Mental Health Parity: Past, Present, & Future

Past

     For decades, there has been unequal treatment of mental health conditions as compared to physical health conditions, specifically regarding health insurance coverage [1].  Researchers, mental health advocates, and patients have fought for parity for quite a while, gaining little ground. 

     Some advances were made in September 1996, when President Clinton signed the federal Mental Health Parity Act, into law.  It prohibited limits on annual and lifetime mental health coverage [2].  However, more needed to be done as limits on visits for outpatient or days for inpatient still existed [2].  Secondly, the law did not apply to substance abuse [4].  The Act expired on September 30, 2001 [3]. 

Present:  2007-2009

     In the fall of 2007, the Senate passed the Mental Health Parity Act and the House of Representatives approved the Paul Wellstone Mental Health and Addiction Equity Act in March 2008 [1].   The two bills were reconciled and Bush signed full mental health parity into law on October 3^rd, 2008 to close the discrimination gap for those wanting health insurance coverage for mental health and substance use diseases [6].  The law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (HR 6983), closes some of the loopholes (e.g. eliminating limits on outpatient visits) from the 1996 Mental Health Parity Act. 

     The new law, effective January 1, 2010, applies to: group health plans with more than 50 employees, Medicaid managed care plans, and some State Children’s Health Insurance Program plans [2, 6].  It is included as an amendment to the Employee Retirement Income Security Act (ERISA).  The Act requires that the financial requirements and treatment limitations can’t be more restrictive for mental health/substance abuse services than for medical/surgical services [6].  Insurers will not be able to limit coverage that is “medically necessary.”  There are some exemption clauses, which should be addressed in future legislation. 

     In July 2008, Congress also passed the Medicare Improvements for Patients and Providers Act, to phase in federally mandated mental health parity for Medicare beneficiaries, although all states except for two (Idaho and Wyoming) have existing mental health parity laws [2].  The current Medicare beneficiary cost for psychotherapy and other mental health services will be reduced to 20% by 2014 [2].  The Medicare Improvements Act also expands Part D benefits regarding mental health, including coverage of two new medication classes:  benzodiazepines and barbiturates [2, 8].

Future:  2010 and beyond

     It is likely that utilization of medially necessary mental health services will increase after January 1, 2010.  [9].

     It is less likely that costs for mental health services will increase.  A study of the Federal Employees Health Benefit (FEHB) Program found that parity in health insurance does not increase costs for behavioral health care [10], and the Congressional Budget Office stated that adding mental health parity will increase health insurance premiums by less than .4% annually [2].  Costs were also reduced with full mental health substance abuse parity for children in the FEHP [12].  However, special attention will need to be paid to keeping costs under control while maintaining and improving upon quality health care services. 

     Despite the promises of the 2008 parity legislation, we are not without a good number of limitations.  First, the insurance parity is limited in scope and does not apply to group health plans with less than 50 employees, Medicare Part A, Medicare managed care, or individual insurance plans [9]. 

     Secondly, only 4 of the 179 quality indicators included in the National Healthcare Quality Report (issued by the Agency for Healthcare Research & Quality) are related to mental illness and the Institute of Medicine (IOM) has suggested new quality measures for mental health care [13, 14].   This will take significant resources, but needs investing in to better assess quality of care for mental health. 

     Third, even if co-payments are made equal for mental health services and medical services, most mental health services cost less than medical health services (e.g. using social workers and group therapy) and therefore may actually still represent higher coinsurance for value of service provided [9]. 

     Mental health parity has been a topic of concern for decades and we are currently making significant strides toward achieving equality of services for mental and substance abuse disorders.  The recently passed Paul Wellstone and Pete Domenici Mental Health and Addiction Equity Act of 2008 provides some promise toward the goal of mental health parity.  However, time will tell the true impact of the Act on equality of mental health and substance abuse services.  There is a great amount future work and implications for researchers, policymakers, professional organizations, patients, providers, and payers.  As our health system enters reform, mental health services will need to be handled with equality to medical services.  

References available upon request, but cut out due to space limitations.  This is an excerpt of a paper I wrote for Managed Care & Health Insurance at Johns Hopkins.  This breakthrough legislation of 2008 is huge for health advocates, patients, and health providers.