Impact of Mental Health Insurance Legislation on Mental Health Treatment in a Longitudinal Sample of Adolescents.

BACKGROUND: Mental health insurance laws are intended to improve access to needed treatments and prevent discrimination in coverage for mental health conditions and other medical conditions. OBJECTIVES: The aim was to estimate the impact of these policies on mental health treatment utilization in a nationally representative longitudinal sample of youth followed through adulthood. METHODS: We used data from the 1997 National Longitudinal Survey of Youth and the Mental Health Insurance Laws data set. We specified a zero-inflated negative binomial regression model to estimate the relationship between mental health treatment utilization and law exposure while controlling for other explanatory variables. RESULTS: We found that the number of mental health treatment visits declined as cumulative exposure to mental health insurance legislation increased; a 10 unit (or 10.3%) increase in the law exposure strength resulted in a 4% decline in the number of mental health visits. We also found that state mental health insurance laws are associated with reducing mental health treatments and disparities within at-risk subgroups. CONCLUSIONS: Prolonged exposure to comprehensive mental health laws across a person's childhood and adolescence may reduce the demand for mental health visitations in adulthood, hence, reducing the burden on the payors and consumers. Further, as the exposure to the mental health law strengthened, the gap between at-risk subgroups was narrowed or eliminated at the highest policy exposure levels.

Achieving Mental Health and Substance Use Disorder Treatment Parity: A Quarter Century of Policy Making and Research.

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 changed the landscape of mental health and substance use disorder coverage in the United States. The MHPAEA's comprehensiveness compared with past parity laws, including its extension of parity to plan management strategies, the so-called nonquantitative treatment limitations (NQTL), led to significant improvements in mental health care coverage. In this article, we review the history of this landmark legislation and its recent expansions to new populations, describe past research on the effects of this and other mental health/substance use disorder parity laws, and describe some directions for future research, including NQTL compliance issues, effects of parity on individuals with severe mental illness, and measurement of benefits other than mental health care use.

Parity Could Use Some Fixing, But at Least It Won't Be Dismantled.

Nonquantitative treatment limitations may be why care for mental health and substance abuse disorders isn't keeping up with coverage gains.

Q&A: A Conversation with Patrick J. Kennedy. Parity Advocate Sees More Talk Than Action.

Insurers are playing "small ball" and not showing leadership, says the former congressman. And some "spin-dry" inpatient providers are doing more harm than good in combating the opioid epidemic. Meanwhile, Kennedy, who chronicled his own harrowing mental health and addiction struggles in a 2015 memoir, says he has been sober for more than six years.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees.

OBJECTIVE: The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees. METHODS: We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization. RESULTS: MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)]. CONCLUSIONS: MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

Effects of the mental health parity and addictions equality act on depression treatment choice in primary care facilities.

Objective The Mental Health Parity and Addictions Equality Act (MHPAEA) of 2010 in the United States sought to expand mental health insurance benefits on par with medical benefits. As primary care facilities are often the first step in identifying mental health concerns, it is essential to examine the association of this policy with primary care physicians' choice on depression treatment. Method A retrospective cross-sectional study was conducted using data from the 2007-2012 National Ambulatory Medical Care Survey, including a weighted total of 162,699,930 depression patients. Using the Heckman two-step selection procedure, a logistic and a multinomial regression were conducted to examine the association of the MHPAEA with physicians' two-step process of deciding whether and which type of treatment was prescribed. Sociological factors were controlled. Results Treatment was significantly more likely to be provided after the MHPAEA. Psychotherapy was used for treatment for 10.0% of the sample while medication was used for 75.0% of the sample. Patient race/ethnicity, practice setting, physician specialty, and primary source of payment were associated with diverging likelihood of being prescribed depression treatment. Non-Hispanic White patients were more likely to be provided treatment than non-Hispanic Black patients. Patients were less likely to be prescribed only medication than only psychotherapy after the MHPAEA enactment. Conclusions The MHPAEA was associated with primary care providers' decision and choice on depression treatment. Educational and policy interventions aimed at improving physician's understanding of their own treatment tendencies and decreasing barriers to depression treatment may impact the disparities in underserved, minority, and older populations.

Legislations and policies to expand mental health and substance abuse benefits in health insurance plans: a community guide systematic economic review.

BACKGROUND: Health insurance plans have historically limited the benefits for mental health and substance abuse (MH/SA) services compared to benefits for physical health services. In recent years, legislative and policy initiatives in the U.S. have been taken to expand MH/SA health insurance benefits and achieve parity with physical health benefits. The relevance of these legislations for international audiences is also explored, particularly for the European context. AIMS OF THE STUDY: This paper reviews the evidence of costs and economic benefits of legislative or policy interventions to expand MH/SA health insurance benefits in the U.S. The objectives are to assess the economic value of the interventions by comparing societal cost to societal benefits, and to determine impact on costs to insurance plans resulting from expansion of these benefits. METHODS: The search for economic evidence covered literature published from January 1950 to March 2011 and included evaluations of federal and state laws or rules that expanded MH/SA benefits as well as voluntary actions by large employers. Two economists screened and abstracted the economic evidence of MH/SA benefits legislation based on standard economic and actuarial concepts and methods. RESULTS: The economic review included 12 studies: eleven provided evidence on cost impact to health plans, and one estimated the effect on suicides. There was insufficient evidence to determine if the intervention was cost-effective or cost-saving. However, the evidence indicates that MH/SA benefits expansion did not lead to any substantial increase in costs to insurance plans, measured as a percentage of insurance premiums. DISCUSSION AND LIMITATIONS: This review is unable to determine the overall economic value of policies that expanded MH/SA insurance benefits due to lack of cost-effectiveness and cost-benefit studies, predominantly due to the lack of evaluations of morbidity and mortality outcomes. This may be remedied in time when long-term MH/SA patient-level data becomes available to researchers. A limitation of this review is that legislations considered here have been superseded by recent legislations that have stronger and broader impacts on MH/SA benefits within private and public insurance: Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Patient Protection and Affordable Care Act of 2010 (ACA). IMPLICATIONS FOR FUTURE RESEARCH: Economic assessments over the long term such as cost per QALY saved and cost-benefit will be feasible as more data becomes available from plans that implemented recent expansions of MH/SA benefits. Results from these evaluations will allow a better estimate of the economic impact of the interventions from a societal perspective. Future research should also evaluate the more downstream effects on business decisions about labor, such as effects on hiring, retention, and the offer of health benefits as part of an employee compensation package. Finally, the economic effect of the far reaching ACA of 2010 on mental health and substance abuse prevalence and care is also a subject for future research.

The impact of mental health insurance laws on state suicide rates.

In the 1990s and early 2000s, a number of states passed laws requiring mental health benefits to be included in health insurance coverage. The variation in the characteristics and enactment date of the laws provides an opportunity to measure the impact of increasing access to mental health care on mental health outcomes, as evidenced by state suicide rates. In contrast with previous research, results show that when states enact laws requiring insurance coverage to include mental health benefits at parity with physical health benefits, the suicide rate decreases significantly by 5%. The findings are robust to a number of specifications and falsification tests.

The paradox of parity: limitations in the breakthrough law for mental health equality.

The intent of parity laws is to improve equity in private insurance coverage for mental health care. The groundbreaking legislation of the 1996 Mental Health Parity Act (MHPA) was initially hailed as a major achievement in improving mental health coverage. However, research suggests that because of political compromises and employer exemptions, the potential impact of the MHPA was weakened. This paper summarizes the extent and scope of the MHPA and the 2008 Mental Health Parity and Addiction Equity Act, highlighting the goals and accomplishments of each; examines limitations of the legislation, explicitly accounting for exemptions, uninsured Americans, and access to care; and provides recommendations for further improvement and implementation of mental health coverage.

The effect of comprehensive behavioral health parity on choice of provider.

BACKGROUND: "Parity" laws remove treatment limitations for mental health and substance-abuse services covered by commercial health plans. A number of studies of parity implementations have suggested that parity does not lead to large increases in utilization or expenditures for behavioral health services. However, less is known about how parity might affect changes in patients' choice of providers for behavioral health treatment. RESEARCH DESIGN: We compared initiation and provider choice among 46,470 Oregonians who were affected by Oregon's 2007 parity law. Oregon is the only state to have enacted a parity law that places restrictions on how plans manage behavioral health services. This approach has been adopted federally in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. In 1 set of analyses, we assess initiation and provider choice using a difference-in-difference approach, with a matched group of commercially insured Oregonians who were exempt from parity. In a second set of analyses, we assess the impact of distance on provider choice. RESULTS: Overall, parity in Oregon was associated with a slight increase (0.5% to 0.8%) in initiations with masters-level specialists, and relatively little changes for generalist physicians, psychiatrists, and psychologists. Patients are particularly sensitive to distance for nonphysician specialists. CONCLUSIONS: Our results suggest that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act may lead to a shift in the use of nonphysician specialists and away from generalist physicians. The extent to which these changes occur is likely to be contingent on the ease and accessibility of nonphysician specialists.

Coverage mandates and market dynamics: employer, insurer and patient responses to parity laws.

Parity in coverage for mental health services has been a longstanding policy aim at the state and federal levels and is a regulatory feature of the Affordable Care Act. Despite the importance and legislative effort involved in these policies, evaluations of their effects on patients yield mixed results. I leverage the Employee Retirement Income Security Act and unique claims-level data that includes information on employers' self-insurance status to shed new light in this area after the implementation of two state parity laws in 2007 and federal parity a few years later. My empirics reveal evidence of strategic avoidance on behalf of insurers in both states prior to the passage of state parity, as well as positive increases in mental health care utilization after parity laws are implemented - but context matters. Policy heterogeneity across states and strategic behaviors by employers and commercial insurers substantively shape the benefits that ultimately flow to patients. Insights from this research have broad relevance to ongoing health policy debates, particularly as states retain great discretion over many health coverage decisions and as federal policy continues to evolve.

Behavioral modification. With the historic enactment of mental health parity legislation, providers may see themselves freed from treatment limitations.

The huge financial bailout passed in Washington last week also brought relief for another sector: behavioral health. When it becomes effective Jan. 1, 2009, the mental health parity legislation is expected to give more than 100 million people access to coverage and will free providers from treatment limitations. "This is long overdue to cover these illnesses," says Mark Covall, left.

Behavioral Health Coverage In The Individual Market Increased After ACA Parity Requirements.

As of January 1, 2014, the Affordable Care Act designated mental health and substance use services as an essential health benefit in Marketplace plans and extended parity protections to the individual and small-group markets. We analyzed documents for seventy-eight individual and small-group plans in 2014 (after parity provisions took effect) and sixty comparison plans in 2013 (the year before parity provisions took effect) to understand the degree to which coverage for mental health and substance use care improved relative to medical/surgical benefits. The results suggest that plan issuers did what the provisions required them to do. Although in 2013 a lower proportion of plans covered mental health or substance use care, compared to medical/surgical care, in 2014 the proportions were the same. If essential health benefit requirements were to be removed and mental health and substance use coverage becomes similar to that in 2013, as many as 20 percent of the plans in our sample would not cover these conditions. To determine whether increases in behavioral health coverage will result in improved access to behavioral health services requires complementary data on the size of provider networks and use of services.

National estimates of mental health insurance benefits.

This article presents estimates of the proportion of the U.S. population that had mental health benefits in 1999, of the extent of their coverage, and of the proportion that were enrolled in health plans subject to the Mental Health Parity Act of 1996 (MHPA). Findings indicate that over three-quarters (76%) of the U.S. population had mental health benefits as part of their health insurance. Approximately 18% of the population had no mental health benefits, and for the remaining 6%, mental health benefits could not be determined. Of the 18% with no mental health benefits, most (84%) had no health insurance whatsoever, while the remainder (16%) had health insurance that did not cover mental health benefits. Estimates of the generosity of coverage indicate that 44% of the population had benefits that included prescription drugs, and that provided at least 30 inpatient days and 20 outpatient visits for psychiatric care. For 12% of the population, benefit generosity could not be determined. Finally, study results suggest that the MHPA affected only 42% of the U.S. population.

The political evolution of mental health parity.

This article traces the evolution of the mental health parity debate in American politics, with a focus on how interest groups and politicians have attempted to influence perceptions about treatment effectiveness and the cost of benefit expansion. When parity laws are in place, they require health plans operating in the private health insurance market to provide an equivalent level of coverage for mental health and general medical care. Business and insurance industry groups oppose parity due to cost concerns. The mental health community has framed parity as an antidiscrimination measure that would achieve greater insurance equity across disease groups. The role of personal experience with mental illness among lawmakers and others in framing the parity debate is also considered.

Behavioral Health Services in the Changing Landscape of Private Health Plans.

OBJECTIVE: Health plans play a key role in facilitating improvements in population health and may engage in activities that have an impact on access, cost, and quality of behavioral health care. Although behavioral health care is becoming more integrated with general medical care, its delivery system has unique aspects. The study examined how health plans deliver and manage behavioral health care in the context of the Affordable Care Act (ACA) and the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). This is a critical time to examine how health plans manage behavioral health care. METHODS: A nationally representative survey of private health plans (weighted N=8,431 products; 89% response rate) was conducted in 2010 during the first year of MHPAEA, when plans were subject to the law but before final regulations, and just before the ACA went into effect. The survey addressed behavioral health coverage, cost-sharing, contracting arrangements, medical home innovations, support for technology, and financial incentives to improve behavioral health care. RESULTS: Coverage for inpatient and outpatient behavioral health services was stable between 2003 and 2010. In 2010, health plans were more likely than in 2003 to manage behavioral health care through internal arrangements and to contract for other services. Medical home initiatives were common and almost always included behavioral health, but financial incentives did not. Some plans facilitated providers' use of technology to improve care delivery, but this was not the norm. CONCLUSIONS: Health plans are key to mainstreaming and supporting delivery of high-quality behavioral health services. Since 2003, plans have made changes to support delivery of behavioral health services in the context of a rapidly changing environment.

Costs of mandates for outpatient mental health care in private health insurance.

Various methods for estimating the cost of mandated mental health benefits have been devised, each resulting in substantially different estimates. These methods neglect to distinguish between the two components of cost to the insurer: social cost (due to increased utilization) and shifted cost (from other sources of payment). We apply a method we developed for estimating the two types of costs of mandates for outpatient mental health services that integrates data from insurers with information from the literature on financing of mental health services. We applied our method to legislation recently proposed in Massachusetts that would double the mandated minimum benefit level from +500 to +1,000. We expect payments by the largest carrier in the state to increase by a factor of 1.65. More than half of this increase represents shifted costs rather than new costs to society.