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WHO KNOWS

• Dean Rosen
• Ken Libertoff

Dean Rosen is the senior vice president of policy and general counsel to the Health Insurance Association of America (HIAA).

We oppose any kind of mandate on insurance companies to offer any particular benefits or cover particular providers, and so we have opposed mental health parity. The content of products ought to be driven by consumer choice, not government's choice of benefits. Ultimately, the employers who provide the coverage and the consumers who purchase it have to foot the bill, and they ought to have the choice about what they can afford. The concern about mandates generally is they create costs.

To the extent that [the act] increased costs, it affected consumers more than insurers. The Federal Mental Health Parity Act was more limited than some of the state proposals or other federal proposals. It only limits the annual and cumulative out-of-pocket [expenses] and doesn't affect other utilization controls. There were a number of exceptions for smaller companies ... and therefore [they do not] have to comply with the mandate. So it was limited relative to what it would have been if it were full-blown parity.

We're not talking about mental health benefit mandates in an environment that's totally divorced from other benefit mandates. We've had a 25-fold increase over the last couple of decades of state mandated benefits. Literally hundreds of mandates have been added across the states in the last year. Those things add up. Advocates [for mental health parity] have done research showing that in a very tightly managed environment this can have a minimal impact on cost. That is definitely true. But the majority of people are not in tightly managed behavioral health and some of the same folks that advocate for mental health parity are attacking in a legislative context some of the managed care controls that help hold down costs. I [want Congress to understand] this basic message: You can do this, but let's be honest about the cost impact and the impact on consumers.

The state legislation has had an impact. We did a study with Bill Custer from Georgia State University a couple of years ago. Bill looked at the likelihood that people would be uninsured in states with mental health mandates versus states without and found a statistically significant correlation between the uninsured and that mandate. The impact of benefit mandates is exacerbated by the fact that such mandates tend to affect smaller employers.

[The question] is, historically, why there is a difference in coverage. Some types of mental illness are biologically based, but there are other kinds of mental illness that are not biologically based. This makes mental illness a little more amorphous and difficult to diagnose and treat than physical illnesses. Most everyone believes that significant bipolar illness ought to be treated; on the other hand, general unhappiness or job dissatisfaction may not be something that should be covered by a health insurance policy. I think there are both historical and also medical reasons as to why the coverage is more limited for mental health benefits.

Ken Libertoff is the director of the Vermont Association for Mental Health.

First, parity represents a real civil rights issue. There has been fundamental discrimination against people who suffer from the diseases of mental illness and substance abuse. Second, the behavior of the insurance industry and its neglectful attitude towards coverage of these illnesses has created an unfair burden on our public mental health sector and public dollars. Third, parity is critically important for the future health of children. Early screening and early intervention programs go a long way in not only reducing costs in the provision of health care, but in the early identification of problems. Fourth, and finally, parity is the ultimate campaign to end stigma against a particular illness.

The parity law passed in 1997 and went into effect in January of 1998. There are many positive initial outcomes. We have eliminated specific discriminatory constraints in health care coverage in Vermont. Mathematica [a major research firm] will conduct a two-year study that answers the question: What has been the impact of parity? This study will collect and analyze data from the point of view of the patient, consumers, practitioners, and payers. We have initial financial data, which is really the driving force to a large extent. Thus far, we have seen the cost for major insurers has actually been lower than expected.

The business community is definitely complying with the law. We also have seen no great movement of companies out of the state because of this mandate. It's very important that this is a mandate. In some other states they've passed partial legislation where it doesn't include a mandate. It's an option, and options are an incredibly weak tool in the business market place.

In some cases, the process is going to have to be incremental. Therefore it certainly makes sense to try to move forward in a variety of ways. There's no question that politics is also the art of compromise. However, I warn people to be very careful that they're not deluding themselves into thinking that small gains mean that the fundamental discrimination has been addressed. Partial parity is the continuation of discrimination. It's just reducing the discriminatory impact.

Right now the probability of passing a comprehensive parity bill is not great. But major developments are changing the landscape. One is that the general attitude about mental health has undergone a radical change over the last decade in terms of much more public awareness about the diseases, their impact, and the fact that treatment works. In the year 2001, all federal employees will have comprehensive parity like we have in Vermont. If we can do it for federal employees why can't we do it for all folks?

Managed care is a technique that could be somewhat helpful or it could be a disaster and we've seen both in behavioral health. In Vermont there ... has been poor administration and a host of other problems. However, the notion of having gatekeepers or having some kind of oversight over the provision of both physical health care and behavioral health care has some importance and some utility.

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