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Parity at last: business and insurance groups' support was key to its passage.

An advocate's work is never done.

After last month's historic House vote that sent the mental health and substance use parity bill to President Bush's desk, supporters across the field began rejoicing. As people came together in impromptu celebrations, Pamela Greenberg, MPP, chair of the Coalition for Fairness in Mental Illness Coverage, was still hard at work, writing a press release about the important victory.

"It was the adult decision," she jokes, admitting she was very tempted to join in the immediate get-togethers.

Greenberg's and many, many others' long fight for parity finally was realized on October 3, when Bush signed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, part of the $700 billion financial bailout package.

The new federal parity law applies to Medicaid managed care plans, State Children's Health Insurance Programs, and group health plans with more than 50 employees that provide mental health and substance use benefits. Under the new law, health plans' financial requirements for mental health and substance use benefits can be no more restrictive than financial requirements for most medical and surgical benefits. This includes co-pays, co-insurance, deductibles, out-of-pocket expenses, and annual and lifetime limits (the latter having been established with the 1996 parity law). The law does not mandate coverage for mental health or substance use care or for specific conditions.

While the legislative ins and outs that lead to parity will be analyzed for years to come (Greenberg says it surely will be the topic of someone's dissertation), one thing is quite cleat immediately. The behavioral healthcare field would not have achieved this victory without the business and insurance communities' support.

"This bill passed in large part because of them, so they deserve the recognition, too," says Greenberg, who is also president/CEO of the Association for Behavioral Health and Wellness, representing managed behavioral healthcare organizations (MBHOs), as well as a member of Behavioral Healthcare's Editorial Board.

Support from the other side

For years the business and insurance communities were opposed to parity legislation. But senators working for its passage invited them to the negotiating table--a game-changing moment.

"As contentious as it was within the field, the decision by the Senate to build a coalition and negotiate directly with the business and insurance communities was probably the turning point," says Chuck Ingoglia, vice-president of public policy and practice improvement at the National Council for Community Behavioral Healthcare. "We finally then had an ability for us to sit down with our biggest opponents and come up with a bill that is pretty darn good."

E. Neil Trautwein, chair of the ad hoc coalition representing business and insurance interests in the parity discussions, says being included definitely helped bring them onboard: "That process of working with the Hill, working with the advocates, helped build confidence, made this into a shared enterprise, and ultimately led to full-fledged coalition support for the bill."

Trautwein, vice-president and employee benefits policy counsel at the National Retail Federation, says employers' growing interest in health benefit policy and employee wellness also "made it easier certainly for me as a representative of the retail industry, and the business community generally, to bend a little bit more when it came to the parity compromise."

Businesses and insurers did score what Trautwein terms a "very, very big win" when references to the DSM-IV were removed from the legislation. Although behavioral healthcare advocates preferred its inclusion, Greenberg says their flexibility on this issue was vital.

"The Fairness Coalition felt that without the support of the business and managed care/insurer community, we wouldn't have been able to get a bill through Congress. And the DSM was not something they were going to compromise on," she explains.

Business and insurance groups had argued for years that including the DSM in the legislation would mean they would have to pay for conditions such as caffeine addiction and jet lag. Greenberg says that in reality MBHOs rarely paid for these conditions, but she acknowledges that this argument was effective.

"I used to joke that the employer and managed care communities were spending more on their ads talking about jet lag and caffeine addiction than [MBHOs] were paying to treat those," she says. "But it was smart on their part, because that's what people remembered. It was very good lobbying."

On the other hand, behavioral healthcare advocates scored a major victory last year when the business and insurance communities agreed to federal legislation that would not preempt state parity laws.

"The insurers and the business community had initially said one of the reasons they were willing to have this [parity] discussion was so that they would have a uniform federal law and they wouldn't have to comply with the patchwork of state laws," Greenberg recalls. "I never thought they would be willing to compromise in that area."

"Unfortunately, in the give-and-take of the negotiating process, we lost preemption," says Trautwein. "We would have preferred a strong federal rule." Yet Trautwein sees the final legislation as a result of a "classic compromise: not everything we wanted, not everything they wanted."

Greenberg hopes the willingness of the behavioral healthcare field and the business and insurance communities to work together will continue: "One of the mistakes we make in the behavioral health field is that we don't talk enough to the business folks, if nothing else to just let them know what we are doing. ... If they understand better what they're purchasing and why, it can only help us."

Adds Trautwein: "We've built friendships that will certainly survive the enactment of this law and we've certainly learned from and hopefully helped them understand our concerns a little better."

Next steps

Group health plans must comply with the federal parity law at the beginning of the plan year that begins one year after the legislation was signed. So for most this means January 1, 2010, as most plans are on calendar years. The law does not need to be re-passed by Congress annually as the 1996 parity law did (that law's "sunset" provisions have been eliminated as well). Although parity is now the law of the land, that doesn't mean advocates can take a breather.

"In a sense, the harder work is yet to come, because the more detailed work of interpretation is yet to come," says Greenberg.

The U.S. Departments of Labor, Health and Human Services, and Treasury (specifically the IRS) now need to develop regulations, what Greenberg calls "the meat behind the legislation." For example, the federal government will need to provide guidance about the non-preemption of state parity laws. Greenberg says that the federal parity law is stronger than most state parity laws, but potentially confusing situations will need to be addressed.

For instance, in Pennsylvania the state requires health plans to offer at least 30 days of substance use treatment. Greenberg says it is unclear how this requirement will interact with the federal parity law, noting that the key question is whether the state law will interfere with the application of the federal law. Some Pennsylvania providers are wary of losing this "minimum" benefit written into state law. Federal law. Some Pennsylvania providers are wary of losing this "minimum" benefit written into state law.

Another area where federal guidance will be needed is how parity is determined. For example, Greenberg wonders that if a health plan has a $10 co-pay for primary care, $25 for specialty care, and $35 for physical therapy, what constitutes an equitable co-pay for mental health and substance use services?

Greenberg says that the federal government also will need to provide more clarification around the law's language allowing group health plans exemption from the parity requirements. Health plans covered by the law must comply with it for the first year. If they demonstrate that within the first six months of compliance their total plan costs increase by 2% or more due to parity, they can seek an exemption from the law for the next year. However, they then have to come back into compliance the following (third) year. If their total costs subsequently increase 1% or more because of parity, they can seek an exemption for the next (fourth) year.

"We purposely made it complicated in hopes that it would discourage employers from opting out," says Greenberg, who notes that studies have found that parity tends to increase premiums by less than 0.5%.

Although Labor's, Treasury's, and HHS's regulations are due by October 3, 2009, employers and insurers must comply with the law even if none has been issued. As advocates help craft these policies, public education will be important, too.

"There's a lot of room for education, both for people within our field plus the general public," Ingoglia says. "With the lead-in to implementation, hopefully our organization and others will be involved in helping to increase awareness and understanding."

Now onto healthcare reform

With advocates savoring parity's passage, they now have an even bigger prize to aim for: national healthcare reform.

"I think parity provides an important component to our overall policy agenda as our nation now turns its attention to healthcare reform," says Ingoglia. "We now start with the premise of parity, that any proposals put on the table will have to treat mental health and addiction disorders the same way." He adds, "It passing the same year as Medicare parity sets an incredible precedent and opportunity for us."

The behavioral healthcare community already is gearing up for the debate. Greenberg notes that the Whole Health Campaign, bringing together a range of mental health and substance use care interests, has begun working on principles that everyone in the field can agree to. Perhaps with the lessons learned from getting parity passed, this task will be made a little easier.

"Parity has done a great job of unifying our field," Ingoglia observes. "I think we're at a time when we can get past some of the prior divisions within our field and see the benefit of working together, and hopefully we will then be able to craft some larger policy priorities and work to achieve those."

RELATED ARTICLE: Perseverance produces parity

by Ronald W. Manderscheid, PhD

Unbridled excitement was evident in the mental health and substance use care communities with the passage of the Emergency Economic Stabilization Act of 2008 on October 3. In a lopsided vote of 263 to 171, the House followed the Senate in allocating $700 billion to stabilize our economy. Field advocates cheered the legislation's passage because it included the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.

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For more than a decade, advocates have worked ceaselessly for the passage of "parity"--legislation to require the same insurance benefits for mental health and substance use conditions as for physical health problems. On this very long quest, defeat seemed imminent at many points, and considerable courage was required to maintain hope. Advocates were buoyed in this journey by Sen. Ted Kennedy (D-Mass.), Sen. Pete Domenici (R-N.M.), Rep. Patrick Kennedy (D-R.L), and Rep. Jim Ramstad (R-Minn.), all of whom introduced the bill in their respective chambers. Earlier, Sen. Wellstone of Minnesota provided boundless energy around the issue until his untimely death in 2002.

The Wellstone-Domenici Act mandates that insurance plans have the same financial requirements and the same benefit limitations for mental health and substance use services as for medical and surgical care. Specifically, this means that deductibles, co-pays, co-insurance, and out-of-pocket expenses; visit and day limitations; and in-network and out-of-network benefits must be the same. Managed care firms are required to disclose their medical necessity criteria.

Insurance plans can opt out of the mandate for one year if costs rise by more than 2% in the first year of implementation or 1 % in succeeding years. Small firms that employ 50 or fewer persons are exempt.

Passage of the Wellstone-Domenici Act signals that the mental health and substance use care fields are corning of age. Most Americans now recognize that mental and substance use conditions are illnesses like any others, and need to be considered as such by the insurance industry and care providers. Legislators also have come to understand this. All of us in these fields know and appreciate that the dividends will be better care and improved quality of community life for care recipients.

Insurance parity also can serve to move the important agenda of integration with primary care. The mechanism seems very straightforward: Insurance parity will promote care equity between specialty and primary care in integrated care settings. Care equity will empower our efforts to develop a consumer-directed medical home that encompasses specialty and primary care. An urgent need exists to accomplish this goal, so that we can reduce the 25-year life-expectancy disparity borne by public mental health consumers. Thus, the full benefits of the Wellstone-Domenici Act are likely to continue unfolding over the next decade.

Our hats are off to all who advocated for so long to produce this magnificent achievement: Pam Greenberg, president and CEO of the Association for Behavioral Health and Wellness, who led the effort; the Mental Health Liaison Group; the National Alliance on Mental Illness; the National Council for Community Behavioral Healthcare; Mental Health America; the Community Anti-Drug Coalitions of America; the Bazelon Center for Mental Health Law; the professional associations that represent providers; and all the member organizations of the Whole Health Campaign. We would be remiss if we did not also recognize the outstanding efforts of the American Public Health Association, which mobilized its members in a major lobbying effort as the final bill moved from the Senate to the House.

Our past success must stoke rather than dampen our future efforts. New challenges do await us! Parity will improve the care of those who already have health insurance coverage, but it will do nothing to address the problems of those who have no health insurance at all. Of the approximately 47 million Americans without health insurance, fully one-third have mental health or substance use conditions. Furthermore, fully one-third of those with mental health or substance use conditions have no insurance--double the national rate of uninsurance for all groups.

In less than two months, a new Congress and administration will enter Washington. Keeping national healthcare reform on their agenda will be a major challenge, as they confront monumental economic problems, the protracted wars in Iraq and Afghanistan, and a very large federal deficit. Yet the Wellstone-Domenici Act energizes us to keep mental health and substance use care at the healthcare reform table as the national debate unfolds.

Ronald W. Manderscheid, PhD, currently Director of Mental Health and Substance Use Programs at the consulting firm SRA International, Inc., worked for more than 30 years in the federal government on behavioral health research and policy. He is a member of Behavioral Healthcare's Editorial Board. To contact Dr. Manderscheid, e-mail ronald_manderscheid@sra.com.

RELATED ARTICLE: Parity milestones

May 12, 1992

Federal mental health parity legislation is first introduced. Various parity bills will be introduced during the next 16 years.

1993 to 1994

Congress debates President Clinton's health plan, which includes a phase-in of full parity by January 1, 2001. The plan is not passed.

1995

The Coalition for Fairness in Mental Illness Coverage is formed, which represents consumers, family members, health professionals, and healthcare systems and administrators in parity negotiations.

September 26, 1996

Clinton signs the Mental Health Parity Act of 1996, which requires parity for only annual and lifetime dollar limits.

1999

Clinton directs the Federal Employees Health Benefits (FEHB) Program to institute mental health and substance use parity, which takes effect January 1, 2001.

April 29, 2002

President Bush endorses parity.

October 25, 2002

Sen. Paul Wellstone (D-Minn.), a strong supporter of parity, dies in a plane crash.

July 23, 2003

President's New Freedom Commission on Mental Health endorses parity.

December 12, 2005

National Business Group on Health issues report that supports voluntary parity.

July 15, 2008

Congress overrides Bush's veto of the Medicare Improvements for Patients and Providers Act of 2008, which over 6 years phases out the 50% co-pay for mental health ambulatory care under Medicare Part B.

October 3, 2008

As part of a financial industry bailout package, Congress passes the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which Bush signs the same day.

October 3, 2009

Parity law regulations are due from the Departments of Health and Human Services, Labor, and Treasury.

January 1, 2010

The legislation takes effect for most group health plan members.

Sources: Pamela Greenberg; Mental Health America; Sundararaman R, Redhead CS. The Mental Health Parity Act: A Legislative History. Congressional Research Service. July 18, 2008.

RELATED ARTICLE: 'Fascist process'?

While the behavioral healthcare field celebrated parity's passage, others seemingly were not so happy about it. Thomas Bowden, an analyst at the Ayn Rand Institute, said in a press release in July that parity legislation "illustrates the insidious, essentially fascist process by which creeping government regulation molds insurance companies into civil servants who slavishly implement political decisions handed down from Washington, D.C., raising everyone's health-care costs in the process." He added, "Health care is not a right. It is a value offered for profit by physicians, hospitals, and drug companies. Likewise, health insurance is not a right--it is a value offered by insurers for profit, and often paid for by employers as part of employee compensation. Insurers, and the employers or individuals who patronize them, have a right to set their own terms of trade. This includes the right to offer or purchase less favorable coverage for mental illness than for physical illness."

--Douglas J. Edwards

RELATED ARTICLE: On parity: I suppose we should celebrate, but ...

A blog posting on behavioral.net by Ann Borders on October 7

The news of the passage of the long-awaited parity bill brings mixed feelings from this corner of the provider world. On the one hand, behavioral health disorders will finally be recognized as bona fide medical conditions. On the other hand, though, I'm sure that many of our readers will mark the occasion by remembering those who didn't survive the pre-parity days.

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I recall a few years ago when an actively suicidal 16-year-old girl was denied inpatient care because she had reached her insurance plan's lifetime maximum for behavioral health. (I believe it was $1,000.) We pasted together a 24/7 safety plan with her family and they made it through the crisis, but I remember wondering if this is the best that our society can do for its young people. Then there was the 15-year-old boy who had made several attempts on his life. He was denied admission at three different hospitals. We couldn't prove it, but we were fairly convinced that his insurance plan wasn't to the liking of those inpatient facilities. While the insurance coverage failed the test, the boy succeeded in taking his own life.

How many other victims were there, and how much suffering could have been prevented by just a little common sense in Washington? (If it had to have been about the money, our elected officials had no excuses because they'd been supplied with compelling evidence of the cost benefits of behavioral health coverage.)

Looking toward the future, we know that many families will benefit from this historic legislation. But let us continue our advocacy in memory of those who lost so much for such pathetic reasons.

To read responses to this blog post, as well as more posts by Ann Borders, president and CEO of Cummins Behavioral Health Systems, Inc., visit behavioral.net/annbordersblog.

by Douglas J. Edwards, Editor-in-Chief
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Author:Edwards, Douglas J.
Publication:Behavioral Healthcare
Geographic Code:1USA
Date:Nov 1, 2008
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