Parity at last

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					Parity at last
Business and insurance groups' support was key to its passage

by Douglas J. Edwards, Editor-in-Chief

                               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.

 U.S. Rep. Patrick Kennedy     Greenberg's and many, many others' long fight for parity
 (D-R.I.) speaks at a parity   finally was realized on October 3, when Bush signed the
 rally in Washington, D.C.,    Paul Wellstone and Pete Domenici Mental Health Parity
 on September 17. Charles      and Addiction Equity Act, part of the $700 billion financial
 Votaw Photography             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
clear 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.”

                                                                            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
Trautwein, vice-president and employee benefits policy counsel at the      Research
National Retail Federation, says employers' growing interest in health     Service. July
benefit policy and employee wellness also “made it easier certainly for 18, 2008.
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.

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.”




Sidebar
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.

                                 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
 Ronald W. Manderscheid,         imminent at many points, and considerable courage
 PhD                             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.I.), 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 coming 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.




Sidebar
‘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




Sidebar
On parity: I suppose we should celebrate, but…
A blog posting on http://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.

                                   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
 Ann Borders                       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
http://behavioral.net/annbordersblog.

Behavioral Healthcare 2008 November;28(11):12-17