New York Times article
Published: March 29, 2010
Even without the new health care law, mental health advocates were getting ready to celebrate parity — a law requiring benefits for substance abuse and mental illnesses to be on par with benefits for medical illnesses.
But that law, passed in 2008 and taking full effect only this July, did not cover everyone with insurance, and it offered no help to the 32 million uninsured Americans.
Now mental health advocates are almost giddy. The law signed by President Obama last week expands parity to a much wider pool, making it possible for millions more people to get the same coverage for substance abuse and illnesses like bipolar disorder, major depression and schizophrenia as they would for, say, diabetes or cancer. There are no exact figures, but the mentally ill are more likely to be uninsured than the general population, advocates and researchers say.
“A lot of this still has to play out in terms of how parity works,” said Michael J. Fitzpatrick, executive director of the National Alliance on Mental Illness, or NAMI, an advocacy group. But the new law “can change the mental health system in America and really give families and individuals an opportunity to get a level of access to care we could only fantasize about before this became law,” he said.
Parity means that deductibles, co-payments and limits on the number of visits or days of coverage must be no more restrictive for coverage of mental illnesses and substance abuse than for coverage of medical and surgical treatments. If a plan provides for out-of-network medical benefits, it must provide out-of-network mental health benefits.
Under the new health law, employees of companies with 50 or fewer workers, whose employers were not required to comply with the existing parity law, would receive equal mental health benefits if their employers opt for the state-run exchange plans, available in 2014.
Peter Newbould, director of Congressional and political affairs at the American Psychological Association, which helped write parts of the legislation, said it was likely that the smaller companies would choose from the exchange programs, and that many may already be subject to state parity laws requiring the mental health benefits. He also said that the latest federal regulations on parity, released last month, left little wiggle room for other insurance companies to deny equal mental health benefits.
Still, in the state plans for purchase, the mental health benefits would be as generous, or as limited, as the plans are for medical health benefits. So those able to pay higher premiums are likely to get the best coverage on both fronts.
Besides increasing the number of people eligible for Medicaid, the new law requiresthat those in Medicaid managed-care plans be offered the same mental-health and substance-abuse benefits as medical and surgical benefits. Previously, only Medicaid-managed care plans provided that coverage.
The health care law is unlikely to affect most employees of large companies, already subject to state and federal parity requirements, although self-insured companies can opt out.
According to the National Institutes of Mental Health, one in four adults suffers from a diagnosable mental disorder in a given year, or about 58 million people. About 1 in 17 suffers from the most serious illnesses.
Fewer than half of those with mental disorders receive treatment, according to the Bazelon Center for Mental Health Law. An additional 22.2 million Americans need treatment for substance abuse or dependence, according to the latest datafrom the Department of Health and Human Services, from 2008.
Many of the changes affecting medical coverage, like the requirement that insurance companies provide coverage despite pre-existing conditions and the elimination of lifetime and annual limits on benefits, will have a big impact on people with mental illnesses.
Theresa Johnson, a nurse at an urban Connecticut hospital, knew that her daughter, Erica, would fall off the family’s plan with Anthem when she graduated from college last year. Ms. Johnson said she had tried to buy her daughter an individual plan with Anthem, but the company said her pre-existing mental illness, generalized anxiety disorder, made Erica “too high risk” and ineligible for coverage. (Her daughter’s pre-existing hypertension and hyperthyroidism did not make her ineligible, Ms. Johnson said she was told.)
Ms. Johnson decided to go with a Cobra option offered to children through her Anthem plan for up to three years after college graduation because she wanted to stay with Erica’s cardiologist and internist. That plan costs $605 a month, covering Erica’s therapy and the Lexapro she is taking for anxiety, and Erica is contributing $200, working three jobs. If Anthem had agreed to provide Erica with an individual insurance plan, the cost would have been roughly $250 a month, Ms. Johnson said.
“It really is discriminatory against people with mental health issues,” she said. “Being a nurse, it really kills me, it just kills me.”
Anthem declined to comment on the case because of privacy laws, but said in a statement that in some cases a pre-existing condition, or a combination of conditions, “may require us to decline coverage.”
Under the new health care law, dependent children can be covered under family plans until they are 26, effective in six months, though Ms. Johnson’s employer has announced that this will take effect for its insurance plans next January. And Erica, now 23, may face yet another period of uncertainty, because the protections for most people with pre-existing conditions do not take effect until 2014.
The new law provides for more training of what it refers to as “behavioral health workers,” but it is too soon to tell whether the mental health arena would face the kind of shortages predicted for primary care doctors, Mr. Newbould said. The law also includes a proposal to set up new nongovernmental research centers to investigate effective treatment for mental illnesses.
Because the law does not specifically define benefits, and many provisions will require many discussions on how to implement them, the devil may be in the details. “I think that’s a cliché we’re going to be hearing a lot,” Mr. Newbould said.
This article has been revised to reflect the following correction:
Correction: April 3, 2010
An article on Tuesday about mental health coverage under the new federal health care law, using information from the American Psychological Association, overstated one provision’s requirements for covering Medicaid recipients. Only those in Medicaid managed-care plans must be offered the same mental-health and substance-abuse benefits as medical and surgical benefits; the new law does not require all Medicaid coverage to include equal benefits.