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