Public Opinion and the Mental Health Parity Debate: Lessons From the Survey Literature

Respondents' answers to survey items about knowledge of mental health and substance abuse conditions reflect the extent to which common misperceptions and stereotypes about mental illness detract from the public's willingness to support legislation expanding treatment coverage. A substantial portion of the data in this category was gathered as part of a nationwide study sponsored by the Robert Wood Johnson (RWJ) Foundation Program on Chronic Mental Illness (4). This study included a telephone survey in which 1,300 randomly selected adults were interviewed about their attitudes toward persons with chronic mental illness.

One-quarter of the respondents described themselves as very well informed about mental illness, yet added that they should know a great deal more about it. This proportion was quite small relative to those claiming to be very well informed about other illnesses mentioned in the survey, including alcoholism (47 percent), cancer (43 percent), drug abuse (35 percent), heart disease (37 percent), and AIDS (30 percent). Perhaps more important was the finding that, regardless of their current knowledge base, 60 percent of the sample responded that they should know more about mental illness.

When respondents were asked to name the chief cause of mental illness, a plurality cited either a chemical imbalance (27 percent) or the stress of daily life (27 percent). Twenty percent of the sample named alcohol and drug abuse, and 13 percent cited "inherited genes." Regardless of respondents' perceptions about the causes of mental illness, nearly nine of ten respondents (89 percent) described mental illness as a serious problem in society.

Clearly, one of the chief purposes of survey research should be to identify gaps in public knowledge and assist in developing appropriate means of filling them. Survey items that probe for respondents' primary sources of information about mental illness are thus particularly important because they may help target educational messages about mental illness to the public at large. In the RWJ survey, mass media were identified as a source of knowledge about mental illness, with 87 percent of respondents citing television news and programs, 76 percent citing newspapers, 74 percent citing magazines, and 73 percent citing radio news and programs. Non-media-related sources of information were less frequently acknowledged, with family and friends mentioned by 51 percent of the sample population, mental health professionals by 31 percent, and doctors by only 29 percent.

The large portion of the public receiving information from the media is especially problematic given that only 34 percent of the surveyed sample rated television, radio, and newspaper stories as very believable or extremely believable in their coverage of mental health issues. Sixty-one percent described such media as somewhat believable in their coverage of mental illness.

The second type of survey data—on Americans' knowledge about policies toward mental health and substance abuse treatment benefits and about the debate on expanding these benefits—addresses the concern that the conceptual isolation of mental health and substance abuse treatment services from physical health care has resulted in a lack of public interest in the current mechanisms for insuring persons with mental illness. This suspicion is supported by the fact that questions that probe for respondents' awareness of current policies addressing mental health treatment are relatively underrepresented in general health care surveys.

However, some data that reflect voters' interest in the ongoing debate over expanding coverage do exist. For instance, in a 1993 telephone survey sponsored by the Harvard School of Public Health and the Henry J. Kaiser Family Foundation and conducted by Princeton Survey Research Associates, respondents were asked about the degree to which they were familiar with various health care reform proposals (5). When asked if they knew whether mental health coverage was included in congressional Republicans' various legislative proposals, 31 percent responded that such a benefit was included, 20 percent that it was not, and 49 percent that they understood the Republican proposals not too well or not at all or that they did not know the answer to the question. These data do not show whether respondents' lack of familiarity with the proposals' mental health components differs from their level of knowledge about the proposals' other components—for example, whether they included pharmacy or dental benefits. However, the data do provide some context for responses to other, more detailed mental health survey items.

A separate item on the same survey revealed a greater level of familiarity with the Clinton administration's proposal. Only 30 percent of the respondents claimed that they were not at all or not too familiar with the Clinton plan or that they did not know the answer to the question. Of the remaining 70 percent of respondents, 58 percent answered accurately that the President's plan did include mental health coverage, while 12 percent replied that the plan did not.

As noted, this discussion organizes the survey data such that the data from the first two categories inform the results from the third, which covers respondents' support for specific mental health and substance abuse benefit reforms. This progression makes sense insofar as a direct relationship exists between respondents' familiarity with mental illness and the relevant policy debate and their base of support for expanding mental health and substance abuse treatment benefits.

Regardless of whether such a link exists, the survey items that address the details of potential policies for treatment benefits bear most directly on the political debate over parity for these services. These surveys include questions designed to assess the public's impressions of a range of proposals for future reform, including whether and how mental illness should be considered distinct from physical illness, whether the two should be programmatically integrated into a single system of coverage, and whether and how much respondents would be willing to pay toward that end. The findings from these survey items are most useful for the parity debate because they reflect the public's concerns about improving and equalizing coverage of mental health and substance abuse benefits and thus indicate the extent of political risk for state and federal legislators who endorse such reforms.

Survey items that assess the appeal of parity for mental health benefits are certainly well represented in the literature (6,7,8,9,10,11). As the data presented in Table 1 imply, a substantial share of objective support for mental health and substance abuse treatment benefits is evident across surveys. However, some evidence suggests that this support is relatively soft in that it deteriorates rapidly if the potential for personal financial sacrifice is acknowledged. For instance, support for a guaranteed mental health benefit dropped from 69 percent of respondents to 34 percent when the survey questions indicated that higher taxes or premiums would be involved (11).

Not surprisingly, when respondents were asked to prioritize the benefits that are most important to them, support for mental health and substance abuse treatment benefits dropped off rapidly as well. For instance, in two separate questions on a Gallup survey, respondents were asked to consider which of five benefits they felt to be the most important and the second most important to guarantee as part of a federal health care reform bill (7). Mental health and substance abuse services did not fare very well on either question, with 8 percent of respondents identifying them as the most important and 15 percent as second most important. One could argue that these benefits were not considered important because only a small proportion of respondents perceived themselves as likely to need them. However, dental care received even less support in the survey, suggesting that the perceived importance of a given service was not necessarily correlated with the likelihood of using it.

A similar question was raised in a 1994 NBC News telephone survey conducted by Blum and Weprin Associates (12). Respondents were presented with a list of benefits and asked to name the one that they most wanted covered by a new health plan, in addition to the costs of physician care and hospital stays. This item in effect asked respondents to identify their third most important benefit. Once again, mental health care did not fare so well; only 3 percent of respondents selected it. In contrast, long-term care was favored by 46 percent of respondents, most of whom were unlikely to be insured for these services; preventive care by 27 percent; and prescription drugs by 19 percent. The remaining 6 percent responded that they were not sure. This distribution of responses may be partly a function of the responses that were offered by the list, particularly because an "other" option was not included.

Using a slightly different approach to question wording, the Los Angeles Times conducted a nationwide telephone survey that asked about the services respondents would be most willing to give up in a health care reform plan (13). This item in effect addressed voters' lowest health care priorities. Mental health coverage received the second largest share (28 percent) of responses. Surprisingly, choice of doctor was the one benefit that a larger number of respondents were willing to do without, with a 40 percent share expressing their willingness to sacrifice this benefit.

As suggested above, one of the likely barriers to consistently strong and widespread support of mental health care coverage is that relatively few people use mental health and substance abuse services—approximately 5 to 10 percent of the privately insured population. Some respondents presumably fear they will be paying for services they will not be using and that they will thus be subsidizing the care of others.

In summary, voters may be less likely to support reform if they do not know how it will affect them personally—for example, how much it will cost them and how they themselves will benefit. These results clearly demonstrate the political importance of devising reliable cost estimates of various policy options for mental health and substance abuse treatment benefits.

Given that the potential impact on future costs of across-the-board expansion of mental health and substance abuse treatment benefits is still unclear, one of the chief policy objectives should be to identify the services that merit most urgent reform. For example, through the use of split samples, the Mellman-Lazarus-Lake survey sought data on one of the more divisive issues in the current debate—whether substance abuse services should be included in benefit expansions for mental health services (10). As the data in Table 2 illustrate, responses varied dramatically across relatively similar survey items, demonstrating the importance of question wording and survey design.

Respondents were on average essentially indifferent to the idea of including substance abuse services in plans for general health benefit reforms; 31 percent were more likely and another 31 percent were less likely to support such coverage. However, the differential was quite dramatic among the sample who were asked about inclusion of mental health services in benefit reform plans; 39 percent supported such coverage, and 16 percent did not.

Another set of items from the same survey illustrated how indifference to the inclusion of substance abuse benefits disappears when the survey question is designed somewhat differently. Responses to a round of questions asked of four split samples suggested that the public was quite sensitive to the manner in which the specific services to be included in the basic health insurance package under national health care reform were presented. When asked about their support for the inclusion of different benefits, only 16 percent strongly favored "substance abuse coverage," compared with 29 percent who favored "mental health care coverage," 24 percent who favored "coverage for mental illness," and 26 percent who favored "coverage for mental disabilities."

This distinction was even more dramatic when the strength of opposition was examined. For example, 20 percent of respondents voiced strong opposition to the inclusion of a substance abuse benefit, and 42 percent either opposed or strongly opposed such a benefit. In contrast, the shares of strong opposition to "mental health care coverage" (6 percent), "coverage for mental illness" (7 percent), and "coverage for mental disabilities" (6 percent) were much smaller.

The same split samples were asked a separate but similar item on how important it was that the benefit be included in a basic benefits package. In response, 27 percent suggested that substance abuse coverage was not at all important, compared with the much smaller shares of respondents who expressed a lack of support for "mental health care coverage" (7 percent), "coverage of mental illness" (8 percent), and "coverage for mental disabilities" (9 percent).

In another split-sample item from the survey, respondents were asked to rate the importance of covering mental health and substance abuse problems to the same extent as physical health problems. This question directly addressed the level of support for a parity-type benefit. Once again, there were significant differences in support for the prospect of coverage of mental health versus substance abuse problems. Seventy-eight percent of respondents indicated that coverage for mental health problems is more important than (10 percent) or just as important as (68 percent) coverage for physical health problems. Fifty-four percent of respondents expressed the corresponding levels of support for coverage of substance abuse problems; 7 percent thought it was more important than coverage of physical health problems, and 47 percent thought it was just as important. Although 41 percent of the split sample responded that covering services for substance abuse problems was not as important as covering services for physical health problems, only 19 percent expressed that attitude toward coverage of mental health services.

In addition to assessing the public's views about different types of benefit packages, the Mellman-Lazarus-Lake survey explored the manner in which public opinion varies across types of mental illness, once again using split-sample questions (10). Responses to these items confirmed the aforementioned skepticism toward including benefits for substance abuse treatment.

For instance, in response to a question about the importance of covering services for individuals with particular diagnoses, 85 percent indicated that covering services for a "child with a mental health problem" was either one of the most important things to cover or very important, 66 percent assigned that level of importance to services to "someone with a mental disability," 55 percent to "someone with schizophrenia," and 52 percent to "someone with manic depression." The categories given the lowest ratings were services for "someone addicted to drugs" and for "someone addicted to alcohol," each of which was considered most important or very important by 41 percent of respondents.

Even though survey respondents may be willing to support the expansion of mental health and substance abuse treatment benefits in principle, survey results suggest they are anxious about what expanded benefits will cost them in higher premiums or taxes. Survey items that address the financial and structural details of reform are designed to explore the roots of these concerns. For instance, the Mellman-Lazarus-Lake survey probed for respondents' reactions to the idea of a 50 percent copayment (10). Although 31 percent of respondents claimed that they either favored (26 percent) or strongly favored (5 percent) this level of cost sharing, a substantially larger share (58 percent) was either opposed (40 percent) or strongly opposed (18 percent) to the idea. However, these respondents were not asked whether they felt the 50 percent copayment was too high or too low.

As for speed of implementation, the key question is whether new benefits should be phased in gradually or implemented immediately. The idea of a phase-in addresses fears about the rise in costs of care that may accompany expansions in mental health and substance abuse treatment benefits. The results of the Mellman-Lazarus-Lake survey suggest that the public is mildly in favor of the gradual approach, with 48 percent of the respondents either strongly favoring (6 percent) or favoring (42 percent) a phase-in, and 41 percent either opposed (31 percent) or strongly opposed (10 percent) to the idea. When respondents were asked about the possibility of unlimited children's benefits, however, the idea of immediate implementation proved overwhelmingly popular. The proposal to implement full coverage for children under 18 without any phase-in or limits but to maintain a more gradual and limited approach to covering adults was favored by 62 percent of the overall sample. Items that address implementation issues are particularly useful as indicators of the degree to which people are skeptical of dramatic, large-scale changes within a cost-conscious system. These findings highlight the need for further public opinion research about the benefits to be included in specific models for reform of coverage for mental health and substance abuse treatment.

Survey items about benefit design are particularly useful if they present the proposed changes as occurring within the current managed care environment. For instance, a large share of the public supports reviewing the appropriateness of treatment as an alternative to imposing limits on treatment days, with 75 percent of respondents claiming that they either favor or strongly favor the imposition of such utilization review techniques (10).

Nevertheless, the public seems slightly less averse to the idea of imposing annual limits on outpatient days than it is to applying similar limits on hospital coverage. This distinction suggests an underlying level of support for coverage of catastrophic mental health care needs and a degree of concern about moral hazard and higher utilization of outpatient services. Although 53 percent of respondents were opposed or strongly opposed to limiting coverage of outpatient mental health care services to 30 days, 63 percent expressed the same degree of resistance to the prospect of a 30-day limit on hospital care (10). Respondents were slightly less opposed to placing limits on both inpatient and outpatient treatment for substance abuse services, with 48 percent opposing limits on outpatient services and 50 percent opposing limits on inpatient services.

Most voters are aware that reform of mental health and substance abuse treatment benefits may bring higher out-of-pocket costs. Survey research in this area can explore the types of expenditure increases to which voters would be most and least averse. For instance, assessing whether voters respond more positively or less negatively to the idea of a percentage increase versus a flat dollar amount may help policy makers ascertain the specific concerns associated with health benefit expansions in general.

Once again using split samples, the Mellman-Lazarus-Lake survey asked respondents whether they would be willing to cover full mental health benefits if the change cost the individual $100 more per year versus a 5 percent increase in annual costs. Among the group told that unlimited coverage would increase respondents' costs by $100 per year, 60 percent were at least in favor of the expansion. The increase of 5 percent per person per year garnered the support of 54 percent of the respondents. Although these results imply that respondents are slightly more willing to support such expansions if they are presented with the actual dollar amount by which their premiums will increase, these results do not appear strong enough to warrant any definitive conclusions.

Many public opinion data are equivocal about respondents' level of support for mandating expansions of mental health and substance abuse treatment coverage. However, this uncertainty is likely due largely to variations in the wording of survey questions and other survey design effects. Regardless of the extent to which the survey literature is incorporated into the policy debate, however, the successful reconciliation of these numbers may offer a valuable lesson about how various proposals for reform may be packaged most effectively.