by Ralph Ibson, Vice President for Government Affairs, Mental Health America

This year Congress will pass a strong law that outlaws discriminatory insurance limits on the duration of mental health care and inequitable cost-sharing requirements. That’s what I would have said several weeks ago. Now, passage of mental health parity legislation looks a bit less certain.

Advocates have, of course, pressed Congress for years to pass a parity law, and, year after year, have watched promising legislation languish and die, despite overwhelming bipartisan support. But 2007 finds us with new leadership in Congress that has signaled support for parity, growing grassroots' momentum, and unprecedented support from longtime parity-opponents.

At this early point in the legislative session, a Senate parity bill has already won committee approval, and in the House of Representatives a parity bill was recently introduced with 255 original cosponsors, well beyond the 218 needed for House passage.

What’s the problem? First, these bills must still traverse a long road. In the House, the Paul Wellstone Mental Health and Addictions Equity Act (H.R. 1424) must clear three different committees. And differences between the Senate and House bills would have to be reconciled. While the landscape for passage of a strong parity bill has not been this favorable in a decade, there's a risk that pursuit of an ideal bill will clash, irreconcilably, with the quest for a good one. The issue is by no means academic. The House measure goes further than its Senate counterpart, and finding middle ground between the two could be elusive.

The two bills have more common features than differences. At their heart are provisions that would prohibit employers and insurers from imposing stricter treatment limitations and financial requirements on mental health coverage than on coverage for any other illnesses. The House bill would require health plans to cover treatment for any mental health condition or substance-use disorder for which benefits are provided under the Federal Employee Health Benefits plan, the program through which Members of Congress and their staffs get health-coverage. In contrast, the Senate's Mental Health Parity Act of 2007, S. 558, does not aim to regulate which conditions must be covered. S. 558 would preserve most protections afforded under state law, while the House bill would go further in specifying that it would not override any provision of state law that provides greater protections.

In weighing these measures, it is helpful to be clear on what the legislation can reasonably be expected to accomplish and what battles may still lie ahead. Closing the loopholes in the 1996 parity law, and thereby outlawing remaining discriminatory practices, will cement the principle of benefits-equity into law.

But a strong parity law alone will not necessarily usher in an era of ready access to needed mental health services. While the bills differ in important respects, neither would prohibit insurers from managing the provision of behavioral health care or from making determinations as to when, what, and how much care is "medically necessary." Both measures make it unlawful to set arbitrary day and visit limits (that are more restrictive than limits on other medical care) in an employer-provided health plan. But neither bars an insurer from using managed care techniques to limit the duration of covered treatment. So, for example, while it would be unlawful under either bill to limit mental health coverage under a health plan to an annual cap of 20 outpatient visits and 30 days' hospitalization, an insurer could still -- based on its own criteria of "medical necessity" -- second-guess the clinician’s judgment that a patient needs outpatient treatment for a specified period of time.

The latitude both bills give to "manage the care," leads analysts to conclude that parity legislation will not result in substantial new costs. Is parity legislation fundamentally flawed if people continue to be denied coverage for care a clinician deems medically indicated? Not at all!

Ending discrimination against behavioral health disorders will afford dignity to persons needing care and the opportunity to achieve their full potential much as civil rights laws of the 1960's afforded these opportunities to those who suffered race-based discrimination. Both represent foundational, transformative laws. Just as we recognize that civil rights laws did not end racism, or instantly quash the many manifestations of discrimination experienced by African-Americans, we should appreciate that a comprehensive parity law is unlikely to erase overnight the stigma surrounding mental illness,or topple all the barriers that deny people access to quality mental health care.

But a parity law promises to change the paradigm. It represents much more than simply a reform of insurance practices. Its enactment would codify the powerful principle that behavioral health disorders must be accorded at least as much urgency and attention as is given other illnesses and health conditions. That principle surely has broad application in areas ranging from health care financing to public health policy.

Finally, the enactment of parity legislation is also likely to be a catalyst to ending the stigma surrounding mental illness. The years-long debate over parity legislation has made clear that discriminatory insurance practices have no rational basis. Mental illnesses are readily diagnosable and treatable, and there are a range of efficacious treatments. Rather than having any medical, scientific or economic foundation, the insurance barriers that will fall with enactment of parity legislation are rooted in lack of understanding about mental illness.

How is it a business could be so short-sighted in purchasing health coverage for its workforce as to erect arbitrary barriers to needed mental health care? Consider the congressional testimony of a Fortune 500 company CEO:

Business leaders should not overlook . . .[the cost of untreated mental illness] when reviewing their insurance coverage as it relates to mental health parity. But unfortunately they do. Too few businesses have really examined mental health parity -- typically because of misunderstandings regarding mental illness, the erroneous belief that parity means additional cost, and misperceptions about the efficacy of treatment. I was one of those business leaders until my personal circumstances made me see what was going on in our own company. . .I do believe that in time, most business leaders will realize, as I have, that providing mental health benefits on par with medical and surgical care is good for the bottom line. But quite frankly, we cannot afford to wait for that time." (James T. Hackett, Chairman, President, and CEO of Ocean Energy, Inc, testimony before the Subcommittee on Health, House Energy and Commerce Committee, July 23, 2002.)

To see trade associations representing the business community and insurance industry supporting a Senate parity bill is to see a not-far-distant day when ignorance and misunderstanding regarding mental illness will give way to an appreciation that mental health is integral to overall health. But for that day to come, it’s critical that Congress pass a strong mental health parity bill this year, even if its provisions fall short of the ideal.

Ralph Ibson is Vice President for Government Affairs at Mental Health America (MHA) where he heads up federal relations’ activity in support of MHA programs and mission, including advocacy in Congress and Executive Branch departments. Prior to joining MHA in 2000, Ralph served for ten years on the staff of the Committee on Veterans Affairs in the U.S. House of Representatives.
Mental Health America hosts a website dedicated to winning enactment of parity legislation at www.equitycampaign.net.