The House health care reform measure that has drawn strong APA support has the most robust parity protections among the leading legislative efforts, as well as other provisions to bolster mental health care.

The House bill, called America's Affordable Health Choices Act of 2009 (HR 3200), was supported by the Mental Health Liaison Group (MHLG)—a coalition that includes APA—in a July 17 letter to the chairs of the three House committees with jurisdiction over health care reform.

Mental health advocates' support for the bill was based on several provisions, particularly strong insurance parity protections and specific inclusion of mental health care among the mandatory benefits in all plans that would be offered through new health insurance marketplaces, also called exchanges.

"Enactment of these provisions in your bill would make a great difference in the lives of persons with mental disorders," stated the MHLG letter, signed by 38 member organizations.

The bill specifically includes coverage of mental health services, including those for substance use disorders, in the required benefit packages of insurance programs in the planned exchanges. It also specifies that mental health parity approved as part of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act—enacted in 2008—will apply.

"We went to great pains to ensure that there were no loopholes for parity," Nicholas Meyers, director of APA's Department of Government Relations, told Psychiatric News. "This builds on parity enacted last year."

The legislation even moves beyond the 2008 landmark federal parity law by requiring that parity provisions apply to all insurers included within the planned exchanges. Last year's law requires parity protection for insurance provided by employers with 50 or more employees. HR 3200 would expand parity coverage requirements to plans offered by smaller employers and to individual plans.

"The justification for having a 50 [employee] and under exemption evaporates once [such employers] are in the health insurance exchange, because they are no longer participating as a small business. [They] are functioning in a health insurance exchange with the bargaining power of the entire exchange," Andrew Sperling, J.D., director of legislative affairs for the National Alliance on Mental Illness, told Psychiatric News.

In addition, the bill will require coverage of rehabilitation services as part of all benefit packages, and it will not require patients to pay for preventive care, even in the basic benefits package. The MHLG praised the bill's provisions to encourage and fund national prevention and wellness strategies, saying that they will help slow the growing cost of treating chronic illness.

The bill includes significant insurance market reforms. Among ones finding favor with mental health advocates are those prohibiting insurers from imposing pre-existing condition limits on individuals and limiting insurers' ability to rate individuals on the basis of health status, medical history, gender, occupation, past claims experience, disability, and evidence of insurability.

Other insurance reforms would ban the use of annual and lifetime dollar limits, which severely impact people struggling with chronic conditions including mental illness. Consumers also should benefit from the bill's caps on premiums and out-of-pocket spending.

Provisions requiring guaranteed renewal and guaranteed issue of insurance could help psychiatrists directly, because many are solo practitioners who purchase insurance in the individual market, where strict underwriting has limited access to insurance choices.

Psychiatrists and mental health professionals also could benefit from the bill's commitment to workforce development within the primary care and public health areas.

"We appreciate the commitment to implementing strategies that will address workforce shortfalls and improve the abilities of health care professionals in these areas, although more can and should be done with respect to the workforce targeting the mental health professions," the MHLG said.

The legislation also addresses shortcomings in Medicare that mental health advocates have identified. One change would extend for two years the current levels of reimbursement for outpatient psychotherapy services.

An impending cut of 21 percent in physician reimbursement under Part B would be eliminated. The bill would replace the sustainable growth rate formula, which the government uses to set reimbursement rates, with a new process that should result in an increase in 2010 reimbursement.

The bill also aims to increase mental health treatment options for Medicare beneficiaries by expanding the types of state-licensed health care providers who are eligible for reimbursement under the program. The change would add licensed marriage and family therapists as well as mental health counselors to the list of Medicare-eligible professionals.

One component of the bill's Medicare reform provisions drew criticism from the MHLG. The bill includes a medical-home pilot project in an effort to reduce health care costs and coordinate health care services when multiple clinicians are treating the same patient. However, mental health and substance use disorder services were not included within the pilot.

The bill's efforts to expand access to Medicaid—one of the nation's largest payers for mental health care—drew praise from mental health advocates. However, the expansion provisions included in the bill supported by the MHLG could be reduced as Congress deliberates. The bill changes Medicaid eligibility, which is currently open to those who fall into specific categories, such as low-income pregnant women. The change would keep those eligibility categories and add any American adult whose income is less than 133 percent of the federal poverty level.

A compromise with conservative Democrats could complicate the Medicaid expansion, however, by requiring states to contribute to the cost of the eligibility expansion and mandating that people with low or moderate incomes spend a higher percentage of their incomes on health care before they become eligible for federal subsidies to help them buy insurance, according to media reports.

But the effort to expand Medicaid access was still seen as praiseworthy because it could provide intensive community-based services to 2.8 million more people.

"This coverage expansion is particularly critical for low-income persons with mental illness and addiction disorders," wrote the MHLG, which cited Kaiser Family Foundation research that found 1 in 5 people below 200 percent of the federal poverty level has a significant mental disorder, such as major depression, schizophrenia, or bipolar disorder.

The MHLG letter is posted at<www.mhlg.org/07-17-09.pdf>.▪