Mental Health Parity Should Benefit New Mothers

Gwen Mayes, JD, MMSc

Disclosures

April 05, 2004

There's a popular commercial running on TV that features old film footage of The Three Stooges -- Moe, Larry, and Curly -- accidentally knocking each other out in their famous comic scuffles. According to MasterCard, regardless of the medical treatment they need -- an x-ray, bone reset, lab test -- it's a $10 copayment. Of course, the punch line--"access to your physician – priceless"-- is what MasterCard wants you to remember.

But what if one of "the three stooges" needed psychotherapy or treatment for depression? Would that be a $10 copayment as well?

Until recent years, mental health services were delivered and paid for by the government. From the 1960s until the mid-1990s, mental health services expanded dramatically, with outpatient services and inpatient and residential programs financed by more diverse sources. By 1997, about three fifths of expenditures for mental health care were made through private or public health insurance programs.[1] With the shift from government to private insurance, coverage of mental health services became subject to the principles of managed care. However, fitting mental health care for a population traditionally in need of long-term services, such as employment assistance, temporary housing, and both psychological counseling and possibly inpatient treatment, into a reimbursement scheme with a finite checks-and-balances system has proved problematic.

Despite the differences in service delivery, mental health advocates have witnessed an increasing number of efforts on the federal and state level to bring parity in coverage of mental health treatment to resemble, at least in fashion, the coverage of physical care.

To help address the discrepancies in coverage, Congress passed the Mental Health Parity Act of 1996 via amendments to the Employee Retirement Income Security Act of 1974 (ERISA) and the Public Health Service (PHS) Act.[2] The law imposed federal standards on mental health coverage offered under most employer-sponsored group health plans. Specifically, the law prohibits employers from imposing annual or lifetime dollar limits on mental health coverage that are more restrictive than those imposed on medical and surgical coverage. Through various Congressional amendments, the sunset date under ERISA and the PHS Act has been extended to December 31, 2004.[3] A bill still in play in the 108th Congress, spearheaded by the late Senator Paul Wellstone (D-Minn) and Senator Pete Domenici (R-NM), would bring parity to copayments and allow for parity in physician visits for mental conditions similar to those for physical conditions.

On a state level, 46 states and the District of Columbia have enacted legislation addressing mental health coverage in some manner.[4] Of those, 36 have enacted mental health parity laws and, although they vary considerably, they generally prohibit insurers from discriminating between mental and physical disorders.

One population undisputedly in need of mental health services is new mothers. There are considerable data to support the claim that mental health problems affect a woman prenatally, during pregnancy, and during the postpartum period. The National Institute of Mental Health has identified significant unmet mental health needs for women, with 80% of women experiencing postpartum "blues" and 10% to 15% experiencing postpartum depression.[5]

"This is one population, although not studied specifically in terms of the impact of mental health parity, that actually should benefit from the laws," said Richard G. Frank, PhD, noted scholar and mental health expert at Harvard Medical School (personal communication, March 3, 2004). "Postpartum women without severe depression may have limited service needs."

Because of the potentially devastating and longstanding effects depression can have on a mother, her children, and their relationship, preventing maternal depression can alleviate distress, maladjustment, and other negative outcomes. There have been few studies of prevention of depression in women, and there are no randomized controlled trials focusing on the treatment of depression during pregnancy and the postpartum period.[6]

Arguably, efforts to improve access to mental health services should benefit women at all points in life, as it is well established that women suffer from such mental health disorders as chronic anxiety and depression at a higher rate than men. According to the National Mental Health Association, approximately 12 million women in the United States experience depression every year, roughly twice the rate of men.[7] Mental health services are also a top concern for nonobstetric patients of childbearing ages. According to the federal Agency for Healthcare Research and Quality, depression was the most common reason for nonobstetric hospital stays among women aged 18 to 44 in 2000.[8]

Much has been written about the impact of mental health parity laws. According to Frank, the concept of parity should be viewed broadly. "If you take a strict view of parity where there is full equity of services, we may be doing a disservice to people with mental health needs. That's primarily because their needs are different. Mental health patients may need housing, case management, or assistance with day-to-day living. We prefer to think of parity in terms of equity in principle, that is, equity in applicable access to services."

Such a broad view has been met with other criticism on the same premise -- that fitting the needs of those in need of mental health services into a parity model with traditional health care is a poor fit. According to the National Center for Policy Analysis in Dallas, Texas, mental health parity is more likely to make the current healthcare system worse by imposing an arbitrary rule that would make it even more difficult for doctors, patients, and insurers to find better ways of delivering mental health services.[9] They cite higher costs, an increase in demand for services, higher taxes, less innovation, and more managed care as reasons for the possible harm.

However, Frank contends that managed care has, instead, "gutted" the arguments that parity will result in higher costs. Where parity has been established within managed-care programs, he writes, increases in spending either have been small or have been offset by reductions in spending.

Two years following enactment of the legislation, the General Accounting Office (GAO) studied compliance to determine employees' access to mental health services.[10] The GAO found that although most employers' plans had parity in dollar limits for mental health coverage, 87% of those who complied with the law also had at least 1 other plan design feature that was more restrictive for mental health benefits than medical and surgical benefits. For example, about 65% of plans restricted the number of outpatient visits or hospital stays. Differences in coverage were implemented to offset claim costs; however, the law seems to have had a negligible effect: only about 3% of employers who responded to the GAO reported that compliance with the law increased their claims cost.

More recently, in the National Mental Health Advisory Council's Report to Congress, it was reported that the cost increases associated with full parity for mental health (as in the Domenici-Wellstone proposal) would represent 1.4% of total health benefits.[11]

Advocates for parity recognize, and to some degree accept, that parity will result in a push-pull theory for insurers. When one service is expanded, another is limited. However, despite these limitations, they rest firmly on their belief that benefits can be achieved and that treatment does work. Citing the 1999 Surgeon General's Report on Mental Health conclusion that the "patchwork of mental health services in the United States has become . . . the de facto mental health system, . . . determined by many heterogeneous factors rather than a guiding set of principles," the prevailing recommendation is that mental health parity is a "necessary objective."[12]

Although more research is needed to reach consensus to differentiate between depression with a postpartum onset and major or minor depression that begins prior to pregnancy and continues during pregnancy and into the postpartum period, the increased access to mental health services brought about by federal and state parity laws should benefit mothers and their children.

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