The Art of the Possible for Parity

One of my key priorities (and of our Association) is achieving nondiscriminatory insurance coverage of mental illness. As this column is written, there are promising indications that the U.S. Senate is on the verge of taking up—and, I hope, passing—S 558, the Mental Health Parity Act of 2007, sponsored by Sens. Edward Kennedy (D-Mass.), Pete Domenici (R-N.M.), and Mike Enzi (R-Wyo.). This is the first meaningful action of Congress in over a decade to realize the promise of the 1996 Mental Health Parity Act.

The case for parity is overwhelming, and for the first time key business and insurance organizations are actively supporting the Kennedy-Domenici parity bill. This development is so unprecedented that some APA members have commented that “anything they're for, we should be against!” I was tempted to make the same initial judgment, as were some of the key business and insurance industry leaders who are now supporters. Yet we have set aside our differences to partner in what promises to make our parity goal a reality. What changed the dynamic?

All parties involved with the Senate bill agreed that it made no sense to have one set of standards for treatment of psychiatric illness and another for other medical/surgical conditions. Responsible business leaders—many of whom work on APA's National Partnership for Workplace Mental Health—recognize the impact of mental illness and understand that not covering mental health care costs businesses far more than covering it.

We also had to agree that once the basic framework of the bill was set, no changes would be made unless all parties—senators, business and insurance groups, and the members of the Fairness Coalition (APA, AMA, National Alliance on Mental Illness, Mental Health America, National Association of Psychiatric Health Systems, American Hospital Association, Associated Psychological Health Services, Federation of American Hospitals, Association for Behavioral Health and Wellness, and American Psychological Association) agreed to the actual legislative language. Further, the senators required participants to pledge they would neither release the language nor describe it in detail until the language was in more-or-less final form.

As a result of our commitment, we have a real chance to succeed in our goal of passing mental health parity this year. Is the proposed legislation perfect? Of course not. Anyone who has been involved firsthand with Congress knows that “perfect” is relative, as well as “the enemy of the good.” But the amended version of the bill approved in February by the Senate Health, Education, Labor, and Pensions (HELP) Committee is better than the version that was initially introduced, and because of our involvement and commitment, the version that will be brought to the Senate floor is vastly improved over the version approved by the HELP Committee.

The engagement of APA and the other members of the Fairness Coalition, as well as the willingness of the business and insurance groups to compromise, has led to modification of the controversial provisions in the bill preempting state laws. The bill leaves intact state laws mandating coverage of mental health treatment, state laws requiring coverage of specific disorders up to and including the full range of diagnoses under DSM-IV, and state laws regulating the practice of managed care. The bill also includes coverage of treatment for “substance use disorders” rather than“ substance abuse treatment” as initially proposed. A detailed analysis of the Senate bill is posted at<www.psych.org/members/download.cfm?file=1663>.

Yes, there are still issues to be resolved, including determining the impact that S 558 may have on some provisions of state parity laws in a few states, including Vermont and Pennsylvania, but a recent analysis suggests that there may be less conflict than feared even in these states. We are, however, a long way from a final bill, and there will be additional opportunities for modification when the House and Senate go to conference.

Bismarck said that “politics is the art of compromise.” Throughout this difficult process, individual APA members have urged APA to walk away from the Senate negotiations and support only the House bill, but the Board has repeatedly affirmed the need to remain fully engaged, believing that the final Senate compromise would be well worth our support. While we still have room for improvements, the work of our leaders, members, and staff has validated our commitment to our Senate sponsors to work with them and the business and insurance groups for the benefit of our patients and their families. The results are an example of my presidential theme at work:“ Our Voice in Action!” ▪