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
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
"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
"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. ▪