Senate Committee Endorses Parity Mandate

Mental health advocates are a step closer to crossing off one major New Year's resolution from their list now that a key Senate committee has given overwhelming approval to a comprehensive mental health parity bill.

On February 14 the Senate Health, Education, Labor, and Pensions (HELP) Committee endorsed by an 18-3 vote a major expansion of the limited parity bill that was passed in 1996.

The Mental Health Parity Act of 2007 (S 558) was introduced two days prior to committee passage by Sens. Edward Kennedy (D-Mass.), who chairs the HELP Committee, Michael Enzi (R-Wyo.), and Pete Domenici (R-N.M.).

APA President Pedro Ruiz, M.D., said in a press release lauding last month's bill introduction that “Americans with mental illness are unfairly singled out when they are required to pay higher copayments, allowed fewer doctor visits or days in the hospital, or made to pay higher deductibles than those that apply to other medical illnesses.”

Parity supporters in the House are expected to introduce a similar parity bill in the next few months.

The HELP Committee's action comes just a few weeks after APA gave the“ Blue Dogs” of Congress an earful about parity coverage of treatment for mental illness, including substance abuse.

APA leaders met with 13 key members of Congress and their staffs for a breakfast briefing focused exclusively on parity. The January meeting was the year's first Blue Dog Democrat Breakfast, a monthly meeting of Democrats from conservative-leaning states, and provided an opportunity to focus on efforts to pass legislation expanding the 1996 federal parity law. This law mandates that group health plans in businesses with 51 or more employees must have annual lifetime dollar limits for mental health care that are the same as for other types of medical care, but does not address discriminatory copayments or visit limits.

“We had 13 representatives and staff to ourselves for an hour,” said Nicholas Meyers, director of APA's Department of Government Relations.“ The Blue Dogs are extremely cohesive and on the issue of parity are bellwethers for the moderates of both parties who must be clear about and comfortable with parity if we are to succeed this year.”

David Fassler, M.D., chair of the APA Board of Trustees Task Force on Parity, discussed the scope and burden of mental illness in clinical and epidemiologic terms. Task force member Howard Goldman, M.D., presented data from his New England Journal of Medicine study on the costs of parity during the first year of its implementation in the Federal Employees Health Benefits Program (FEHBP). That study appeared in the March 30, 2006, New England Journal of Medicine (Psychiatric News, September 16, 2005).

Mental health parity was mandated in the FEHBP in January 2001, when the Office of Personnel Management implemented a directive to the approximately 250 participating health plans requiring that mental health and substance abuse (MH/SA) services be covered to the same extent as general medical care with respect to deductibles, copayments, and limits on physician visits and inpatient days.

As “centrist” Democrats, the Blue Dogs act as a key block of swing voters in a divided government. The group has gained in strategic importance since Democrats regained control of the House and Senate last November. The Blue Dogs, many of whom are from Southern and rural states, now number 44.

All the original members were re-elected in the 2006 midterm elections, with several newly elected members joining the group.

“I spoke briefly about child-psychiatric issues, emphasizing the importance of early diagnosis and treatment,” Fassler told Psychiatric News. “I also cited some of the statistics from the Surgeon General's Report on Mental Health, and from the Centers for Disease Control and Prevention's Youth Risk-Behavior Survey. Finally, I described our experience in Vermont with a very broad-based parity bill, which covers all psychiatric and substance abuse disorders.

“Howard [Goldman] did a great job of summarizing experience with parity in the Federal Employees Health Benefits Program, which is critical, since it demonstrates that in a large, real-world sample, parity can be achieved without a significant increase in overall expenditures.

“We got a number of questions about suicide, cost issues, and some specific aspects of the proposed legislation,” Fassler continued.“ My sense was that there's general support for the concept of parity within this group, and I think they were further reassured by some of the specific research on the cost issues.”

Fassler added that just prior to the breakfast, he spoke with Rep. Stephanie Herseth (D-S.D.). “We discussed adolescent depression and suicide, and access to treatment,” he said.

Though the 1996 federal parity law has consistently been renewed by legislators beyond its sunset date, efforts to expand the law's provisions have not been successful.

“A plan could comply with the 1996 law and still have special restrictions for mental health,” Goldman said. “You could continue to limit stays in the hospital in ways that were different for general medical conditions. There were separate deductibles and all kind of distinctions in cost-sharing arrangements that could be made while continuing to comply with the law. Moreover, the law wasn't extended to covering treatment for substance abuse.”

In addition to the Senate parity bill, Reps. Patrick Kennedy (D-R.I.) and Jim Ramstad (R-Minn.) are traveling the country to hold public forums on parity (see page 4).

In the NEJM study on parity, Goldman and fellow authors compared seven health plans in the FEHBP from 1999 through 2002 with a matched set of health plans that did not have parity mental health and substance abuse treatment benefits. They examined the rate of use, total spending, and out-of-pocket spending among users of mental health services, including treatment for substance abuse.

Their analysis indicated that the observed increase in the rate of use of mental health and substance abuse services after implementation of parity was due almost entirely to a general trend in increased use that was observed in comparison health plans as well as in FEHBP plans. The study found that when coupled with management of care, implementation of parity in insurance benefits for behavioral health care can improve insurance protection without increasing total costs.

Aside from cost, Goldman said some legislators continued to raise an objection to legislative mandates as a matter of principle, arguing that they tend to create inefficiencies in the market. But Goldman explained to lawmakers at the breakfast that in the case of parity, a mandate actually corrects inefficiencies stemming from adverse selection.

“If some plans offer better benefits and others do not, people who are likely to be high users will flock to the better plans, thus concentrating adverse risk in a few plans that are trying to do the right thing,” he said. “So this is an instance where a mandate provides protection to the plan so that it won't suffer any big cost increases due to adverse selection.”

The breakfast meeting with the Blue Dog group was a joint initiative of APA's Division of Government Relations and its political action committee, APAPAC.

Information about the Blue Dog Coalition is posted at<www.house.gov/ross/BlueDogs/bluedogs.shtml>.▪