APA's latest and highest-profile legislative victory—the enactment of
a landmark federal mental health insurance parity law—came in a quick
and little-opposed Congressional vote last month. That outcome wasn't as
smooth and sudden as it seemed to many outside the mental health field: it was
the hard-earned reward for three decades of relentless work by APA leaders,
members, and staff in combination with other mental health advocates.
The parity measure, passed by Congress as part of the massive financial
industry rescue package (HR 1424), requires health plans that offer mental
health coverage to have the same benefits, copayments, and treatment limits as
other types of health care (see New Federal Parity Law Detailed). The law,
which will give 113 million people across the country the right to
nondiscriminatory mental health coverage, goes into effect one year after
enactment or on January 1, 2010, for most calendar-year plans.
"The apparently easy culmination of the struggle to pass parity was
deceptive," said Nicholas Meyers, director of APA's Department of
Government Relations (DGR), "In fact, it was kind of like a duck gliding
along smoothly and calmly on the surface of the pond, while paddling furiously
underwater to stay afloat and keep moving."
APA helped form the coalitions that ultimately pushed Congress to pass the
measure and was at the table during critical negotiations to overcome the
opposition of insurance and business representatives to parity.
Among the first to push for a federal parity measure was Jay Cutler, J.D.,
an effort he began soon after coming to APA as head of DGR in the late 1970s.
(Cutler, who died in 2005, was previously minority counsel and staff director
for the Senate Health and Human Resources Committee.) A critical component of
APA's coalition-building efforts was Cutler's decision, with the full support
of then-Medical Director Melvin Sabshin, M.D., to focus the Association's
legislative resources on measures that directly benefited patients, not just
Cutler's initial success was in improving Medicare's limited mental health
benefit. "Jay Cutler deserves a tremendous amount of the credit. I
remember him and [DGR lobbyist] Ellen Smith lobbying me while I was working on
the Hill in the 1980s to lift Medicare's $250 cap on outpatient mental health
treatment," Meyers said. "At the time, APA, with Jay, was the only
mental health professional association lobbying for patients, not just its
members' own economic interests. That was a big factor in why I wanted to work
Cutler's and other APA advocates' efforts began to pay off with the
introduction of the first federal parity bill in 1992. The bill that was
enacted four years later mandated parity insurance coverage between mental and
physical disorders in lifetime and annual dollar limits.
This victory was achieved through the help of what was the first of many
coalitions APA helped form or joined over the succeeding years to get parity
legislation through Congress: the Coalition for Fairness in Mental Illness
Coverage. Among its members were the AMA and the National Alliance on Mental
Illness (NAMI). "This has always been a collaborative effort,"
Though limited in scope, the law paved the way for many states to enact
their own more generous parity laws in the following years, according to
Meyers. The law also was significant because it was among the first to change
aspects of the federal Employee Retirement Income Security Act (ERISA), which
governs the self-funded plans that cover 82 million individuals and are not
subject to state parity laws, thus protecting them from state coverage
Sen. Pete Domenici (R-N.M.) speaks at an impromptu press conference on
Capitol Hill in April 1996 to rally support for mental health parity after
parity legislation was overwhelmingly passed by the Senate a few days earlier.
Looking on are Sen. Paul Wellstone (D-Minn.), who died in a plane crash in
2002; and Melvin Sabshin, M.D. (middle), then APA medical director. The
legislation, titled the Mental Health Parity Act of 1996, was signed by
President Bill Clinton in September of that year.
Credit: Richard Karel
Among the earliest and strongest congressional supporters of parity were
Sens. Paul Wellstone (D-Minn.) and Pete Domenici (R-N.M.), under whose
leadership Congress passed the first federal mental health parity law in 1996.
Domenici and Wellstone both knew personally of the devastating
impact—financial as well as emotional—on families with a mentally
ill relative and reached across the aisle to promote parity.
Wellstone died in a plane crash while he was campaigning for reelection in
2002. His efforts and the continuing support of Domenici in recent years led
sponsors to title the parity bill that Congress passed last month the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of
It was clear after passage of the 1996 parity law that a stepped-up
lobbying effort was needed by APA. Part of that effort was the creation of
APAPAC. The long-term effort of that group, funded by APA member and
staff contributions, to form bipartisan alliances was critical in moving
parity through the long legislative process as well as the final focused push
for Congress to enact it, said John Wernert, M.D., APAPAC
"APAPAC gave us the access and relationships that allowed us
in the 11th hour when it mattered to address our friends on both sides of the
aisle," Wernert said.
The new law was crafted from several parity measures introduced since 1996,
which included two versions—one in the House and one in the
Senate—with important differences drafted in 2007. Although generally
similar to a House bill sponsored by Rep. Patrick Kennedy (D-R.I.), the Senate
bill emerged from months of exhaustive negotiations between parity
advocates—including APA—and business and insurance lobbies with
different goals. Some parity supporters disparaged the Senate version in favor
of the more generous House bill, while APA strongly supported both.
"To get there, it was necessary for both the House and Senate to pass
the strongest bills they could," Meyers said. "We viewed [the
different versions] as an absolutely necessary part of the process of getting
[parity] to the strongest compromise."
Congressional negotiators eventually compromised on differences in the two
bills last summer after parity leaders—including Sens. Edward Kennedy
(D-Mass.) and Domenici and Reps. Pete Stark (D-Calif.) and Jim Ramstad
(R-Minn.)—continually pushed to keep the measure on Congress's
"We owe them a tremendous debt of gratitude," Meyers said.
The final and most powerful key to parity's passage, Meyers said, was the
broad, sustained support of APAPAC and other APA members who
repeatedly contacted their members of Congress to urge support for parity
Continued APA member involvement will be needed as federal regulators
scramble to decide how to implement the broadly worded parity legislation
before January 1, 2010. Member psychiatrists will be asked in the coming
months to provide comments on proposed regulations.
Among the critical issues that regulators must decide is how to implement
the law's provision allowing employers to opt out of providing parity mental
health coverage if it becomes too costly, according to Meyers. "We still
have a lot of work to do," he said.
Future legislation may be necessary if follow-up studies determine that
companies are dropping mental health coverage altogether or sharply limiting
the psychiatric or substance use conditions they cover.
"I hope our members will experience this landmark achievement as
giving them the energy to follow through and make parity real," said APA
President Nada Stotland, M.D., in an interview.
But APA leaders are also taking a little time to savor the significant
victory of parity enactment, which followed another successful legislative
effort over the summer to equalize Medicare's copay for treatment of mental
illness to that for treatment of other medical conditions and thus eliminate
the longstanding disparity between the two.
The recent legislative accomplishments stem in no small part from APA's
efforts to educate the public as well as members of Congress about mental
illness. Stotland made a public-education campaign about parity the leading
priority of APA's Joint Commission on Public Affairs when she first chaired it
"It took a long time to get Congress to learn that mental illnesses
are no-fault illnesses and that people who have them deserve help," said
Carolyn Robinowitz, M.D., immediate past president of APA.
In addition to the need to educate legislators and the public, the parity
battle taught APA leaders that the use of coalitions and partnerships is
"You don't get what you want just because your cause is right and
just," said APA Medical Director James H. Scully Jr., M.D. "You
have to do the hard work of building coalitions and getting allies."
Wernert also emphasized that future legislative accomplishments will depend
on broadening APA member support of APAPAC beyond the 6 percent who
now contribute to it.
"It takes an ongoing effort," he said. "You can't just
throw money at the problem when a crisis arises."
More information on APA's advocacy efforts, including the new parity
law, can be accessed at<www.psych.org/MainMenu/AdvocacyGovernmentRelations/GovernmentRelations.aspx>.▪