Proposals in several states to expand the number of residents with health
insurance through government-sponsored programs are also mandating that mental
health coverage be part of the package.
Massachusetts and Vermont were in the vanguard, passing laws in 2006 to
achieve near universal coverage and to control cost and quality of health
care. At least 10 other states are considering comprehensive health insurance
legislation or have administrative proposals under review, and several more
have established committees to study health care reform.
The state efforts have many features in common, and most include market
reforms, subsidized health insurance, assessments against employers who don't
offer health insurance, wellness initiatives, disease management, Medicaid
expansions, and qualit y-improvement components. Most plans also include
mental health coverage.
"Mental health has come up a lot in discussion of our plan, and it is
a critical component," said Krista Donahue, chief of policy in the
Illinois Department of Healthcare and Family Services, about the governor's
proposed health coverage expansion.
Illinois Gov. Rod Blagojevich's (D) proposal, known as Illinois Covered,
would provide affordable health insurance to the state's 1.4 million uninsured
adults. The proposal, working its way through the state legislature, requires
all private insurers in Illinois to provide an affordable, comprehensive,
state-subsidized insurance option for employees of small businesses and other
uninsured individuals. Other components include granting an insurance-premium
rebate, allowing parents to include offspring up to age 30 on their insurance,
and expanding eligibility of parents who get coverage through the state to
those earning up to 400 percent of the federal poverty income
The proposal has several mental health components, including a requirement
that the private-insurance option for small employers and individuals cover"
medically necessary" mental health services. These are defined to
include services to "restore, maintain, or prevent deterioration of an
enrollee's condition." The privately offered option would have to accept
individuals regardless of previous or current use of mental health services,
and health status could no longer determine costs of that coverage.
Mental health benefits would cover assessment, emergency care, prescription
drugs, inpatient and outpatient hospital care, physician services, and mental
health clinic services such as counseling, and group therapy.
Advocates of the health care proposal, which requires no federal funding,
hope the Illinois legislature will pass the plan later this year or in early
Less-comprehensive mental healt h changes are part of health care expansion
legislation in Pennsylvania. The Prescription for Pennsylvania proposal,
advocated by Gov. Edward Rendell (D), would make affordable basic health care
coverage available to small-business employees through the private insurance
market. The program would emphasize pay for performance and encourage"
wellness" and preventive care and chronic-disease management.
In addition, the program would require all insurers offering small-group
and individual plans to provide a standard plan that includes basic benefits.
Mental health coverage, including that for substance abuse, would not be
required in the basic plan, but insurers would have to make such coverage
available as an option at additional cost. Insurers would be prohibited from
excluding children with behavioral health needs from coverage.
Donna Cooper, secretary of the Pennsylvania Governor's Office of Policy and
Planning, told Psychiatric News at a Washington, D.C., briefing on
the plan that the program does not place much emphasis on mental health care
because there appeared to be little demand for that from health advocates in
"We haven't had a lot of lobbying on mental health issues when
putting together this plan," said Cooper.
Deb Shoemaker, executive director of the Pennsylvania Psychiatric Society
(PPS), disputed that lobbying claim in an interview with Psychiatric
News, noting that PPS members have testified before several legislative
committees and lobbied their local representatives.
The plan also anticipates major cost savings through an expanded role for
allied health practitioners, including advanced nurse practitioners, midwives,
physician assistants, pharmacists, and other licensed health care providers.
The plan would provide additional authority to nurses to diagnose mental
illnesses and prescribe medications, according to Cooper.
PPS representatives have testified against the scope-of-practice expansion
proposed for clinical nurse specialists, certified nurse practitioners, and
nurse midwives as part of the health care overhaul. The expanded authority
sought for these nurses would allow some to commit patients involuntarily,
prescribe psychotropic drugs, and diagnose mental illness.
"Without the extensive training that psychiatrists have, these allied
health professionals are limited in what they can do for the public,"
said PPS's Shoemaker.
Rendell hopes that the insurance expansion will be in place by January
2008, Cooper said.
Critics of the various state health care proposals maintain that some of
their provisions are illegal under federal law. The 1974 Employee Retirement
Income Security Act (ERISA) prohibits states from requiring employers to set
aside health care paycheck deductions, for example. State officials said they
are getting around ERISA prohibitions on state insurance-plan mandates, in
part, by creating a tax on insurers that is refundable if they offer specific
types of plans.
Donahue said supporters expect the Illinois program to withstand ERISA
legal challenges, although problems could arise if employers offer only
limited coverage, because state officials don't want to force them to offer
Members of Congress have begun to discuss ERISA changes that would allow
more state health care coverage efforts, and the National Governors
Association is expected to announce its support for a number of ERISA changes
Another sticking point for states is how to fund the plans. Illinois is
reconsidering a proposed tax on gross receipts, due to stiff political
opposition. Pennsylvania plans to use previously appropriated but unused
Medicaid funds to pay for part of the expansion.
Among the states that already have approved health coverage overhauls,
Massachusetts uses low-cost insurance plans paid for by enrollees, businesses,
and government subsidies. Vermont funds its program through a Medicaid waiver,
state funds, a tobacco tax, and business assessments.
Most states attempting to implement comprehensive health care programs aim
to build on the Medicaid and State Children's Health Insurance Program (SCHIP)
approaches, which cover the poorest first and expand eligibility up the"
economic ladder," according to Joy Johnson Wilson, health policy
director and federal affairs counsel for the National Conference of State
The challenge for states undertaking such reforms has been finding ways to
keep employers participating in the increasingly expensive employee insurance
market. In recent years, however, states have become more willing to take on
insurance-industry and business-community opposition because of the urgency to
remedy the lack of insurance coverage among so many state residents.
Enrique Martinez-Vidal, acting director of state coverage initiatives at
the Robert Wood Johnson Foundation, said he expects more states to undertake
increasingly ambitious health care overhauls due to federal inaction, growing
support for health care initiatives in state legislatures, and a generally
positive economic outlook at the state level.
"However, it is unrealistic to think that all states have the
financial ability to undertake such comprehensive reforms without strong
federal support," he added.
Information on the Illinois proposal is posted at<www.illinoiscovered.com/>.
Information on the Pennsylvania proposal is posted at<www.gohcr.state.pa.us/prescription-for-pennsylvania/PlainEnglishLegislation.pdf>.▪