Kennedy bill for
healthcare portability. Both Senator Domenici and Senator Wellston,
advocates for mental health treatment (due to personal experiences), collaborated to
create a bill to requiring equal treatment for mental healthcare and general
healthcare claims. .[xi]
Senator Domenici is the father of an adult daughter
who had chronic schizophrenia that was being treated successfully at the time
of the bill, and Senator Wellstone also was acquainted with mental health
disorders through his family; his brother was dually diagnosed with bipolar
disorder and an addiction disorder.
In conjunction with Senators Domenici and Wellston, several large advocacy groups for those in
need of mental healthcare; the National Alliance for the Mentally Ill (NAMI;
for whom Senator Dominica’s wife also happened to be a board member) and the
Coalition for Fairness in Mental Illness Coverage helped to push forward mental
health parity.[xii]
Although mental health parity was initially passed in the Senate as an
amendment to the Kassebaum-Kennedy bill, Senators Kassebaum and Kennedy eventually removed all the amendments
from their bill regarding mental health parity, in an attempt to pass the bill
more easily. This resulted in Senators
Domenici and Wellstone to begin again.
Domenici and Wellstone soon attached the MHPA to the VA/HUD Appropriations
bill, HR 3666. Those in support of the MHPA threatened to filibuster if the
amendment was removed, but still faced opposition from Republicans. The vote on
this bill, with or without amendments was going to be right before an election,
making congressmen very careful of how they voted. Therefore, those in
favor of the parity act agreed to some compromises in order gain the support of
their opposition. The final bill included a sunset provision (the act
would automatically expire September 30, 2001 if not renewed), a one year wait
before going into effect, exemptions for certain kinds of businesses, and other
limitations that appeased opponents.[xiii]
The act was passed and signed by President Clinton in September of 1996 and
went into effect January 1, 1998.
What does the MHPA do? The MHPA is a very simple parity law: It prohibits employers
from having different annual or lifetime benefit limits for mental illness
versus those for medical and surgical. However, there are some
limitations to which plans this applies.
Limitations
The mental health parity act,
which applies to “most group health plans with more than 50 workers”, prevents
insurers from setting lifetime dollar limits on mental health benefits (CMS,
2002). To accompany the Mental Health
Parity Act, The Health Insurance Portability and Accountability Act was enacted
to ensure that insurers could not impose lifetime dollar limitations on
inpatient and outpatient mental health treatment. Insurance companies reacted to this mandate
by imposing inpatient and outpatient visit restrictions (NCSL, 2003). Thus, a consumer of mental health services
may demand long-term treatment but will be restricted to 60 covered visits
(both inpatient and outpatient) regardless of cost (NCSL, 2003). Importantly, a substantial gap still remains,
the law does not pertain to individual health insurance in the private market
(CMS, 2002).
Currently, in the state of
As stated previously, employers with 50 or fewer employees are exempt from
adhering to mental health parity stands.
There is also a clause states if a company can show that adhering to the
act has raised their health care costs by more than 1% they can apply for an
exemption (although there is no guarantee it will be accepted). The last provision was added partially to
quell the fears of rising costs to businesses. Although many would have
liked to be granted this exemption prospectively, it is only given once
evidence is shown there has been a true increase in health care costs due to
the mental health parity act. It was estimated that approximately 10% of
plans that had to adhere to the MHPA might experience an increase in costs
above 1% (approximately 11 million workers and dependents)[xiv]
and according to a survey by William M. Mercer of over 300 major employers,
fewer than 2% intended to try to claim the 1% rule exemption.[xv]
In addition to these exemptions the MHPA does not apply to substance abuse
treatment.. Because substance abuse and other mental
illness often occur simultaneously, the lack of inclusion of substance abuse
treatment may make parity laws more expensive in the long run, rather than
less.[xvi]
The senior vice president for medical affairs of Harvard Pilgrim Health Care
states, “Most of the folly of mental health parity laws is that they don’t
apply to substance abuse. Many people with major mental illnesses have
substance abuse problems as well. And proper treatment of substance abuse is
something we can do relatively effectively in a relatively short period of
time.”[xvii]
There is also no guarantee
that enacting such a law will increase the amount of mental health services
used. A study done by Zuvekas et.al.,
(2001), found that parity is most likely to increase the amount of mental
health services used. This trend would
easily follow a standard demand curve.
The curve would indicate that as out-of-pocket costs for services
decreased the demand for mental health services covered by HMO’s would
increase. Unfortunately, the mental
health consumer market is different than the overall healthcare market. The mental health market alone does not
appear to be consumer driven. In
contrast, insurers appear to have a significant amount of control over the
amount of treatment and providers an individual can receive and visit. What is most interesting is that despite the
demand for mental health services, insurers do not want to provide mental
health coverage. Zuvekas et al., brings
an important issue to the front. An
increase in demand is separate from an increase in service usage. Despite high demand for less out-of-pocket
spending, it would be difficult to predict an increased pattern of service
utilization. This is not to say that
there would not be an increase in service utilization, but, those lobbying for
lower out-of-pocket expenses for mental health coverage may not utilize the
services themselves.
Parity would also give insurers a large incentive to create new
restrictions to mental health care through managed care. If a company
felt that the MHPA was going to increase its health care costs, it could
respond in several ways. First, the MHPA did not prevent the overall decrease
in annual or lifetime ceilings for both mental and medical/surgical health
benefits, or the creation of one universal set of limits including mental as
well as medical and surgical benefits. According
to an analysis conducted by
Third, the insurer could place an unequal limit on the number of mental
health care visits versus other kinds of visits. Lastly, insurers could
raise insurance premiums.
Advantages.
Despite the above weaknesses, advocates have had many reasons to support
the MHPA. First, the general healthcare and mental healthcare market are
competitive. .[xviii]
Generally, health insurance plans want to attract healthy patients in order to
keep down costs; however, because people with mental illness often have a chronic
need for care, they are naturally attracted to plans with better mental health
coverage. Because mental health is so much more expensive to treat,
mental health patients are the last kind of patient an insurance plan would
want to attract. Therefore, the only way to get insurance plans to start
offering better mental health care coverage would be to require all insurance
companies to follow the same regulatory standards.
Secondly, the
MHPA also had to do with the chronic nature of mental illness. Even
though the MHPA would not keep insurance plans from creating new financial
burdens for patients, it would help to increase annual and lifetime
benefits. For people who are chronically ill, (especially those using
inpatient care) this could prevent tremendous costs. In fact, Ronald
Sturm found that children and adolescents have higher inpatient costs for
mental illness treatment. Those families
burdened by the cost of such treatments would receive greater benefits from an increase in
annual and lifetime benefits than their non-ill counterparts.[xix]
Opponents to the mental health parity act would have difficulty publicly
denying treatment due to the vulnerable nature of this population.
Lastly, there is no doubt that part of the push towards parity was a desire
for validation on behalf of those suffering from mental illness. As pointed out
by Hennessy and Goldman (2001), it is already difficult for a person suffering
from a mental disorder to seek help because the disorder impairs their
view of the world. What is worse is the reinforcement of the idea that
those with mental illness are not actually sick, and in need of care, as is
demonstrated by discriminating between mental illness and “real” illness.[xx]
The MHPA could be a first step to reducing the stigma of seeking help for
mental illness.
Opposition
to Parity
Insurers
Like general healthcare
coverage, insurers will set a lifetime limit on mental healthcare
coverage. However, unlike general
healthcare, which has a high lifetime limit in an attempt to help with any type
of catastrophic health condition, mental health services have a very low
lifetime limit. Because of these limits
the burden of cost has been shifted from the insurer to the patient. Insurers cite two main reasons for adopting a
low lifetime limit for mental healthcare: 1. Moral Hazard. This theory suggests consumers of healthcare
will increase service utilization as the insurer absorbs more of the burden of
cost. Thus, unless a consumer is forced
to share costs (i.e. deductibles and co-payments) a patient will never entirely
value healthcare at its full cost. A
study done by RAND to examine moral hazard, found not only do individuals
utilize health services more when the out-of-pocket expense is minimal but, the
outpatient service most utilized was psychotherapy (Manning et al, 1989). 2. Adverse Selection. This theory suggests that consumers of
healthcare will choose a plan that gives the most coverage for a disease or
disorder the patient will need in the future.
However, this unfairly distributes the burden of cost to those managed
care units that are willing to, and can afford to bare said costs. This would in turn suggest that these HMO’s
would be the most attractive to individuals already afflicted with a disease or
disorder. To combat adverse selection
and decrease the enrollment of the severely mentally ill in managed care
settings, insurers decided to limit mental health benefits (Surgeon General,
1999).
Although limiting mental
health coverage is successful at reducing cost for insurers, the limit placed
on benefits does not help to encourage mentally ill consumers to seek the
adequate care needed for their disorder (Bloom et al., 1998). Not only do the limitations restrict the
number of allotted outpatient visits for mental health services, a restriction
is also placed on the provider eligibility for coverage through a specific
managed care system. Consequently, these
restrictions place more barriers between the patient and treatment and may do
nothing more than discourage the consumer from seeking adequate care.
Concerns over costs.
The change in mental health
coverage under the Mental Health Parity Act does not come without cost. An analysis done using actuarial assumptions
found that “full parity” coverage for mental health and substance addiction would
result in 3.6 percent premium increase (SAMHSA, 2004). Despite the fact mental health and substance
addiction expenses would increase by 75 percent, only a 3.6 percent premium
increase would be passed to consumers (SAMHSA, 2004). This small increase is due to the small
proportion of health care expenses for mental health and substance addiction
allocated at time of enrollment.
Approximately, 4 to 6 percent of a healthcare plan is spent on mental
health and substance addictions at the time of enrollment. Premium increases are subject to variability
with regard to the type of plan a consumer is enrolled. The more stringently run HMO’s have a lower
premium, while PPO’s and FFS plans can have an increase anywhere from 5 to 5.1
percent (SAMHSA, 2004).
Although this increase is an
attempt to share a small portion of the burden of cost with the consumer, there
is a concern that there still would remain a substantial out-of-pocket
cost. Thus, many individuals requiring
mental health services may continue to have unmet needs.
In 1997, the “median” number
of days allotted for outpatient care through a managed care system was 25,
while the most number allotted was 30.
The approximately $25,000 on average as the lifetime limit for mental health
inpatient and outpatient services, often has not been enough to cover all
necessary treatments or long-term care (Buck et al, 1999). Thus indicating the high cost of both short
term and longterm mental healthcare coverage.
The cost estimates of the original Domenici-Wellstone proposal ranged from
an increase of 2.5% to 11.4%[xxi]
Many retorted that these estimates
represented costs to the older indemnity plans that did not control costs as
well as the more modern managed care plans. Parity advocates believed
that with the newer, more cost effective health care management plans,
increases in costs would be minimal if at all.[xxii]
Furthermore, they stated, that even minimal costs would be offset by gains made
from the reduced absenteeism and greater productivity that would result from
increased access to mental health services for employees.[xxiii]
The predictions of three major studies and state experiences did not,, support the idea that costs would rise significantly.
First, The Congressional Budget Office predicted a cost increase of .4% as a
result of the final Domenici-Wellstone proposal and possibly as low as .16% if
employers reduced certain other mental health benefits to compensate for the
cost of adjusting cost ceilings of their mental health coverage.[xxiv]
Finally, one of the most famous studies around the time parity was being
debated, used data from 24 managed behavioral health care plans with 140,000
enrollees and concluded that the federal law’s removal of dollar ceilings would
increase costs for a plan with a $25,000 annual limit only by $1 per enrollee
per year. This same study also found that for a plan with no deductible
and small co-payments, allowing unlimited inpatient days and outpatient visits
would only cost enrollees an additional $7 per year.[xxvi]
Roland Sturm, the author of the study thought that costs for parity in the form
of managed care, “[were] not going to go through the roof.”[xxvii]
The experiences of states that had already experimented with parity also
supplied helpful information.
These reassurances that costs would not go up significantly, may have
seemed fairly convincing, but the research done was confounded by the
introduction of managed care. As pointed out by a report by the National
Advisory Mental Health Council, “Because in all cases to date parity was
implemented in conjunction with managed care, it is difficult to assess the
effects of parity alone.”[xxxii]
No more mandates!
Another objection to
parity was the increasing intrusion of the government on the health insurance
industry. R. Lucia Riddle, vice president for government relations of the
Principal Financial Group warned that even if the cost of the MHPA is small, it
is just one of many present and possibly future mandates. “…We get hit
with a number of mandates, and those costs do add up.” She pointed out a study which
showed about 30% of every premium dollar
in state-regulated plans were due to mandates.[xxxiii]
In 1998, it was estimated by one health insurance official that the total
number of all state mandates was near 1,300.[xxxiv]
Advocates for mental health parity questioned if the increasing number of mandates strengthened
their case that regulation is necessary to ensure proper health coverage.[xxxv]
Push towards more managed care.
When parity was first introduced in many states, managed care was not as
ubiquitous or as tight as it is now. The introduction of mandates like parity
fueled the growing trend toward managed care. At least one study showed
that in the states that adopted parity laws, a switch to managed care soon
followed in almost every occasion in which parity was adopted.[xxxvi]
The Mathematica study (commissioned by SAMHSA) which looked at
the experiences of states who adopted various forms of parity before the MHPA,
found that not only did the introduction of managed care at the same time as
parity prevent an increase in costs, but it also greatly decreased the amount
of mental health and substance abuse services used.[xxxvii]
It could have been argued that if costs due to parity were kept down through
restricting access to mental health services or otherwise discouraging them,
then parity may not really be as helpful as lawmakers meant it to be.
Mental Health Parity and the Consumer
Within the last decade a
movement toward increasing mental health benefits for health maintenance
organizations (HMO’s) /managed care recipients has been a heated debate. Currently, HMO’s will only cover a set number
of outpatient care services for mental health related problems. The decision to set mental health care
benefit limitations was supported by insurers who believed an individual with a
mental illness would require an extensive amount of treatment; resulting in
increased costs and spending for long-term care and hospital visits (Surgeon
General 1999). Because of the known need
for long-term care treatment for inpatient and outpatient mental healthcare,
insurers began to limit the number of visits allotted to a patient enrolled in
a managed care system for mental health services. Consequently, consumers of mental health
services were given another barrier to overcome toward service
utilization. Consumers would now have to
pay out-of-pocket for any services needed which extended the allotted visits
for mental illness. In an attempt to
decrease the amount of money spent on high-risk enrollees (severely mentally
ill), insurers attempted to shift responsibility of long-term outpatient mental
health care from the private sector to the public sector (Goldman et al.,
1994).
The Mental Health Parity Act
of 1996 and The Health Insurance Portability and Accountability Act mandate
that dollars for mental healthcare be equivalent to that of general healthcare
coverage. However, restrictions on
number of visits are still a growing concern.
If there is no lifetime or annual limitation on dollars spent on
coverage but there is a limitation on the amount of services allowed for access
than there is by default a cap on spending.
A 2001 study conducted by Haas et.al, examined three groups; usual care,
health education, and enriched mental health benefit. The usual care group was allotted 20 visits
for outpatient psychotherapy per one year scheduled 4-6 weeks apart with a
group therapy option as well. The health
education group was given educational classes focusing on “stress management”
techniques that met once a week for 6 weeks.
This group was not provided contact with a psychiatrist or psychologist
during the study. Finally, the enhanced
mental health benefit group was provided an extensive amount of mental health
services. A psychologist was retained
for consultations and supervision of medications and other mental health
treatments. The study concluded that
those individuals in the enhanced mental health group were more likely to
utilize services. Furthermore indicating
how the removal of visit limitations would increase patient utilization.
Even with insurance it is not unlikely for an individual to be unable to
pay for mental health care treatment. It
is also not unlikely for many severely mentally ill patients to drop well below
the poverty line and become eligible for publicly supported healthcare (Ohio
H.B. 33). Within the state of
Not only do visit
restrictions decrease patient utilization of services, visit limitations
increase the potential for harm to the patient.
Despite a diagnosis of mental illness an individual is still only
allotted a specific number of outpatient or inpatient visitation days. The patient and his provider can petition to
his HMO to request an extension of visits but is most often denied. A considerable ethical dilemma is
encountered. The provider must stop
treatment for the patient because he cannot continue to pay out-of-pocket for
care, yet the decision to stop treatment was determined by a managed care
system, not a physician. An article
written by Perina (2002), most accurately portrays what is occurring in the
managed care system. “…After 30 days as an
inpatient at Porter Adventist Hospital in Denver, Hochalter's behavioral
managed-care provider, PacifiCare, ruled hospitalization no longer medically
necessary, forcing her into a partial-treatment program. One week after her
inpatient discharge, Hochalter entered a gun shop, asked for a pistol, loaded
the weapon and killed herself on the spot.”
In an attempt to lower costs by denying extended care, the managed care
system, in this case PacifiCare may have been responsible for Hochalter’s
death.
The Aftermath of Federal Parity
The management of care
As was seen in other states, and as predicted by some involved in the
federal debate, managed care found ways to circumvent increased costs due to
parity. For example, major report by
Mercer/Foster Higgins found Since the introduction of the MHPA, one third
of firms with more than 500 employees introduced changes in day or visit
limits.[xxxviii]
In addition, according to the U.S. General Accounting Office report issued in
May of 2000, 14% of employers had yet to comply with the MHPA, and of those who
did comply, 87% continued to limit their mental health benefits in some other
way.[xxxix]
Do these changes made by managed care negatively affect access to mental
health care? Yes. According to Sturm, et
al., who conducted a national household survey found
that although those in managed care are less likely to receive no mental health
care at all, they experience more delays in treatment or less treatment than
desired, than those in unmanaged care settings.[xl] A NIMH
(National Institute of Mental Health) study supports this; they found that
while the number of people seeking outpatient care increased, the number of
visits per person did not increase, and the use of inpatient mental health
services declined.[xli]
Because the managed care
system is now being forced to make changes for the treatment of acute mental
health problems, there is a growing concern that the majority of severally
mentally ill consumers will utilize healthcare in the public sector (Goldman
et. al., 1999). This presents another
problem. As severally mentally ill
consumers enter into the public healthcare sector taxpayers become responsible
for their care. This shifts the burden
of cost to yet another source. Public
sector insurance (in this case Medicaid) is supported through taxpayers and
federal entitlements (although a switch is being made to block grants). The money allotted to public healthcare
(Medicaid) requires a specific set of services be covered through
reimbursement. States are encouraged to
match or exceed the funds provided with federal dollars but are not required to
do so. Thus, some states may have
extensive coverage for the severely mentally ill while others may have less
than adequate mental health coverage. Clearly,
there is no guarantee that shifting the higher risk enrollee to public sector
insurance will ensure the individual receives the necessary and sufficient
healthcare.
Costs
NIMH assessed the findings of many large studies, including that of a large
state that introduced parity. They determined that parity contributes little
if at all to total healthcare costs. NIMH is thus far unable to
determine, however, to what degree costs were shifted between different
healthcare sectors due to parity.[xlii]
The Surgeon General also found no reason to fear parity, characterizing it as, “an affordable and effective objective.”[xliii]
Getting the ball rolling
The enactment of Federal Parity may have been the
impetus for more states to enact their own parity laws, some of which are even
more powerful than the MHPA. The NIMH (2000) report states:
“Following the 1996 MHPA, 14 States also enacted
statutes to match the federal parity statute including: in 1997, Alaska,
Arizona, Delaware, Indiana, Kansas, Louisiana, Montana, Nevada, North Carolina,
South Carolina, Tennessee, and West Virginia; and in 1998, Florida and New
Mexico. Of the 14, seven States matched the federal statute in 1997 or 1998,
and then opted to have a "stronger" State parity statute:
Different states enacting different parity laws
give rise to the opportunity for researchers to look at the effects of a
variety of legislation on health care. This could provide the federal
government with valuable ideas for parity policy supported by scientific
data.
The MHPA also may have influenced increased parity
for about 9 million employees covered by the Federal Employees Health Benefits
Program. In 1999, President Clinton had the Office of Personnel
Management benefit federal employees with not only full mental health parity,
but also full parity for substance abuse services.[xlv]
Current Legislation
The Mental Health Equitable Treatment Act
Recognizing the setting of the sun on the MHPA, in March of 2001,
Senators Domenici and Wellstone once again introduced an amendment enforcing
parity for mental health. The Mental Health Equitable Treatment Act of
2001 (S. 543), is much closer to full parity than is the MHPA. This piece
of legislation mandates that health plans that provide mental health coverage
cannot provide different regulations between mental health coverage and medical
or surgical coverage for the following: frequency of treatment, number of
visits or days in the hospital, general duration of treatment, deductibles,
coinsurance, co-payments, or other costs to the consumer.
S. 543 passed the Senate committee of Health, Education, Labor, and
Pensions, and was attached by the Senate to a fiscal
year 2002 Labor-HHS appropriations bill in October of 2001. However, S.
543 did not replace the existing mental health parity act as hoped and was
removed from the appropriations bill, however, President George W. Bush signed
a one-year extension to the MHPA, ensuring one more year of mandated mental
health coverage. The MHPA is now scheduled to expire December
31, 2002.
The
potential for expanded federal parity is far from over. As of this
writing, S. 543 is still alive in the Senate, awaiting passage.
Furthermore, on March 13, 2002, the U.S. House of Representatives Committee on
Education and the Workforce Subcommittee on Employer-Employee Relations held a
hearing entitled, "Assessing Mental Health Parity: Implications for
Patients and Employers", the first House hearing ever on parity. Shortly after this hearing, on March 20, 2002,
Reps. Marge Roukema (RNJ) and Patrick Kennedy (D-RI)
introduced a version of S. 543 to the House: The Mental Health Equitable
Treatment Act of 2002.[xlvi]
This bill is very similar to its version in the Senate, but it goes even
further in that it includes a provision for studying the cost of including
substance abuse in federal parity regulations.
Conclusion
Despite the current push for stronger federal parity, the question still
remains how effective it really is. Even when the original MHPA was first
introduced, many believed that parity would not actually benefit consumers
because in order to comply with the new requirements, managed health care plans
would just cut back in other areas.[xlvii]
The Mercer/Foster Higgins and the General Accounting Office reports mentioned
above both bear this out. Furthermore, substance abuse is still not
included as a mental illness under the MHPA. The House version of the Mental
Health Equitable Treatment Act of 2002 may move in this direction, but only by
very little.
Lastly, there are still more than forty million Americans have no health
insurance at all.[xlviii]
Some feel that we ought to be focusing first on finding a way to grant access
to basic health care for the many before we start spending money as a nation to
give better health care to the few.[xlix]
In contrast
to these arguments, modern advances in the understanding and treatment of
mental illness beg the question, why should mental illness be treated
differently? The 1999 Surgeon General Report on Mental Illness clearly
showed with a preponderance of evidence that mental illness is real illness
that can treated. Millions of people who are currently suffering could be
leading much more satisfying and productive lives, to the benefit of us all.[l]
If parity laws do not actually help the mentally ill in the short run with
improved access to services, perhaps they will help in the long run as a
symbolic gesture that mental illness is just that, an illness, and it can be
treated.
While there is no guarantee
that if Mental Health Parity was accepted by all states and visit restrictions
were eliminated, insurers in the managed care system would not attempt to find
loopholes to decrease costs. It is
evident that HMO’s will make it as difficult as possible for mental health
consumers to obtain the necessary treatment and services to maintain a
productive lifestyle. With the rising of
healthcare costs, even fewer individuals will be able to pay out-of-pocket
costs for much needed extended mental health treatments. Thus, it is imperative something is done to
ensure equal coverage in both lifetime dollar limitations and visit limitations
for those with mental illness and those with general healthcare coverage
needs.
Endnotes
[i] Pescosolido,
B, Martin, K, et al. Americans’ views of mental health and illness at century’s
end: continuity and change.
[ii] National Advisory Mental Health Council. 1997. Parity in
coverage of mental health services in an era of managed care. An interim report to Congress.
[iii]
[iv] Mental Health: a report of the Surgeon General.
[v] Otten,
A. Mental health parity: what can it accomplish in a market dominated by
managed care?. Milbank Memorial Fund
1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[vi] Fein R. Economics of
mental illness: a report to the staff director, Jack R. Ewalt,
1958.
[vii] Hennessy, K. &
Goldman, H. Full parity: steps toward equity for mental and addictive
disorders. Health Affairs 2001; 20:58-67.
[viii] Otten,
A. Mental health parity: what can it accomplish in a market dominated by
managed care?. Milbank Memorial Fund
1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[ix] Ibid.
[x] Ibid.
[xi] Levinson, CM. and Druss, BG. The evolution of mental health
parity in American politics. Administration and Policy
in Mental Health 2000; 28:139-146.
[xii] Senate vote confirms
public’s demand for parity in mental health benefits. (1996, April 24). [Newswire}. PR Newswire. As cited in Levinson & Druss. (2000).
[xiii] Levinson, CM. and Druss, BG. The evolution of mental health
parity in American politics. Administration and Policy
in Mental Health 2000; 28:139-146.
[xiv] Otten,
A. Mental health parity: what can it accomplish in a market dominated by
managed care?. Milbank Memorial Fund
1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xv] Mercer/Foster Higgins.
1997. National Survey of Employer-Sponsored Health Plans.
[xvi] Otten,
A. Mental health parity: what can it accomplish in a market dominated by
managed care?. Milbank Memorial Fund
1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xvii] Ibid.
[xviii] Frank, G, Goldman, H,
& McGuire, T.
[xix] Sturm, R. 1997. How
Expensive Is Unlimited Mental Health Care Coverage under Managed Care? Journal
of the American Medical Association 278:1533-7.
[xx] Hennessy, K & Goldman, H. Full parity: steps toward equity for
mental and addictive disorders. Health Affairs 2001; 20:58-67.
[xxi] Watson Wyatt Data
Services. 1995. 1995-96 Survey Report on Employee Benefits.
[xxii] Otten,
A. Mental health parity: what can it accomplish in a market dominated by
managed care?. Milbank Memorial Fund
1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xxiii] Ibid.
[xxiv] Congressional Budget
Office. “CBO’s Estimates of the
Impact on Employers of the Mental Health Parity Amendment in H.R. 3101.”
[xxv] Sing, M, Hill, S, Smolkin,S, and Heiser, N.
1998. The costs and effects
of parity for mental health and substance abuse insurance benefits. DHHS pub. no. (SMA) 98-3205.
[xxvi] Sturm, R. 1997. How
Expensive Is Unlimited Mental Health Care Coverage under Managed Care? Journal
of the American Medical Association 278:1533-7. As cited in Otten (1998).
[xxvii] Otten,
A. Mental health parity: what can it accomplish in a market dominated by
managed care?. Milbank Memorial Fund
1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xxviii] Ibid.
[xxix] Ibid.
[xxx] Ibid.
[xxxi] Ibid.
[xxxii] National Advisory Mental Health Council. 1997. Parity in
coverage of mental health services in an era of managed care. an interim report to Congress.
[xxxiii] Otten,
A. Mental health parity: what can it accomplish in a market dominated by
managed care?. Milbank Memorial Fund
1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xxxiv] Ibid.
[xxxv] Ibid.
[xxxvi] Ibid.
[xxxvii] Sing, M, Hill, S, Smolkin,S,
and Heiser, N. 1998. The costs and
effects of parity for
mental health and substance abuse insurance benefits. DHHS
pub. no. (SMA) 98-3205.
[xxxviii] Mercer/Foster Higgins.
1998. National Survey of employer-sponsored health plans.
[xxxix] General Accounting
Office. (200). Mental health parity act: despite new federal standards, mental
health benefits remain limited (GAO Publications No. HEHS-0095).
[xl] Sturm, R, and Kenneth Wells. “Health insurance
may be improving—but not for individuals with mental illness.” Health Services
Research 2000; 35:251-260.
[xli] National Institute of
Mental Health, Insurance parity for mental health: cost, access, and quality:
final report to Congress by the National Advisory Mental Health Council.