As states take the lead in expanding health care access for more Americans,
mental health advocates worry that people with psychiatric conditions and
substance use disorders are being left behind.
Their concerns stem from a report released in June on the mental health
components of health insurance plans from the 18 states (see map) with the
most generous health care coverage programs or plans.
The report, by the National Alliance on Mental Illness (NAMI) and the
National Council for Community Behavioral Healthcare (National Council), is
titled "Coverage for All: Inclusion of Mental Illness and Substance Use
Disorders in State Healthcare Reform Initiatives."
The report examined the Medicaid programs, state health care coverage laws,
and insurance expansion proposals in 18 states to quantify the extent to which
treatment for people with mental illness, including substance use problems, is
According to the report, about 60 percent—or 11 of the 18 states
studied—provide at least one insurance plan with equal coverage for
mental illness among their programs and proposed plans for the uninsured.
Seven of these states did not provide at least one mental health parity
option, but had preexisting parity statutes governing only private insurance
plans—not the state-funded programs. Coverage for substance use
disorders was even poorer. Only 28 percent of the state reform plans studied
offered at least one insurance plan with parity coverage for substance use
disorders. Just five of the 18 states—Colorado, Indiana, Maine,
Minnesota, and Vermont—had parity coverage for substance use disorders
in at least one of their programs or proposals for the uninsured.
The impact of the coverage shortfall could be significant, as the report
concluded that more than 25 percent of adult Americans who lack insurance
coverage have a mental illness, substance use disorder, or co-occurring
"Many states are trying to cover the uninsured but need to do more in
these critical areas that affect 1 in 4 Americans," said Michael
Fitzpatrick, NAMI's executive director.
The report also said that states that provide less than a parity benefit
for substance use disorders impose a variety of service limits, including caps
on outpatient treatment visits, limitations on inpatient stays, and maximum
States generally viewed as closest to achieving universal coverage,
according to the report, were more likely to provide mental health parity as a
component of their health care reform effort. For example, Maine and Vermont
include equal benefits for mental illness and substance use disorders and
other health conditions in their health insurance programs. Massachusetts
provides equal coverage for serious mental illness, co-occurring disorders,
and physical health conditions, while coverage for the treatment for
alcoholism must meet minimum standards mandated by state law.
About 90 percent of the programs in the eight states that have proposed or
implemented health insurance coverage programs for residents of all incomes
require mental health parity for serious mental illness or for a broader
category of mental illness.
Serious mental illness is also referred to in some states as"
biologically based" mental illness, according to the report. It
typically includes schizophrenia and other psychotic disorders, bipolar
disorder, major depressive disorder, obsessive—compulsive disorder, and
About 40 percent of these states provide parity for treatment of substance
"We can effectively treat substance use disorders and mental
illnesses, and people [who] suffer from these debilitating conditions deserve
treatment," said Linda Rosenberg, president and CEO of the National
Council. "It is distressing that there are insurance plans and health
care reform initiatives that continue to discriminate."
Even among the state plans that include parity mental health benefits, the
report noted that copayments are increasing, which is a trend throughout
health care plans. Most programs have "significant" copayments,
including those targeting low-income and small-employer populations.
Only Minnesota exempts outpatient mental health and substance use services
from copayments to remove a financial barrier to accessing these services.
Medicaid plans and a few other state programs have very low or no
copayments, though most states are charging more per visit or
Few state reform plans for the uninsured, according to the report, include
efforts to address workforce shortages in mental health and substance use,
chronic-care management of these conditions, or wellness benefits for these
"Basic parity is not enough," Rosenberg said. "More
states need to address problems with scope of benefits, copayments, prior
approvals, and shortages of mental health professionals."
Among the exceptions to states lacking parity for mental illness prevention
measures is Indiana. In addition, Vermont's program for the uninsured and
Illinois's health care reform proposal, as well as the Illinois Medicaid
program, include mental illness and substance use disorders in their
The National Council report found that federal waivers allowing Medicaid
expansions have been a component of reform in approximately 75 percent of
states with implemented programs, which highlights the importance of federal
policy in future state health care reform efforts.
Although states with various levels of mental health and substance use
benefits have been granted federal waivers to expand the eligible population
for Medicaid coverage, the programs with the broadest array of services and
those closest to universal coverage receive additional federal funds through
waivers from the federal government. The widespread use of federal waivers to
expand state Medicaid programs underscores the reliance on federal funds for
state health care expansion, according to the authors, and the influence of
the Centers for Medicare and Medicaid Services' policy of furthering health
The authors of the report cited a need for a federal parity mandate. They
concluded that proposed legislative restrictions on federal waiver financing
also will have a negative impact on the ability of states to move toward