Early Signs From Massachusetts Give Hope to MH Advocates

The rollout of Massachusetts's comprehensive health care system this summer has provided the widest statewide insurance coverage in the nation, while maintaining one of the most generous mental health parity requirements for insurance plans.

When Chapter 58 of the Acts of 2006 became law on April 12, 2006, its goal was to achieve nearly universal health coverage for Massachusetts residents. The program, which faces a three-year rollout, began enrolling residents last summer, and the individual participation mandate was launched on July 1. The health plan's key aspects include the following: an affordable health insurance option to be offered by every private insurer; a subsidized insurance plan for low-income residents; employer insurance requirements, such as annual fees based on the number of uninsured employees; individual insurance requirements, which add an annual tax assessment to residents who cannot prove they have insurance coverage; expansion of the State Children's Health Insurance Program (SCHIP) and Medicaid (MassHealth) programs; a merger of the individual and small-group insurance markets; and increased payments to and quality reporting for hospitals and physicians.

Successes Noted

The complex plan is still in its early stages, but mental health advocates said preliminary successes included the plan's basic design, which continues a strong mental health parity insurance requirement enacted in the state's 2000 parity law. That law requires all private insurance plans to cover the costs of the diagnosis and treatment of major mental disorders, such as schizophrenia and bipolar disorder, to the same extent that they cover physical disorders. The law also bars some health insurance plans from placing stricter annual or lifetime dollar or unit-of-service limitations on coverage of qualifying mental disorders than those placed on other types of health conditions.

Mental health advocates in the 2006 legislature had to fight for the continuation of parity, which then-Gov. Mitt Romney (R) proposed cutting to lower the cost of mandated insurance.

“Although what we have is not total parity, it does provide substantial coverage,” said state Rep. Ruth Balser (D), a leading mental health advocate in the legislature.

The parity required in the final law was considered a starting point, and Balser has introduced legislation (HB 1871) to expand the requirement to full parity for all conditions listed in DSM-IV.

A further indication of early success has been the public's aggressive acceptance of the insurance. The number of Massachusetts residents covered by MassHealth and Commonwealth Care, the new, publicly subsidized insurance program for low-income residents, increased by 122,000 in the year since the law was signed. That is about one-third of the 372,000 Massachusetts residents whom state health officials estimated were uninsured in June 2006, according to a May report by the Blue Cross/Blue Shield of Massachusetts Foundat ion. Commonwealth Care had 105,000 people enrollees, significantly more than the 70,000 that state planners had estimated would be signed up by last month.

Psychiatrists Have 'Guarded Hopefulness'

The early signs of success indicate that the plan will benefit many of the state residents who were without insurance and provide some level of mental health care coverage for the estimated 100,000 residents who need that type of care, according to Tobia Fisher, policy director at NAMI Massachusetts.

“Any time you expand access to mental health care, it's a good thing for the commonwealth,” Fisher said in an interview with Psychiatric News.

Whether the increased coverage for mental health care will translate into increased access to psychiatric care in particular is less certain. Gene Fierman, M.D., president of the Massachusetts Psychiatric Society (MPS), said his members “have guarded hopefulness” that the plan will open access to care but also see early signs of trouble.

Although more state residents will have coverage for psychiatric care, their access will be limited by a documented shortage of psychiatrists. This situation was detailed in the Massachusetts Medical Society's “2007 Physician Workforce Study,” which identified physician shortages in primary care, psychiatry, and other areas of medicine.

“We will create more demand for services [with the new law], and my question is how is that demand going to be met,” Fierman said, in an interview.

The new plan also fails to address policies by insurance companies that tightly restrict payments to psychiatrists in general and child psychiatrists in particular, which force many people with insurance coverage to seek care outside of their insurance network. The MPS has had discussions with insurance companies on the low reimbursements and the extensive paperwork psychiatrists are required to fill out, Fierman said, but little progress on improving the situation has been made.

The impact on public clinics of the plan's MassHealth expansion also remains unclear. The public mental health clinics now employ few psychiatrists after money-saving initiatives “de-professionalized” them from a model in which leadership was provided largely by psychiatrists to one generally organized around counselors.

Specific approaches that the low-cost health insurance plans require from each insurance company also remain a question. One plan, for example, opted to provide access to a large number of specialists but tightly restrict the number of primary care physicians from which its beneficiaries can seek care.

“Everyone is very hopeful that this state plan will open up access to mental health care, but given problems already facing psychiatrists, one wonders how this increasing demand will be met,” Fierman said.

Mental health advocates achieved some of their primary goals by having the new law adhere to Massachusetts's existing mental health parity law, Fisher said. Another achievement was the broad access it granted to psychiatric medications.

Brian Rosman, director of research at Health Care for All, a patient-advocacy group, said the next push related to maximizing the mental health benefit will come during a September meeting by a Massachusetts policy committee in which there will be a discussion of whether to add medications without generic alternatives to the no-deductible list. State regulators had interpreted the law to require that low-cost insurance plans could not charge a deductible for generic medications but could charge for name-brand medications.

“That has a big impact on people with mental illness, who often need these drugs,” Rosman said.

Further proposed legislative changes to the plan will include the MPS-backed push for full parity coverage for all mental illness and substance abuse care in Massachusetts.

“Substance abuse is a very big concern, and for now we continue to insufficiently cover it,” Balser said.

A description of the coverage in the Massachusetts health plan is posted at<http://www.kff.org/uninsured/upload/7494-02.pdf>. The bill to expand Massachusetts parity legislation is posted at<www.mass.gov/legis/bills/house/185/ht01pdf/ht01871.pdf>.▪