On October 3, 2008, the United States Congress passed into law the Paul Wellstone & Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.  With the President’s signature affixed later the same day, the bill became law, ending over a decade of effort by the behavioral health advocacy community.

The Act amends the Mental Health Parity Act of 1996 to require that a group health plan of 51 or more employees (or coverage offered in connection with such a plan)—that provides both medical and surgical benefits and mental health or substance use benefits—ensure that financial requirements and treatment limitations applicable to mental health/substance use disorder benefits are no more restrictive than the predominant requirements and limitations placed on substantially all medical/surgical benefits.1

Under the bill, if an insurer chooses to provide mental health coverage, it must “include benefits” for any mental health condition listed in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. 2

The fight for Mental Health and Substance Abuse insurance parity brought together the behavioral health advocacy community, the private sector, and lawmakers in a rarely seen act of cooperation and mutual support.   Opponents were plentiful, and had a variety of concerns with cost at the top of the list even though the Congressional Budget Office has estimated that the law will increase premiums by only 0.2 percent to 0.4 percent for group health plans.

A Long Road

Prior to the federal parity legislation being passed, 41 states already had parity laws mandating some form of parity, ranging from statutes that require insurance plans to offer coverage for mental illness, to those that limit the amount or percentage of coverage that can be collected by the policy-holder.

Efforts for federally mandated insurance parity began in 1992, with Senators Wellstone and Domenici leading the way. Wellstone had a brother with a mental illness, and Domenici is the father of a schizophrenic daughter.  That year the two introduced the Mental Health Parity Act which would require insurance companies to treat physical and mental illnesses equally. After four years of pushing the bill, they succeeded in passing a weakened version that was signed into law by President Clinton in 1996. The bill’s passage was a major victory, but Wellstone and Domenici were disappointed that the final version allowed employers to shift the cost to employees by raising co-payments and deductibles on insurance policies.3

Support in Congress for Wellstone/Domenici was not much of an issue over the last few years.  Over half the members of the House of Representatives co-sponsored the most recent version of the bill, as did 68 senators.  President Bush repeatedly promised to sign the legislation upon its passage.  The chief obstacle was the calendar:  Congress is only in session for a set number of days each year, and time is precious.  The leadership of each chamber determines what bills come to the floor for a vote, and the parity legislation kept getting shut out.

In the end, the parity legislation was attached to HR 1424, the infamous  $700 billion “bailout” bill (as was quite a bit of additional legislation,) which passed in October 2008.
Its provisions will go into effect in January 2010.

Compliance and Enforcement

A key concern now is assuring that those who now will have access to care are aware of the options they have.  “Even with a benefit; if [an individual] is so dysfunctional that they don’t know how to access service, they have an impossible time actually getting treated; we are still going to have thousands of persons who are mentally ill, who are homeless, in jails and prisons; also they will continue to pack our emergency rooms. These concerns need to be addressed in any reform,” said Leon Evans, president of the Center for Health Care Services in San Antonio.  To address these concerns, the legislation requires The Labor Secretary, in cooperation with the Health and Human Services (HHS) and Treasury Secretaries, to publish and disseminate guidance for plans, participants and beneficiaries, applicable State agencies, and the National Association of Insurance Commissioners concerning the requirements of this Act, and the continued operation of applicable state law. The departments are to inform participants and beneficiaries as to how they can obtain assistance, including assistance from state consumer and insurance agencies.4

As under the 1996 law, Labor, HHS, and Treasury will continue to coordinate enforcement of the Federal parity requirements, and are required to issue regulations to implement the Act not later then one year after the enactment date. The Treasury Department may continue to impose an excise tax on any plan for failure to comply with the requirements of the Act. 5

By 2012 and every two years after, the Labor Secretary will be required to submit to Congress a report on group health plan (or coverage) compliance with the Act. The report will include the results of any audits or surveys, along with an analysis of reasons for any failures to comply with the law if necessary.  Also, the U.S. Government Accountability Office (GAO) will conduct a study that analyzes the specific rates, patterns and trends in coverage, any exclusion of specific mental health and substance use diagnoses by health plans, and the impact of this Act on such coverage and costs.

Reactions to Victory

“This bill targets insurance plans that cover more than 50 employees. About 113 million people, we figure, are in group insurance plans that have, as part of their health care, mental health coverage,” said Senator Domenici. “All of those, now, will have imposed on their insurance policy by operation of law that the insurance company will pay for mental health treatment in exactly the same way they cover physical ailments — the same amount of days in the hospital, the same amount of co-pay, and all the other technical words will be equal. And that’s not what it used to be, and not what it is today. Insurance companies were already moving in that direction, but now we’ve made it so they can’t slide backwards.”6

“The parity law is very significant in that it signals that Congress views mental health and substance abuse as health care matters,” said John Carnevale of Carnevale Associates.  “A key to parity’s success is getting all businesses to provide substance abuse and mental health coverage in their insurance policies provided to their employees.”

“I think the behavioral health community should build on the relationships that we have developed with the business and insurance community during the parity debate,” suggested Pamela Greenberg, President of the Association of Behavioral Health and Wellness.

What’s next?

The behavioral health advocacy community has achieved a tremendous victory with the passage of the Wellstone Domenici Act, but is not resting on its laurels.  Quite the opposite, their agenda is still aggressive.  Many view the parity legislation as only the beginning of a broad, ambitious legislative agenda. There is still work to be done, and many see this as a new beginning, not a culmination. “Perhaps the next Congress can start by mandating that all insurance plans offered to federal employees include model insurance benefits in these areas,” said Carnevale.

“It is imperative that we shift our national drug strategy from primarily interdiction and criminal justice to a public health approach that emphasizes prevention, treatment, and recovery support services,” maintains John Coppola, Executive Director of the NY Association of Alcoholism and Substance Abuse Providers (ASAP). “Particularly during times of economic crisis, increased emphasis on treatment and prevention can save much needed resources, improve results and enhance public health and public safety.”

While the new legislation will aide those who have access to health care, millions still lack coverage.  Among the uninsured are millions who require treatment for behavioral disorders. “The uninsured have exceptionally high rates of untreated mental illnesses with co-occurring addiction disorders and there is no safety net,” said Linda Rosenberg, the executive director of the National Council of Community Behavioral Health Centers.

For the behavioral health community, screening and prevention remain top priorities.  While the parity legislation addresses treatment, it does little in the way of improving prevention services.  Sue Thau, a policy consultant to the Community Anti-Drug Coalitions of America (CADCA) realizes this and will continue to make prevention a top priority, as it has been for decades at CADCA.  “We will be working to ensure that programs that fund the prevention of drug use and underage drinking, which have been severely under resourced relative to their effectiveness, are once again recognized as important investments of scarce federal funds,” she said.

“We must have increased emphasis on and greater funding for research-based education and prevention practices. We have prevention and education programs that work. Research-based prevention programs that reduce the risk of…serious emotional disturbance by treating maternal depression,” said Rosenberg.

In addition to prevention issues, advocates are focused on assuring that the provisions of the parity legislation are properly implemented. “Victory on Wellstone-Domenici bill was just the first step in ending discriminatory policies that are keeping people from getting the help that they need to enjoy long-term recovery from addiction to alcohol and other drugs,” said Tom Coderre, the former National Field Director of Faces & Voices of Recovery.  “Looking ahead, we want to see strong regulations and an education campaign so that people can exercise their hard-won rights if they do have private health insurance. We also look forward to addressing other discriminatory housing and employment policies and we are focusing on strengthening recovery community organizations which create a culture of recovery.”

“We still need to make the case with purchasers about the value of the behavioral health benefit and our new allies can help us with this,” added Greenberg.

It took close to 16 years to pass the parity legislation envisioned by its authors.  The behavioral health advocacy community has no intention of waiting that long for results again.

1 Mental Health America

2 New York Times, March 6, 2008

3 Wellstone Action,

4 Mental Health America

5 Ibid.

6 Time Magazine, October 10, 2008

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