Eye on Washington

Mental Health Parity-Just an Illusion?

Maureen R. Killeen, PhD, RN, FAAN

The illusion of mental health parity-now you see it, now you don’t.

Mental-health parity is an important issue in the battle to remove barriers to care for the mentally a. In addition, the history of the Mental Health Parity Act of 1996 is a re- minder of the difficulties that healthcare advocates face in promoting legislation to ensure patients’ rights to treatment.

Mental health has taken center stage as a broad public health concern in the last few years. Between 1999 and 2001, U.S. Surgeon General David Satcher issued six men- tal health-related reports, including the landmark Surgeon General’s Report on Mental Health (U.S. Department of Health and Human Services [USDHHS], 1999) and the Re- port of the Surgeoil General‘s Conference on Clzildren’s Mental Health: A National Action Agenda (USDHHS, 2000). The most recent publication was a supplement focusing on culture and etlmicity and mental health (USDHHS, 2001 ).

It wasn’t just the United States that was focusing on mental health as a broad public health issue. In 1996, the World Health Organization (WHO) issued a report on the global burden of disease (Murray & Lopez, 1996). Not surprisingly, the report found that mental disorders are among the most common conditions causing loss of healthy years of Me. Among 15- to 44-year-olds, depres- sion was the second leading cause of health burden, and self-inflicted injuries, alcohol-use disorders, schizophre- nia, and bipolar disorder were ranked (6,5, 8, 9, respec- tively) among the top 10 illnesses producing significant health burden. Most recently, the WHO focused its 2001 World Health Report on mental health. It confirmed what most mental health providers have known for quite some time, namely, that mental disorders are com- mon, universal, have sigxulicant economic repercussions, and produce “[massive] negative effects on the quality of life of individuals and families” (WHO, 2001, p. xiv). The report’s subtitle-Mental Health: Nezo Understanding, New Hope- reflects the new emphasis on mental illnesses as treatable health conditions that are within the main- stream of public health concerns. Among the recommen- dations in the report was that nations should develop policies and legislation based on current scienthc knowl- edge and human rights concerns. A specific recommen-

dation was that health insurance policies should not dis- criminate against people with mental disorders.

Throughout these reports, there is consensus that the needs of the mentally ill are not being adequately ad- dressed either in the United States or globally. In this context of consensus on the need to lower barriers to treatment for mental illnesses, it is not surprising that a mental health parity bill was introduced in Congress. It is somewhat surprising, and clearly disappointing, that Congress ultimately failed to pass it.

On January 1, 1997, the Mental Health Parity Act of 1996 became effective, but it included a provision that re- quired it to sunset on September 30,2001. Thus, the ben- efits of the 1996 act would cease unless Congress passed a new bill to continue the provisions of the original bill. The proponents of true mental health parity saw this as an opportunity to strengthen the original act, wluch had a number of gaping loopholes. The 1996 act required businesses with more than 50 employees that offer men- tal health benefits to set annual and lifetime caps equal to those set for medical and surgcal conditions. But the law allowed health insurance plans to set different benefit levels for co-payments, deductibles, out-of-pocket pay- ments, inpatient days, and outpatient visits. Companies also could decide not to offer any mental health coverage at all, even if they provided health insurance for other conditions (National Mental Health Association [NMHA], 2001). As a result of these exceptions, full in- surance parity, and, therefore, nondiscriminatory access to treatment for mental disorders, remained elusive. US. Senators Wellstone of Minnesota and Domenici

of New Mexico, the original authors of the 1996 act, in- troduced the Mental Health Equitable Treatment Act (S. 543) in the Senate in early 2001, and a similar bill was in- troduced in the House of Representatives by Represen- tative Roukema of New Jersey. The Senate bill focused on severe biologically based mental illnesses, and pro- vided all insured Americans with coverage similar to that enjoyed by current and retired federal employees. Insurers participating in the Federal Employees Health Benefit Program have been required to provide parity coverage for mental illnesses since 2001, as the result of

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Eye on Washington

an executive order signed in 1999 by President Clinton (National Alliance for the Mentally I11 [NAMI], 2001).

The proposed bills strengthened the 1996 Mental Health Parity Act by requiring equal co-pays and de- ductibles for mental health benefits, and the same num- ber of hospital days and provider visits for mental ill- nesses as for other medical and surgical illnesses. The bill prohibits limits on the scope or duration of treatment, such as frequency or number of allowable visits (Gitter- man, Sturm, & Scheffler, 2001). Services provided by in- network managed care providers would be covered by the parity requirements, but out-of-network services would not be included. Coverage for substance-abuse treatment was included in the House bill but not in the Senate bill.

Despite overwhelming bipartisan support, the bill died in the conference committee as the result of pres- sure on the Republican conferees brought by the chairs of several House committees. The bill died on a party line vote, with the Republican House conferees rephng the measure and the Democratic conferees voting to sup- port it (Pear, 2001). Both Republican and Democratic supporters of the bdl spoke out forcefully after the defeat and issued a call to action for next year (NMHA, 2001).

Psychiatric nursing organizations were among the 154 organizations expressing support for mental health par- ity. Both NAMI and NMHA lobbied hard for its passage. Each of these organizations views the lack of mental health parity in insurance coverage as discriminatory. Certainly, in light of the focus on mental illness as a sig- nificant public health concern, the opponents of parity legislation Seeill out of step with both scientific and pub- lic opinion.

For advocacy views of the parity debate, go to the Web sites for the National Alliance for the Mentally Ill, www.nami.org, and the National Mental Health Associa- tion, wMw.nmha.org.

Maureen Reed Killeen, PhD, RN, FAAN Professor Emerita

Mcdictll College of Georgin Sclzml of Niirsing Fellmu, Institute for Behavioral Resenrch

U?iiversity of Georga, Athens, GA.

Author contact: mkilleen@mail.mcg.edu, with a copy to the Editor: Poster@uta.edu

References Gitterman, D.P., Sturm, R., & Scheffler, R.M. (2001). Toward full mental

health parity and beyond. Health Affairs, 20(4), 68-76. Retrieved from h ttp: // www. medscape.com / ProjHope / HA / 2001 / v20.nO4 / hdW.O2.gitt/pnt-h&2W

Murray, C.J.L., & Lopez, A.D. (Eds.). (1996). Thp global burden of disease: A comprehensive asxssmerit of mortality and disability from disuses, in- juries and risk factors in 1990 and prujected to 2020 (Global Burden of Disease and Injury Series, Vol. I). Cambridge, MA: Harvard School of Public Health on behalf of the World Health Organization and the World Bank.

National Alliance for the Mentally Ill. (2001). Parity in itisitrunce c w u g e . Retrieved hum http://www.nami.org/update/unitedparity.h~.

National Mental Health Association. (2001). Sirprters 7 m to win battle nexf year. Retrieved from http://www.nmha.org/newsmom/sys- tem/lal.vw.cfm?do=vw&rid=371

Pear, R. (2001, December 19). Drive for more mental health coverage fails in Congress. The Ncm Yurk Times, p. A20. Retrieved from http: //nytmes.com

US. Department of Health and Human Services. (1999). Mental healfh: A report of the Sicrgeon General. Rockville, MD: Author. Available at www.surgeongeneral.gov.

U S . Department of Health and Human Services. (2000). Report of the Siirgeuri General's conference on children's mental health: A national ac- tion agenda. Rockville, MD Author. Retrieved from http://www. surgmngeneral.gov

US. Department of Health and Human Services. (2001). Mental health: Culture, race, ethnicity. Supplement to Mental health: Reporf of the Sitrgeon General. Rockville, MD: Author. Retrieved from www. surgeongeneral .gov.

World Health Organization. (2001). f i r World Health RPport, 2001: Men- tal health: New understanding, new hope. Retrieved from http:// www.who.int/whr/2001 /main/en/index.htm

Search tern: Nami, NMHA

Culture Bound continued from P . 36

Author contact: eyearwood@pace.edu, with a copy to the Editor: Poster @uta.edu

References Bell, C., & Fink, I? (2000). Prevention of violence. In C.C. Bell, (Ed.), Psy-

chiatric aspects of riolence: Issites in prnantion and treatinnit (No. 86, pp. 37-47). San Francisco, C A Jossey-Bass.

Bell, C.C., Gamm, S., Vallas, P., & Jackson, P. (2001). Strategies for the p w vention of youth violence in Chicago Pubfic Schools. In M. Shafii & S. Shafii (Eds.), School Violence: Contributing fnctors, management, and pre- iwition (pp. 251 -272). Washington, DC: American Psychiatric Press.

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