The long and painful birth of mental health parity, and the story of its overdue delivery at the federal level, may hold some lessons for health system reform, now in the throes of its own painful labor.

Though the two efforts are markedly different in scope of purpose and potential impact, passage of the landmark parity bill offers some lessons for the more ambitious goal of health system reform, say psychiatrist Howard Goldman, M.D., Ph.D., and mental health policy expert Colleen Barry, Ph.D., in a commentary in the American Journal of Psychiatry this month.

Interviews with Congressional staffers and stakeholders involved in the parity battles led Goldman and Barry to emphasize three hard-won lessons:

Goldman is editor of the APA journal Psychiatric Services. Barry is an associate professor of public health at Yale University School of Public Health.

The interviews are part of an effort by Goldman and Barry to write a comprehensive account of the passage of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act.

"We were interested in doing a behind-the-scenes analysis of the passage of parity," Barry told Psychiatric News. "The idea was to talk to everyone who was involved, including key interest groups and congressional staffers, to understand how we were able to achieve this after so many years of trying. The interviews were quite interesting for the parallels they yielded with health system reform."

The most prominent of those is the importance of cost containment to stakeholders in both efforts. Barry and Goldman noted that opposition to parity for many years centered on the fear of "breaking the bank." But as data gathered from states where parity had been enacted and from the Federal Employees Health Benefits Program proved otherwise, that opposition was overcome.

"The market shift from indemnity insurance to managed care created a readily available method for enacting parity without driving up costs," they wrote in the commentary. "Resolving the dilemma of how to assemble a viable combination of financing and cost-containment provisions poses a more daunting challenge for health care reformers. However, the parity experience suggests that the sooner Congressional architects can agree upon a strategy for financing reform, the sooner attention will shift back to negotiating the contours of insurance expansion."

Barry told Psychiatric News, "From the standpoint of health care reform, costs need to be viewed as reasonable within a certain threshold. Our observation from the parity legislation is that you have to make the case that you have a viable cost-control strategy in place before you start talking about other issues."

A second lesson from parity is that bringing opponents together behind closed doors to air their differences can make it easier for them to find common ground when they have to go public.

Barry and Goldman noted that in the run-up to the passage of parity, Congress scrapped its traditional method of "shuttle diplomacy" whereby congressional committees met first with one group, then another; rather, they brought opposing stakeholders into the same room for candid discussions away from the glare of the media and public eye.

It's a lesson in "realpolitik" that runs counter to the current motif of "transparency" in all things. "I think you can differentiate transparency of process from transparency of results," Goldman told Psychiatric News. "A certain amount of behind-the-doors debate allows you to get to a result where people realize they have common interests."

The third piece of advice relates to what might be called "insider baseball" since it involves attention to a process largely unobserved by the general public—the regulatory rule-making process that follows formal passage of a bill.

The "implementation" phase, in which federal regulatory agencies write what sometimes amounts to pages and pages of regulatory" guidance," is where interpretive "meat" is put on the language of a bill.

With regard to parity, for instance, APA has insisted in communications with Health and Human Services Secretary Kathleen Sibelius that regulatory language should ensure that health plans and employers are prohibited from using certain indirect methods of restricting access to care—such as differential reimbursement schedules for different providers or separate-but-equal deductibles for mental health care—while still nominally complying with the law (Psychiatric News, June 19).

Goldman and Barry said that policymakers seeking health system reform would do well to look ahead to the implementation period since stakeholders will use it to lobby the government for their own interpretation of whatever law is passed.

"The implementation period effectively creates a second bite of the apple, whereby interest groups can fight out the smaller and sometimes not-so-small issues around interpretation of a bill, and try to argue for [an interpretation] that is most attractive to their interests," Barry said." It is wise strategy to work out as many of the details as possible so that there will be as narrow as possible a set of issues remaining."

Several examples—the agreements the White House has reached separately with such disparate groups as the AMA and the pharmaceutical industry around cost reduction and the president's focus on reform as vital to long-term economic stability—indicate these lessons have not gone unheeded. And yet, from the vantage point of the August congressional recess and the fierce opposition to reform at town-hall meetings around the country, reform would appear to still face an uphill climb.

Goldman and Barry said that the differences between the parity and reform efforts are great—most notably in the fact that parity affects only those who already have insurance.

"It's not so easy to come up with an answer for health system reform since the basic problem is about adding people who are previously uninsured," Goldman said.

But he added that incrementalism has been the constant in American health system policy, and he expressed confidence that a major reform can be passed—even if much remains to be perfected.

"My experience is that all of health policy reform is incremental," he said. "It's just a matter of how big a bite you take each time. Just to get on the table the principle that everyone should be insured is an enormous advance. Because the president has made it a central mission of his administration and because there is a Democratic Congress, we should be able to get something."

"Lessons for Healthcare Reform From the Hard-Won Success of Behavioral Health Insurance Parity" can be accessed at<http://ajp.psychiatryonline.org> under the September issue. ▪