More than three-quarters (76 percent) of the U.S. population in 1999 had
mental health benefits as a component of their health insurance plan,
according to a report prepared by Mathematica Policy Research Inc. for the
Substance Abuse and Mental Health Services Administration.
But that relatively positive finding is complicated by other factors,
according to researchers Myles Maxfield, Lori Achman, and Anna Cook.
The generosity of mental health benefits, for example, is affected by
whether their source is private or public insurance and by the laws in the
state in which they are offered. In the case of employer-sponsored insurance,
the generosity of benefits is related to the size of the firm offering
In "National Estimates of Mental Health Insurance Benefits,"
researchers offer answers to such basic questions as these:
Mental health care benefits are offered through private and public
insurance programs with varying degrees of generosity. The authors offered
estimates of the source of primary health insurance in 1999 for those aged
0-17 years and 18-65 years.FIG1
Forty-six percent of those in the group aged 17 or younger had private,
employer-sponsored health insurance. Other sources of coverage for that group
and the percentage of those who had them were Medicaid, 17 percent; State
Children's Health Insurance Program (SCHIP), 3 percent; Medicare, 1 percent;
and other public insurance, 13 percent. Coverage from outside the household
and individually purchased insurance each accounted for 3 percent. Eleven
percent of individuals up to age 17 were uninsured.
For those 18 to 65, the figures are private, employer-sponsored health
insurance, 53 percent; Medicaid, 5 percent; Medicare, 3 percent; and other
public insurance, 14 percent. Individually purchased insurance was 4 percent,
and coverage from outside the household was 2 percent. Nineteen percent of
these people were uninsured.
The authors estimated that at least 90 percent of the U.S. population who
had health insurance had mental health benefits as a component of that
insurance, after comparing benefits offered through each type of insurance
program with the number of individuals covered by it.
When the number of uninsured people was considered, the percentage of the
U.S. population with mental health benefits dropped to 76 percent.
The authors defined "benchmark level of generosity" for mental
health insurance benefits as coverage for 30 inpatient days, 20 outpatient
visits, and prescription drugs.
Lawrence Lurie, M.D., chair of APA's Managed Care Committee, pointed out,"
We have to remember that these figures represent a maximum of what a
person can receive. When these benefits are managed on the basis of `medical
necessity,' the actual benefits available to patients might be much
The authors noted that the level of benchmark coverage represents a level"
typical of many health plans" and not a "measure of plan
In 1999 approximately 59 percent of individuals with private,
employer-sponsored health insurance provided through a firm with 10 or more
employees had mental health coverage that met the benchmark. The authors do
not have benchmark data on smaller firms, but noted that the likelihood of
meeting the benchmark increased with firm size.
The authors categorized the traditional Medicare benefit as not meeting the
benchmark because at the time of the study, Medicare did not provide
prescription drug benefits. However, they estimated that 62 percent of
Medicare beneficiaries had some prescription drug coverage through another
source and, therefore, met the benchmark.
Children covered by Medicaid are eligible for services meeting the
benchmark. Six states did not meet the benchmark because of utilization limits
for adults, according to the authors. The authors noted that although payment
for inpatient care in psychiatric hospitals is excluded by federal law, states
provide inpatient psychiatric care in general hospitals.
Federal programs including the Federal Employees Health Benefits Program
(FEHBP), TRICARE, Veterans Affairs (VA) health services, and the Civilian
Health and Medical Program of the VA (CHAMPVA) met the benchmark.
Approximately 52 percent of individuals with health insurance had mental
health benefits that met or exceeded the benchmark.
When the uninsured are included, that figure dropped to 44 percent of the
U.S. population who had mental health benefits that met the benchmark.
The authors stipulated that full financial parity requires mental health
benefits to be the same as medical and surgical benefits in terms of dollar
limits, utilization limits, and cost-sharing requirements.
In 1999 approximately 14 percent of individuals with private,
employer-sponsored health insurance provided through a firm with 10 or more
employees had full parity in their mental health benefits.
As firm size increased, firms were less likely to provide parity in mental
health benefits. The authors speculated that larger firms are more likely to
be self-insured and thus not subject to state mental health parity laws
because of the Employment Retirement Income Security Act (ERISA).
ERISA exempts self-insured employer-sponsored health plans from state
regulations, thereby precluding the application of state parity laws. The
authors estimated that nearly 49 million individuals—approximately 39
percent of the employer-sponsored health insurance market—were in
In terms of public programs, Medicare does not provide parity. It requires
50 percent cost sharing by beneficiaries on essentially all outpatient mental
health services as opposed to 20 percent for other outpatient services.
Medicaid meets parity requirements for children and adults, if one assumes
that inpatient psychiatric care is provided in general hospitals.
In 1999 the FEHBP did not require that its participating plans meet
standards for parity, but as of 2001 it did. VA and CHAMPVA health services
met parity standards.
In 1999, 32 percent of individuals in the United States had parity in
mental health benefits. An equal percentage had mental health benefits without
parity. Twelve percent had benefits of unknown generosity, 7 percent had a
plan whose mental health benefits were unknown, and 2 percent had health
insurance with no mental health benefits. Fifteen percent of the population
was uninsured (see chart on page 23).
Lurie said, "Questions of actual access for patients remain even if
parity in benefits technically is provided. Strategies to manage care very
frequently have followed the provision of parity in mental health benefits.
Introduction of managed care means that psychiatrists receive low fees and are
subjected to administrative hassles and late payments. As result, they are
reluctant to accept patients whose benefits are managed."
According to the 2002 National Survey of Psychiatric Patients conducted by
the American Psychiatric Institute for Research and Education's Practice
Research Network, 52 percent of responding psychiatrists were not on any
managed care panels (Psychiatric News, March 19, 2003).
The Department of Health and Human Services and the Office of Personnel
Management have funded a study to evaluate the implementation and impact of
the policy directive that required participating plans of the FEHBP, as of
January 2001, to provide parity in mental health and substance abuse
Research study director Howard Goldman, M.D., Ph.D., said that final
results are expected this fall.
Goldman is the editor of the APA journal Psychiatric Services and
director of mental health policy studies and a professor of psychiatry at the
University of Maryland School of Medicine.
The data sources for the study included the March 2000 Current Population
Survey, the 1999 Medical Expenditure Survey-Insurance Component, and the
Mercer Worldwide National Survey of Employer-Sponsored Health Plans. Each
survey uses a nationally representative probability sample, with 1999 serving
as the reference period for each survey.
"National Estimates of Mental Health Insurance Benefits"
will be posted at<www.samhsa.gov>