As negotiations on a Senate mental health parity bill are under way, APA has continued to push for changes expanding the bill's protections for existing state parity laws that are more stringent. District branches in states with strong mental health parity laws also raised concerns about the impact of preemption wording in the Senate legislation.

Although APA supports the Senate measure, it is working to strengthen the parity provisions within it, while keeping district branches and state associations informed of provisions—as approved by a Senate committee—that could affect the parity laws in their states.

Although similar parity bills were introduced in both the House (HR 1424) and Senate (S 558) recently, supporters said the differing rules in the two chambers require a greater degree of compromise in the Senate measure.

The Senate Health, Education, Labor, and Pensions (HELP) Committee approved the Senate bill sponsored by Sen. Pete Domenici (R-N.M.) in March, but other senators raised concerns that supporters worry could stall the bill before it reaches the Senate floor.

Both measures would amend the Mental Health Parity Act of 1996, which requires insurance equality only for annual and lifetime dollar limits. They would also require health plans that offer mental health coverage to provide mental health benefits at parity with benefits for other types of health care.

One aspect of the Senate bill that concerns parity advocates is that it does not require health plans to provide an out-of-network benefit for mental health services, even if they provide such benefits for other illnesses. However, plans that do provide out-of-network mental health benefits must do so at the same level as for other medical and surgical out-of-network benefits.

"Under this bill, in some states patients would lose coverage," Seth Stein, executive director and general counsel of the New York State Psychiatric Association, told Psychiatric News, "although it may be that more people, as a whole, would gain coverage in the aggregate."

Representatives of several New York state district branches sent APA leaders a letter in April outlining their concerns about the Senate bill, such as its preemption of the state's law that mandates coverage of specific minimum hospital days and outpatient visits.

"These limitations and restrictions in the [Senate bill] would not be fundamentally problematic if the federal provisions were a floor for benefits," the letter noted. "However, the Senate bill provides that the provisions of the federal law would preempt state laws that provide more extensive coverage or that do not provide a cost exemption included in the bill."

Nicholas Meyers, director of APA's Department of Government Relations (DGR), said that overall even the limited Senate bill would have a strongly positive impact. He agreed that it is possible some patients in a few states would lose specific mandated benefits, such as a coverage for a minimum number of inpatient days. Those loses would be balanced with a historic requirement that plans provide coverage at parity.

"You have to balance [some losses] against the fact that far more states covering far more individuals would see a net significant improvement in mental health coverage," Meyers said. "And, of course, for the first time tens of millions of individuals in ERISA plans would also have a parity coverage requirement that is not possible under current law."

The New York letter called on APA leaders to reach out to district branches and state associations for input and recommendations and to help assess the impact of the bills on the 41 states with parity laws.

Meyers said his office is working to keep APA members informed of the legislation, although he noted that the ongoing Senate negotiations make it unclear what final shape the measure will take.

A weekly legislative e-mail update is sent to district branch officials, which APA members can access at the "Advocacy" section of the Association's Web site. Also, DGR has issued a special report on parity and plans to issue more reports when the House and Senate pass their respective bills and go to conference. Also under consideration are conference calls between DGR staff and district branch officials concerned about the federal parity legislation's impact on their state laws.

"We understand the concern of district branches that might find some specific provision of state parity laws preempted by provisions in the Senate parity bill, but the language is still under consideration," Meyers told Psychiatric News.

He encouraged APA members who have questions or concerns to feel free to contact the DGR staff.

Stein agreed that "judgments have to be made" during the give and take of legislative negotiations and emphasized that the letter was intended to ensure good communication between APA leaders and district branches.

Some good news for parity supporters is that the Senate bill includes parity coverage for substance abuse treatment. Negotiators turned back an attempt by Sen. Tom Coburn (R-Okla.) to remove addiction-treatment language, which also is included in the House bill.

Nonetheless, members of A PA's Council on Addiction Psychiatry have raised concerns that the Senate bill's use of the term "substance abuse treatment" could limit its strength because it varies from the field's terminology of "substance use disorders." APA is working through Senate parity supporters to change the original language.

Negotiators also agreed to a change in the bill that would allow companies that temporarily drop parity coverage if costs spike to not report that decision publicly. Business advocates said such public reports could hurt businesses by revealing the status of their finances to competitors.

Although APA prefers that no measure preempt state laws that are stronger than a federal measure, parity advocates acknowledge that the Senate measure will not advance without some preemption provision. APA urged Senate negotiators to clarify the preemption language so that only treatment and financial areas are included. The bill would replace the treatment and financial parity laws in most states with the first national standard for financial requirements and treatment limitations. The House bill would only set a floor state laws could build on.

Parity advocates hope to resolve the major areas of contention in the Senate bill and to have the chamber pass it soon. Passage in one chamber makes it more likely that the other chamber will take action on its version of the bill.

APA leaders continue to testify on the need for parity before various legislative committees. Steven Sharfstein, M.D., immediate past president of APA, testified before the House Ways and Means Subcommittee on Health in March that implementing parity in 2001 did not significantly increase services or health costs in the managed care plans of the Federal Employees Health Benefits Program (see APA Tells Congress: End Medicare's Higher Copay for MH Treatment).

Parity received another endorsement when the American Psychological Association joined APA in mid-March in calling for enactment of a federal parity law. ▪