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Although all the attention was focused on the financial ramifications of October's Emergency Economic Stabilization Act of 2008 (HR 1424), mental health providers across the country rejoiced that patients were receiving a bailout of their own in terms of breaking down barriers to much-needed care.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which was rolled into the financial bailout package, closes loopholes in an earlier law that ultimately paved the way for a private insurance system where mental health provisions were often weighted differently than physical health benefits.

Mental Health America hailed October 3 – the day President George W. Bush signed the legislation into law – as "a great civil rights victory." The American Psychiatric Association called it "a win for patients," and the American Psychological Association deemed it "historic legislation."

Provisions of the bill broadly outlaw health insurance discrimination against those seeking treatment for mental health or substance abuse.

"The bill is in many respects a very simple one," said Ralph Ibson, vice president for government affairs for Mental Health America (MHA) – formerly the National Mental Health Association. "It essentially prohibits a group health plan from imposing stricter treatment limitations or financial requirements on mental health coverage than on general health coverage if that plan offers mental health benefits."

The new law provides parity for 82 million Americans covered by self-insured plans and also protects an estimated 31 million more citizens in plans subject to state regulations by setting the new federal law as the minimum acceptable standard. While most plans currently offer mental health benefits, it has been common to see a limit on the number of outpatient visits or days of hospitalization allowed in a calendar year. Additionally, it wasn't unusual to find higher co-pays for mental health services.

"Implicit in this law is a recognition that mental health is integral to overall health," Ibson stated.

To understand how mental health parity became part of an economic bailout package, Ibson said you have to view the progression of the parity issue … and know a bit about how things work in Washington, D.C.

In 1992, mental health providers, representative associations and other interested stakeholders began lobbying Congress to pass some sort of measure to ensure access to care for mental health on par with that for physical care. Evidence-based data, the advocates argued, clearly indicates the correlation between mental and physical health. By 1996, Congress did approve legislation that required equality in terms of lifetime limits, but that law unintentionally opened the door for new barriers to spring up.

Ibson said a study of the law's implementation by the General Accounting Office, which was released in May 2000, found that most employers did comply with the letter of the law but did not comply with the spirit of the law. About that same time – in April 2000 – the Clinton administration directed health plans participating in the Federal Employees Health Benefits Program to institute true mental health parity.

"Both of those events were powerful levers for advocates to close the loopholes in the '96 law," Ibson noted of the GAO report and Clinton policy.

He added, "Year after year, individual states were adopting their own parity laws – some stronger than others." Ibson noted that by the time the new law passed in October, an overwhelming number of states had some type of mental health parity law on the books. However, he pointed out, those provisions were for state plans and didn't apply to self-insured plans in the corporate marketplace.

By 2008, there was broad, bipartisan agreement that a stronger federal law needed to be passed. However, coming to a consensus on the specific provisions and a funding mechanism wasn't easy. Ibson said the Senate passed their version in September 2007 with the House following in March 2008. By early summer, the two had struck a compromise on policy. However, the Congressional Budget Office analysis projected there would be costs attached to the legislation.

"While there was agreement on the policy, there was no immediate agreement on how to offset costs," he said. "Despite enormous agreement on the substance itself, there was a risk of deadlock over the vehicle with which it would pass."

Ibson said even up through the final weeks of September, each chamber passed entirely different pieces of parity legislation. "It was clear neither side was predisposed to accept the other's bill."

However, after the financial rescue package failed to pass in the House, Washington dealmakers began looking for ways to make it more attractive.

"Parity would make a difference to some," Ibson said, "so it became a sweetener," he added, of how the bill became part of the larger piece of legislation.

Since the law reads there must be parity if mental health coverage is included in the benefits package, there is a theoretical concern that policies could drop mental health coverage. However, Ibson said that was highly unlikely. The Washington Business Group on Health, an employer-based organization, recommends mental health coverage citing higher productivity and a reduction in costs on the general medical side.

"What we've seen over the years is an increasing recognition on the part of employers that mental health coverage is good for the bottom line," he said, adding the expectation is that cost increases as a result of the law would be quite small. Ibson also noted the law gives employers latitude to address cost increases through steps that would be far less extreme than dropping coverage.

Despite the obvious excitement and benefits resulting from the new law, Ibson actually urged caution.

"I think we can expect too much from this law," he warned. "It would be premature to think it will topple all the barriers that people have faced in attempting to access mental health care.

"It's a first step … it's a terribly important step, but there are likely many more battles for mental health advocates to fight," he said.

Still, he added, "It should result at the very least in reduced out-of-pocket costs and greater access."

Tags:

Addiction Equity Act, Emergency Economic Stabilization Act, HR 1424, Mental Health America, Mental Health Parity, Paul Wellstone, Pete Domenici

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