Mental Health Parity Bill Passes House, But Differs From Senate Bill

Susan Jeffrey

March 07, 2008

March 7, 2008 -- The US House of Representatives has passed a bill requiring group health plans to provide coverage for mental illnesses that is more comparable to that for physical illnesses.

The Paul Wellstone Mental Health and Addiction Equity Act, HR 1424, which was passed March 5 by a vote of 268 to 148, extends the parity in annual and lifetime dollar limits for mental healthcare provided by the Mental Health Parity Act of 1996 to include parity in cost-sharing requirements such as copays and deductibles and treatment limitations such as day and visit limits.

"We commend the House of Representatives for making the sound decision to pass HR 1424 and for its continued effort to enact legislation that will end discrimination against patients with mental illnesses," American Psychiatric Association (APA) president Carolyn Rabinowitz, MD, said in a statement from that organization.

In an interview with Medscape Psychiatry , James Scully, MD, medical director and CEO for the APA, called the passage "historic." "We're very pleased and applaud finally that, after many years -- indeed decades -- of trying to end discrimination against people with mental illness in the insurance world, this bill passed the House. It's long overdue, but we know it's been a long struggle to educate people that mental illnesses are real and diagnosable and treatable the same way as other medical illnesses."

Key Differences

However, the bill approved by the House has some key differences from a similar bill, the Mental Health Parity Act of 2007, S 558, that was passed by the Senate in September 2007. The House bill, for example, mandates that if a health plan offers coverage for mental health or substance abuse disorders, it must offer coverage for all disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed ( DSM-IV ). The Senate bill requires only that plans comply with existing state and federal standards. The House bill would preempt state standards where they differ from the DSM-IV .

Both bills exempt employers and group health plan sponsors with 50 or fewer workers and have cost-increase exemptions that would waive the parity agreement for 1 year for plans in which premiums would rise more than 2% as a result of complying with the bill.

The differences, however, have caused division among even those who would support the concept of parity and who have already said they would support the Senate bill.

Among the adversaries is the Bush administration. On March 5, the White House issued a policy statement supporting the Senate version of the parity bill, saying, "The Administration supports passage of mental health parity legislation that does not significantly increase health coverage costs. However, the Administration has concerns with HR 1424, which would effectively mandate coverage of a broad range of diseases and conditions and would have a negative effect on the accessibility and affordability of employer-provided health benefits and would undermine the uniform administration of employee benefit plans," the statement notes. "For example, the bill's confusing preemption provisions could be read to add a patchwork of remedies that vary from state to state. Therefore, the Administration strongly opposes House passage of HR 1424 or any legislation that expands benefits and remedies beyond what is included in the Senate-passed S 588."

The House bill lays out budgetary offsets for funding these proposals, including an increase in the Medicaid rebate paid by pharmaceutical companies to have their drugs reimbursed through Medicaid programs and restrictions on physician-owned hospitals.

The White House policy statement also explicitly objects to these offsets, noting, for example, that it is unclear how changes in the Medicaid drug rebate would affect non-Medicaid beneficiaries and other payers.

The Senate bill also has the support of business leaders as well as the insurance industry. In a statement from America's Health Insurance Plans, president and CEO Karen Ignagni says the House bill would "turn back the clock on advances in the quality of care and impose excessive costs on patients and employers. Though well-intentioned, this legislation would undermine the progress that has been achieved in improving behavioral health benefits through coordinated-care strategies." The Senate bill has the association's support, the statement adds, "because it is a balanced approach that would preserve access to health plans' medical management and quality-improvement programs."

Both the Senate and the House bills are bipartisan efforts, with well-known lead Democratic sponsors: father and son Sen. Edward Kennedy of Massachusetts and Rep. Patrick Kennedy of Rhode Island. Some are concerned that the differences between those backing the House and Senate bills may prevent any parity bill from ultimately being passed into law.

In a report Mar 6, WebMD noted that several conservative senators have threatened to block the House and Senate from meeting to reconcile the bills. Reporter Todd Zwillich quotes Sen. Pete Domenici, a Republican from New Mexico and cosponsor with Sen. Kennedy of the Senate bill, as saying a final agreement could be impossible because the House was intent on passing a broad parity bill.

"I'm very sorry that they are," Domenici told WebMD. "I worked very hard to convince them that we won't get health parity because we can't pass it in the Senate."

Perfect the Enemy of the Good?

Dr. Scully told Medscape Psychiatry that he is confident nevertheless that the will is there to pass some kind of parity bill.

 

"In terms of there being a difference between the Senate and the House, that happens, we understand that, and they'll conference it," he said. "Whatever the details are, it's important for the insurance industry to catch up with the American public, where there has been longstanding agreement that illnesses such as depression and posttraumatic stress disorder are real and deserving of care."

They will continue to study the effect of any change in law has on the more than 100 million people affected by it, Dr. Scully said, "but we're not interested in getting into a fight about which bill." The details of both bills have already changed many times and will very likely change again, he added. "We want it to be as good as possible, but not to lose it, with the perfect being the enemy of the good. To not accept a less-than-perfect bill might mean that we get nothing, so we want to make this step forward."

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