Mental Health Parity At Last

At long last, the Administration has released the final rule implementing the Mental Health Parity and Addiction Equity Act of 2008.

This will extend mental health insurance benefits on a par with medical/surgical benefits to at least 30 million more people. 

And, more importantly, we have finally ushered in a 21^stCentury response to a set of diseases for which we still often employ 19^thCentury treatments – locking the door and throwing away the key.

The Mental Health Parity Act (MHPA) was passed in 2008.  Its purpose was to end insurance discrimination against people with mental illness.  

For larger group health plans, it outlawed annual and lifetime limits on mental health or substance use disorder benefits when there are no annual or lifetime limits on medical/surgical benefits. And it required that co-insurance and co-payments be substantially the same for both mental health and regular medical/surgical procedures.

As it turned out, the MHPA needed the Affordable Care Act (ACA) for it to work most effectively.  And vice-versa.

ACA extended MHPA protections to the small group and individual markets, and made mental health and substance use disorder benefits “essential benefits” that all marketplace insurers (i.e., non-grandfathered plans) had to cover.

But ACA also relied on state benchmark plans to determine how the essential mental health benefits were defined.  This opened the door to the possibility that a state might use its own definition of parity – one less strict that the federal government’s – in defining those benefits, even though the MHPA set a standard federal approach.

For years, we have wondered how the final rule would reconcile the two laws.

Good news – the final rule makes the uniform, minimum parity standard come to life.

According to the final rule, states can require better parity coverage than is required by the federal law.   

But they cannot set minimum levels of coverage that are less than those demanded by the MHPA.  And if there is a dispute about this, the rule’s preamble clearly spells out how such a dispute should be resolved: “An insurer subject to MHPAEA may be required to provide mental health or substance use disorder benefits beyond the state law minimum in order to comply with MHPAEA.” (p. 46)

Still, there are limitations to the law and the rule.

For one thing, the MHPA does not by itself mandate that all insurance products include behavioral health coverage – we need ACA for this. As the rule notes, while treatment limitations are not permitted under the MHPA, “a permanent exclusion of all benefits for a particular condition or disorder… is not a treatment limitation for purposes of this definition.”  (Sec. 54-9812-1, p.103)  

Also, it does not establish uniform co-pays for providers.  The co-pay for a behavioral health provider’s service may still be different from, say, the co-pay for a primary care provider’s service.  Instead, the co-pays are calculated based on the co-pays set for all similar medical/surgical services covered in the plan.

And in high-deductible plans certain prevention services, such as screening, may be covered at no cost, while other mental health services may either have a cost or not be covered at all (see the preamble, p. 18-19).

Finally, the rule does not entirely resolve the question of provider rate-setting – a post-MHPA issue that arose in Florida when one insurer singled out mental health providers and reduced their rates in late 2011: “Plans and issuers may consider a wide array of factors in determining provider reimbursement rates for both medical/surgical services and mental health and substance use disorder services.… The NQTL provisions require that these or other factors be applied comparably to and no more stringently than those applied with respect to medical/surgical procedures…. The Departments may provide additional guidance if questions persist with respect to provider reimbursement rates.” (p. 24)

But all in all, this is a good rule.

It extends the parity provisions that have covered most of the 130 million people in large groups under the interim rule to an additional 30 million people (p. 64), and does so at an affordable price.

This expanded coverage will cost an estimated $10.55 per person initially, and up to $1.13 billion over five years (p. 78).  It will result in an insurance premium increase of less than 1 percent in both the individual and small group markets.

The new rule will cover all plans issued, or renewed, after July 1, 2014.  That will be a good day for fairness and equity.

Note:  I started writing Our Health Policy Matters exactly three years ago, in November, 2010.  Since then, I've published at least one new column per week, without a break.  So, for the first time, I'll be taking a couple of weeks off.  I will not publish next Wednesday or the week after, but will return with new columns after Thanksgiving.  If there is breaking news between now and then (and no, I don't consider the low Obamacare enrollment numbers to be newsworthy right now, but about what should have been expected based on the enrollment numbers for the now-put-to-bed PCIP program!), I may publish something off-schedule, and catch you up after vacation if you don't visit the site between now and then.  In the meantime, if you enjoy OHPM, I encourage you to take a look at some of the older columns you might not have had time to read in the past.  And feel free to contact me directly with ideas you may have for future columns! And thanks for reading - I've been averaging 13,000 readers per month lately.  Not huge by some Web standards, but not too bad either for a once-a-week health policy effort.  I thank you, and wish you a very Happy Thanksgiving!

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

The Lost War on Drugs

I admit it.  I have Obamacare fatigue.

I’m tired of endless stories about website glitches and the small numbers of people who rushed to buy health insurance three months before it would even go into effect.  But I am most fatigued by the newest invented controversy about the so-called “health-insurance-you-like” policies that have been outlawed because they do not meet even the bare minimum standards established by the law.  That’s right – the American people just love lousy health insurance!

Source: NSDUH, 2013

So I thought I would write about something less controversial – drugs.  Because some new facts suggest that if we really want to change a useless federal policy, we will end – as quickly as we can – our failed War on Drugs.

President Richard M. Nixon declared “War on Drugs” in June of 1971.  We have been fighting this war for forty-two years now, long enough to determine if it has made any difference in our lives.  It has. 

The War on Drugs has loaded up our jails and prisons, but has resulted in no discernible impact on illicit drug use among children or adults – except, maybe, to increase it.

Please don’t take my word for this.  Just take a look at the data.

According to the 2012 National Survey on Drug Use and Health, released a little over a month ago, only 19 percent of people over the age of 65 have ever used illicit drugs during their lifetime.  This was the last group that entered adulthood before the War on Drugs was declared.

But 47 percent of those born between 1948 and 1952 say they have used illicit drugs.  This was the group entering adulthood when the War on Drugs was declared. 

And for everyone entering adulthood after the declaration of war, lifetime illicit drug use is now greater than 50 percent.

So drug use may be up a little over the last forty years.  Is that enough to declare that the war is a failure? 

Maybe not, but here are some facts that are.  According to the NSDUH:

• An 18 year old (for whom drinking is illegal) is 10 percent more likely to drink than a 65 year old;
• A 16 year old (for whom smoking is illegal) is 36 percent more likely to smoke than a 65 year old;
• A 12 year old is three times more likely to use illicit drugs than a 65 year old.

So we’re losing our children to this war.  And not just compared to that older, pre-drug war generation.  In fact:

• A 15 year old is more likely to use illicit drugs than someone over the age of 40.
• An 18 year old is more likely to drive under the influence of alcohol than someone over the age of 45.
• And more than half of those who start to smoke still do so by age 18 – even though the number of people who first started to smoke after the age of 18 nearly doubled between 2002 and 2012.

When drug use leads to drug problems, it leads to jail and prison, but not to comprehensive drug treatment.

Thank goodness for peer support services, about which I have just written for Health Affairs.

Among the 4 million persons who received treatment for alcohol or illicit drug use last year, more than half – or 2.1 million – received that treatment from a self-help group. 

And despite the fact that prison populations have more than quadrupled since 1978 and that up to 75 percent of prisonershave been found to be dependent on alcohol or drugs at some point in their lives, year only 388,000 – a number equal to just 18 percent of the combined prison and jail population – received alcohol or drug treatment while in prison.

As pitiful as that percentage is, it is still better than what we offer in communities. 

Inadequate funding for drug treatment has meant that for the 1 million youths between the ages of 12 and 17 who needed treated for illicit drug use in 2012, only 121,000 – or 11.6 percent – received treatment in a treatment facility.  And of the almost 900,000 more who needed treatment for alcohol dependency, only 76,000 – or 8.9 percent – were treated in a facility.

And for everyone over the age of 12, 65 percent of those who needed treatment did not get it either because they had no coverage for it or no access to it.  

So you tell me - is this a war we won?

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/