Anna L. Zendell, MSW School of Social Welfare, University at Albany,
State University of New York
NADD U.S. Public Policy Committee
Access to comprehensive mental health services has long been a struggle for people with dual diagnoses. Health insurers typically provide less coverage (visit caps, higher co-payments, and higher deductibles) for mental health and substance abuse than for general medical care. This inequity can lead to adverse outcomes. Many people with co-occurring developmental disability and mental disorder, particularly children, are covered under their parents' insurance plans and regularly face this disparity.
The federal government and most states have passed laws to restrict these practices. The Mental Health Parity Act (MHPA) of 1996 prohibits insurers from placing lifetime and annual dollar limits on mental health benefits. By October 2003, 46 states had enacted their own parity legislation (NCSL, 2003), though most require only limited parity. Not all states cover substance abuse and many do not cover the full spectrum of psychiatric diagnoses. Arkansas, Maryland, New Hampshire, New Jersey, and New Mexico offer comprehensive parity for most mental illness (NCSL, 2003).
The MHPA requires that dollar limits for both medical and mental health coverage be identical when both types are offered as part of a group insurance plan. It does not apply to plans with fewer than 51 workers, or to health insurance coverage obtained through the state, welfare assistance, or on the individual market. It does not affect companies that do not offer mental health benefits. The MHPA contains loopholes that have spurred congressional leaders and advocates to seek more comprehensive parity legislation. For example, the General Accounting Office found that plans cut costs by imposing stricter limits on medications and outpatient mental health care (Kjorstad, 2003). The law also did not provide a definition of mental illnesses to be covered, allowing insurers to defray costs by limiting types of psychiatric disorders covered.
Many advocates are frustrated by the lack of improvement in mental health care access and utilization. A growing body of evidence suggests that comprehensive parity is affordable and would improve the lives of people with psychiatric disorders. The U.S. Surgeon General (1999) reports that, in states requiring parity, cost increases were nearly imperceptible as long as the care is managed. An actuarial analysis by the National Advisory Mental Health Council estimates that full parity would increase premiums by only 1.4% (Feldman, Bachman & Bayer, 2002).
The Senator Paul Wellstone Mental Health Equitable Treatment Act (MHETA) of 2003, presently under consideration in both the House and Senate, is intended to sharply reduce insurance disparity. Originally introduced in 2001, the MHETA would prohibit group plans from imposing treatment limitations or financial requirements on mental health benefits unless the same requirements were placed on general medical benefits. It would require coverage for all categories of mental disorders under the DSM-IV and close loopholes on time limitations for coverage, deductibles and co-payments. Employers of fifty or fewer people would still be exempted. Standard managed care tools such as prior authorization, preferred within-network coverage, and utilization reviews would be permitted to maintain affordability for employers and accountability among providers.
The MHETA would greatly reduce insurance inequity, sharply reducing fears for many individuals and families of exceeding insurance caps before the person stabilizes or receiving less effective intervention due to insurance. This landmark legislation has the support of President Bush, over two-thirds of the Senate, half of the House, and advocates from most disability groups (Kjorstad, 2003). While the MHETA does not cover Medicaid or Medicare, it may be a stepping-stone to passage of parity legislation for these two programs over time.
Nearly 300 national organizations support this legislation, including The NADD. Despite this broad-based support, business and insurance lobbies have consistently blocked passage, citing fears of dramatic cost increases. While some factions appear willing to compromise, many compromises would involve covering only the most "severe" mental health disorders, a move that would limit diagnoses covered for persons with co-occurring disorders.
This year will be crucial for the MHETA. Senators Domenici (R-NM) and Kennedy (D-MA) are planning to move the MHETA to the full senate for a vote early this spring. Advocates must follow the bill through both houses of Congress to assure that it is not weakened or set aside. Advocacy organizations, including The Bazelon Center, National Alliance for the Mentally Ill, The ARC of the US, and National Mental Health Association, provide action alerts informing people how to influence important legislation, such as writing or telephoning congressional representatives. Additionally, the Parity Hotline (1-866-PARITY4) provides direct access to the Capitol switchboard and connects directly to senators and representatives.
The importance of contacting local congressional representatives cannot be emphasized enough. Passage of the MHETA would help dispel the societal norm that people with mental disorders, particularly those with co-occurring developmental disabilities, are "less deserving" of treatment than those with physical illnesses and would dramatically improve treatment options for persons with dual diagnoses.
Feldman, S; Bachman, J. & Bayer, J. (2002). Mental health parity: a review of research and a bibliography. Administration and Policy in Mental Health, 29(3), 215-228.
Kjorstad, M.C. (2003). The current and future state of mental health insurance parity legislation. Psychiatric Rehabilitation Journal, 27(1), 24-42.
National Conference of State Legislators. (2003). Mental health parity. State Health Lawmakers' Digest 1(2). Retrieved from http://www.ncls.org/programs/health/forums/shld/23.htm.
US Department of Health and Human Services (1999). Mental health: a report of the surgeon general. Rockville, MD: National Institute of Mental Health.