A political history of federal mental health and addiction insurance parity

PERSPECTIVE: Health Economic Interests at NIMH and NIDA to Improve Delivery of Behavioral Health Services

BACKGROUND

Effective financing mechanisms are essential to ensuring that people can access and utilize effective treatments and services. Financing mechanisms are needed not only to pay for the delivery of those treatments and services, but also ancillary costs, while also keeping care affordable.

AIMS

This article highlights key areas of the interest of the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) in supporting applied health economics and health care financing research. Specifically, this article discusses the long-range impact of NIH's earlier investments in applied health economics research, and NIH's ongoing efforts to communicate its interests in health economics research. We discuss the 2023 NIMH-NIDA-sponsored health economics conference, and the ideas presented there for developing and assessing innovative behavioral health care financing models; three of the presented papers were recently published in the Journal of Mental Health Policy and Economics.

METHODS

We describe the history and impact of NIMH- and NIDA-sponsored economic research and identify current research interests as identified in the NIMH and NIDA Strategic Plans and recent funding announcements. We examine themes presented at the NIMH-NIDA Health Economics conference. The conference included over 300 participants from 20 countries, from six continents.

RESULTS

The topics highlighted at the conference highlight the ways in which NIH-funded research has promoted the development of innovative health care financing methods, both from the supply side (e.g., providers and payers) and demand side (e.g., service users and families). Invited speakers discussed the findings from NIH-supported research in the topic areas of payment and financing, behavioral economics and social determinants of health. Keynote speakers highlighted emerging topics in the field, including the economics of health equity, biases in mental health models in health care, and value-based insurance design.

DISCUSSION

We demonstrate a resurgence of and explicit interest in health economics and policy research at NIMH and NIDA. However, more work is needed in order to design funding mechanisms that fully provide access to and facilitate use of effective evidence-based practices to improve mental health outcomes. For example, it is important that policy and health economic research projects include decision makers who will be the end users of data and study results, to ensure that results can be meaningfully put into practice.

IMPLICATIONS FOR HEALTH CARE

Designing effective and efficient funding mechanisms can help ensure that service users have access to effective treatments and that clinicians and provider organizations are adequately compensated for their work.

IMPLICATIONS FOR HEALTH POLICIES

Federal, state, and local policies, as well as policies of payers and health care organizations, can influence the type of care that is supported and incentivized.

IMPLICATIONS FOR FURTHER RESEARCH

As demonstrated by the research interests as outlined in their respective Strategic Plans and funding announcements, NIMH and NIDA continue to fund health economic and policy research that aims to improve health care access, quality and outcomes for people with or at risk of developing behavioral health conditions in the US and around the world.

PERSPECTIVE: A Path to Value-Based Insurance Design for Mental Health Services

BACKGROUND

Aligning cost of mental health care with expected clinical and functional benefits of that care would incentivize the delivery of high value treatments and services. In turn, ineffective or untested care could still be offered but at costs high enough to offset the delivery of high value care.

AIMS

The authors comment on Benson and Fendrick's paper on Value-Based Insurance Design (VBID) for mental health in the September 2023 special issue of this journal. The authors also present a preliminary framework of key ingredients needed to consider VBID for mental health treatments and services.

METHODS

The authors briefly review current and past efforts to contain costs and improve quality of mental health care, which include (for example) use of carve-out and carve-in programs, evaluation of cost sharing models, impact of accountable care organizations, and studying other benefit designs and impact of federal and state policies.

RESULTS

Using PTSD as an example, key ingredients of VBID for mental health services were identified and include the following: tools for case identification and monitoring progress over time at the population level; specific treatments and services with evidence of clinical effectiveness, cost-effectiveness, and health equity; and an approach to document the specific treatment or service was delivered (versus another treatment or service that may lack evidence).

DISCUSSION

The inability to afford mental health care is a top barrier to treatment seeking. People who do elect to spend time and money on mental health care are further disadvantaged by accessing care that is not well regulated and the quality at best is questionable. VBID could be an important lever for increasing access to and use of high value mental health care. Partnerships among the research, practice, and policy communities can help ensure research solutions meet needs of these two communities.

IMPLICATIONS FOR HEALTH CARE

VBID holds promise to make high value mental health care more affordable while discouraging low value treatments and services.

IMPLICATIONS FOR HEALTH POLICIES

While evidence gaps remain, these gaps can be filled concurrently with pursuit of VBID for mental health services.

IMPLICATIONS FOR FUTURE RESEARCH

This paper identifies important research opportunities to help make VBID a reality for mental health care.

How policymakers innovate around behavioral health: adoption of the New Mexico "No Behavioral Health Cost-Sharing" law

State policymakers have long sought to improve access to mental health and substance use disorder (MH/SUD) treatment through insurance market reforms. Examining decisions made by innovative policymakers ("policy entrepreneurs") can inform the potential scope and limits of legislative reform. Beginning in 2022, New Mexico became the first state to eliminate cost-sharing for MH/SUD treatment in private insurance plans subject to state regulation. Based on key informant interviews (n = 30), this study recounts the law's passage and intended impact. Key facilitators to the law's passage included receptive leadership, legislative champions with medical and insurance backgrounds, the use of local research evidence, advocate testimony, support from health industry figures, the severity of MH/SUD, and increased attention to MH/SUD during the COVID-19 pandemic. Findings have important implications for states considering similar laws to improve access to MH/SUD treatment.

Earmarked Taxes for Mental Health Services in the United States: A Local and State Legal Mapping Study

Policy Points Local governments are increasingly adopting policies that earmark taxes for mental health services, and approximately 30% of the US population lives in a jurisdiction with such a policy. Policies earmarking taxes for mental health services are heterogenous in their design, spending requirements, and oversight. In many jurisdictions, the annual per capita revenue generated by these taxes exceeds that of some major federal funding sources for mental health.

CONTEXT

State and local governments have been adopting taxes that earmark (i.e., dedicate) revenue for mental health. However, this emergent financing model has not been systematically assessed. We sought to identify all jurisdictions in the United States with policies earmarking taxes for mental health services and characterize attributes of these taxes.

METHODS

A legal mapping study was conducted. Literature reviews and 11 key informant interviews informed search strings. We then searched legal databases (HeinOnline, Cheetah tax repository) and municipal data sources. We collected information on the year the tax went into effect, passage by ballot initiative (yes/no), tax base, tax rate, and revenue generated annually (gross and per capita).

FINDINGS

We identified 207 policies earmarking taxes for mental health services (95.7% local, 4.3% state, 95.7% passed via ballot initiative). Property taxes (73.9%) and sales taxes/fees (25.1%) were most common. There was substantial heterogeneity in tax design, spending requirements, and oversight. Approximately 30% of the US population lives in a jurisdiction with a tax earmarked for mental health, and these taxes generate over $3.57 billion annually. The median per capita annual revenue generated by these taxes was $18.59 (range = $0.04-$197.09). Per capita annual revenue exceeded $25.00 in 63 jurisdictions (about five times annual per capita spending for mental health provided by the US Substance Abuse and Mental Health Services Administration).

CONCLUSIONS

Policies earmarking taxes for mental health services are diverse in design and are an increasingly common local financing strategy. The revenue generated by these taxes is substantial in many jurisdictions.

The Future of Public Mental Health: Challenges and Opportunities

Policy Points Social policies such as policies advancing universal childcare to expand Medicaid coverage of home- and community-based care for seniors and people with disabilities and for universal preschool are the types of policies needed to address social determinants of poor mental health. Population-based global budgeting approaches like accountable care and total cost of care models have the potential to improve population mental health by incentivizing health systems to control costs while simultaneously improving outcomes for the populations they serve. Policies expanding reimbursement for services delivered by peer support specialists are needed. People with lived experience of mental illness are uniquely well suited to helping their peers navigate treatment and other support services.

A policy implementation study of earmarked taxes for mental health services: study protocol

BACKGROUND

Insufficient funding is frequently identified as a critical barrier to the implementation and sustainment of evidence-based practices (EBPs). Thus, increasing access to funding is recognized as an implementation strategy. Policies that create earmarked taxes-defined as taxes for which revenue can only be spent on specific activities-are an increasingly common mental health financing strategy that could improve the reach of EBPs. This project's specific aims are to (1) identify all jurisdictions in the USA that have implemented earmarked taxes for mental health and catalogue information about tax design; (2) characterize experiences implementing earmarked taxes among local (e.g., county, city) mental health agency leaders and other government and community organization officials and assess their perceptions of the acceptability and feasibility of different types of policy implementation strategies; and (3) develop a framework to guide effect earmarked tax designs, inform the selection of implementation strategies, and disseminate the framework to policy audiences.

METHODS

The project uses the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to inform data collection about the determinants and processes of tax implementation and Leeman's typology of implementation strategies to examine the acceptability and feasibility strategies which could support earmarked tax policy implementation. A legal mapping will be conducted to achieve aim 1. To achieve aim 2, a survey will be conducted of 300 local mental health agency leaders and other government and community organization officials involved with the implementation of earmarked taxes for mental health. The survey will be followed by approximately 50 interviews with these officials. To achieve aim 3, quantitative and qualitative data will be integrated through a systematic framework development and dissemination process.

DISCUSSION

This exploratory policy implementation process study will build the evidence base for outer-context implementation determinants and strategies by focusing on policies that earmarked taxes for mental health services.

An Examination of Factors Affecting State Legislators' Support for Parity Laws for Different Mental Illnesses

Mental health parity legislation can improve mental health outcomes. U.S. state legislators determine whether state parity laws are adopted, making it critical to assess factors affecting policy support. This study examines the prevalence and demographic correlates of legislators' support for state parity laws for four mental illnesses- major depression disorder, post-traumatic stress disorder (PTSD), schizophrenia, and anorexia/bulimia. Using a 2017 cross-sectional survey of 475 U.S. legislators, we conducted bivariate analyses and multivariate logistic regression. Support for parity was highest for schizophrenia (57%), PTSD (55%), and major depression (53%) and lowest for anorexia/bulimia (40%). Support for parity was generally higher among females, more liberal legislators, legislators in the Northeast region of the country, and those who had previously sought treatment for mental illness. These findings highlight the importance of better disseminating evidence about anorexia/bulimia and can inform dissemination efforts about mental health parity laws to state legislators.

Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid

Understanding the extent to which beneficiaries can "realize" access to reported provider networks is imperative in mental health care, where there are significant unmet needs. We compared listings of providers in network directories against provider networks empirically constructed from administrative claims among members who were ages sixty-four and younger and enrolled in Oregon's Medicaid managed care organizations between January 1 and December 31, 2018. "In-network" providers were those with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a given health plan. They included primary care providers, specialty mental health prescribers, and nonprescribing mental health clinicians. Overall, 58.2 percent of network directory listings were "phantom" providers who did not see Medicaid patients, including 67.4 percent of mental health prescribers, 59.0 percent of mental health nonprescribers, and 54.0 percent of primary care providers. Significant discrepancies between the providers listed in directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information.

A Qualitative Exploration of the Views of Policymakers and Policy Advisors on the Impact of Mental Health Stigma on the Development and Implementation of Mental Health Policy in Singapore

Few studies have examined the views of policy makers regarding the impact of mental health stigma on the development and implementation of mental health policies. This study aimed to address this knowledge gap by exploring policymakers' and policy advisors' perspectives regarding the impact of mental health stigma on the development and implementation of mental health programmes, strategies, and services in Singapore. In all 13 participants were recruited for the study comprising practicing policymakers, senior staff of organisations involved in implementing the various mental health programmes, and policy advisors. Data was collected through semi-structured interviews, which were transcribed verbatim and analysed using reflexive thematic analysis. Data analysis revealed three superordinate themes related to challenges experienced by the policymakers/advisors when dealing with mental health policy and implementation of programmes. These themes included stigma as a barrier to mental health treatment, community-level barriers to mental health recovery, and mental health being a neglected need. Policymakers/advisors demonstrated an in-depth and nuanced understanding of the barriers (consequent to stigma) to mental healthcare delivery and access. Policymakers/advisors were able to associate the themes related to the stigma towards mental illness with help-seeking barriers based on personal experiences, knowledge, and insight gained through the implementation of mental health programmes and initiatives.

Carve-out plan financial requirements associated with national behavioral health parity

OBJECTIVES

To examine changes in carve-out financial requirements (copayments, coinsurance, use of deductibles, and out-of-pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA).

DATA SOURCE/STUDY SETTING

Specialty mental health benefit design information for employer-sponsored carve-out plans from a national managed behavioral health organization's claims processing engine (2008-2013).

STUDY DESIGN

This pre-post study reports linear and logistic regression as the main analysis.

DATA COLLECTION/EXTRACTION METHODS

NA.

PRINCIPAL FINDINGS

Copayments for in-network emergency room (-$44.9, 95% CI: -78.3, -11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: -$7.4, 95% CI: -10.5, -4.2; preparity mean: $17.8), and out-of-network coinsurance for emergency room (-11 percentage points, 95% CI: -16.7, -5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: -5.8 percentage points, 95% CI: -10.0, -1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In-network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent).

CONCLUSIONS

MHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients.

Factors associated with state legislators' support for opioid use disorder parity laws

BACKGROUND

In the United States, state behavioral health parity laws play a crucial role in ensuring equitable insurance coverage and access to substance use disorder treatment and services for people that need them. State legislators have the exclusive authority to adopt these laws. The purpose of this study was to identify legislator beliefs independently associated with "strong support" for opioid use disorder (OUD) parity.

METHODS

Data were from a 2017 cross-sectional, state-stratified, multi-modal survey of state legislators (N = 475). The dependent variable was "strong support" for OUD parity. Primary independent variables were beliefs about state parity laws. Bivariate analyses and mixed effects logistic regression were conducted.

RESULTS

Legislators who "strongly supported" OUD parity were significantly more likely than legislators who did not "strongly support" OUD parity to be female (64.1% vs. 46.5%, p<.001) , Democrat (76.2% vs. 29.3%, p<.001), and have liberal, compared to conservative, ideology (85.6% vs. 27.1%, p<.001). After adjusting for legislator demographics and state-level covariates, beliefs such as agreeing that state parity laws do not increase health insurance premium costs (aOR=6.77, p<.01) and that substance use disorder treatments can be effective (aOR=5.00, p<.001) remained associated with "strong support" for OUD parity. These state legislators' beliefs were more strongly associated with "strong support" for OUD parity than political party, ideology, and other demographic and state-level characteristics.

CONCLUSIONS

Dissemination materials and communication strategies to cultivate support for OUD parity laws among state legislators should focus on the fiscal impacts of parity laws and the effectiveness of substance use disorder treatments.

Definitions of Community for Individuals with Serious Mental Illnesses: Implications for Community Integration and Recovery

While recent work on community integration for individuals with serious mental illnesses (SMIs) has focused on the multi-dimensionality of community integration, it has not been fully rooted in how consumers define and experience communities for themselves. Guided by symbolic interactionism theory, the goal of the present study is to explore definitions of community as provided by individuals with SMIs, and to incorporate those definitions into a theoretical framework of community to inform community integration efforts in the context of mental health services and recovery. Semi-structured interviews were conducted between November 2017 and September 2018 with 90 racially/ethnically diverse participants who were 18 years and older with an SMI and receiving community mental health services. Interviews were audio-recorded, transcribed, and analyzed using ResearchTalk's "Sort and Sift, Think and Shift" methodology. Themes derived from participants' definitions of community included a structural aspect of people and places; a functional aspect of socializing, helping and receiving resources; and an experiential aspect of shared struggles and experiences, finding safety, and identifying with others. To this end, we propose a Structural, Functional and Experiential (SFE) model of community. The SFE model of community provides a conceptual framework and guidance for clinicians, researchers, policy makers and service stakeholders regarding the complexity and variability of community for their consumers, which is essential to their recovery. Application of the SFE framework for assessment and intervention is discussed.

Substance Use Disorders in Later Life: A Review and Synthesis of the Literature of an Emerging Public Health Concern

Substance use disorders (SUDs) among older persons are among the fastest growing health problems in the United States. The number of older persons is projected to exceed 72.1 million persons by 2030, following a trend of general population growth in the mid-1940s to 1960s. The generation, known as "baby boomers," who refashioned drug use during their 20-30s, are increasingly continuing drug habits into later life. This review aims to assess the epidemiology, impact, and treatment of geriatric SUDs. Academic databases including PubMed, PsychInfo, Ovid, and Medline, were queried up to December 2018 for terms of "geriatric," "older," "elderly," "substance abuse," "drug," "drug use," "drug abuse," "drug dependency," "illicit drugs," and "geriatric psychiatry." Articles identified included 17 government documents, 29 studies based upon government documents, 43 studies not related to US government surveys, 19 review articles, 9 commentary pieces, 4 newspaper articles, 2 textbooks, and 1 published abstract. Evaluated studies and documents together suggest that older individuals are using illicit drugs and meeting criteria for SUDs at higher rates than previous geriatric cohorts resulting in substantial negative impacts on medical and psychiatric conditions. These findings represent a novel trend since previous cohorts of older individuals were thought to rarely use illicit substances. Current treatment models are inadequate to address the new wave of older individuals with SUDs. The fields of geriatrics, addiction, and geriatric psychiatry must work together to establish comprehensive care models and treatment modalities for addressing this emerging public health concern.

State Legislators' Support for Behavioral Health Parity Laws: The Influence of Mutable and Fixed Factors at Multiple Levels

Policy Points When communicating with state legislators, advocates for state behavioral health parity laws should emphasize that the laws do not increase insurance premiums. Legislators' opinions about the impacts of state behavioral health parity laws and the effectiveness of behavioral health treatment have more influence on support for the laws than do their political party affiliation or state-level contextual factors. Reducing legislators' stigma toward people with mental illness could increase their support for state behavioral health parity laws CONTEXT: Comprehensive state behavioral health parity legislation (C-SBHPL) is an evidence-based policy that improves access and adherence to behavioral health treatments. However, adoption of C-SBHPL by state legislators is low. Little is known about how C-SBHPL evidence might be most effectively disseminated to legislators or how legislators' fixed characteristics (eg, ideology), mutable characteristics (eg, beliefs about the policy's impact), and state-level contextual factors might influence their support for behavioral health policies. The purpose of our study is (1) to describe the associations between legislators' fixed and mutable characteristics, state-level contextual factors, and support for C-SBHPL; and (2) to identify the mutable characteristics of legislators independently associated with C-SBHPL support.

METHODS

We conducted a multimodal (post mail, email, telephone) survey of US state legislators in 2017 (N = 475). The dependent variable was strong support for C-SBHPL, and the independent variables included legislators' fixed and mutable characteristics and state-level contextual factors. We conducted multivariable, multilevel (legislator, state) logistic regression.

FINDINGS

Thirty-nine percent of the legislators strongly supported C-SBHPL. After adjustment, the strongest predictors of C-SBHPL support were beliefs that C-SBHPL increases access to behavioral health treatments (aOR = 5.85; 95% CI = 2.41, 14.20) and does not increase insurance premiums (aOR = 2.70; 95% CI = 1.24, 5.90). Stigma toward people with mental illness was inversely associated with support (aOR = 0.86; 95% CI = 0.78, 0.95). After adjustment, ideology was the only fixed characteristic significantly associated with support for C-SBHPL. State-level contextual factors did not moderate associations between mutable characteristics and support for C-SBHPL.

CONCLUSIONS

Legislators' mutable characteristics are stronger predictors of C-SBHPL support than are most of their fixed characteristics and all state-level contextual factors, and thus should be targeted by dissemination efforts.

Mental Health Parity and Addiction Equity Act and the Use of Outpatient Behavioral Health Services in the United States, 2005-2016

Objectives. To assess the impact of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) on mental and substance use disorder services in the private, large group employer-sponsored insurance market in the United States. Methods. We analyzed data from the IBM MarketScan Commercial Database from January 2005 through September 2015 by using population-level interrupted time series regressions to determine whether parity implementation was associated with utilization and spending outcomes. Results. MHPAEA had significant positive associations with utilization of mental and substance use disorder outpatient services. A spending decomposition analysis indicated that increases in utilization were the primary drivers of increases in spending associated with MHPAEA. Analyses of opioid use disorder and nonopioid substance use disorder services found that associations with utilization and spending were not attributable only to increases in treatment of opioid use disorder. Conclusions. MHPAEA is positively associated with utilization of outpatient mental and substance use disorder services for Americans covered by large group employer-sponsored insurance. Public Health Implications. These trends continued over the 5-year post-MHPAEA period, underscoring the long-term relationship between this policy change and utilization of behavioral health services.

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.

Do coverage mandates affect direct-to-consumer advertising for pharmaceuticals? Evidence from parity laws

Direct-to-consumer advertising (DTCA) for prescription drugs is a relatively unique feature of the US health care system and a source of tens of billions of dollars in annual spending. It has also garnered the attention of researchers and policymakers interested in its implications for firm and consumer behavior. However, few economic studies have explored the DTCA response to public policies, especially those mandating coverage of these products. We use detailed advertising expenditure data to assess if pharmaceutical firms increase their marketing efforts after the implementation of relevant state and federal health insurance laws. We focus on mental health parity statutes and related drug therapies-a potentially ripe setting for inducing stronger consumer demand. We find no clear indication that firms expect greater value from DTCA after these regulatory changes. DTCA appears driven by other considerations (e.g., product debut); however, it remains a possibility that firms respond to these laws through other, unobserved channels (e.g., provider detailing).

The Mental Health Parity and Addiction Equity Act (MHPAEA) evaluation study: Did parity differentially affect substance use disorder and mental health benefits offered by behavioral healthcare carve-out and carve-in plans?

BACKGROUND

To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services.

METHODS

MH and SUD copayments and coinsurance, 2008-2013, were obtained from benefits databases for carve-in and carve-out plans from Optum®. Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans.

RESULTS

MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: -$51.17; out-of-network: -$34.39) and outpatient (in-network: -$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans.

CONCLUSION

Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum® plans. MHPAEA's SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance.

Integrated mental health services in China: challenges and planning for the future

Eager to build an integrated community-based mental health system, in 2004 China started the '686 Programme', whose purpose was to integrate hospital and community services for patients with serious mental illness. In 2015, the National Mental Health Working Plan (2015-2020) proposed an ambitious strategy for implementing this project. The goal of this review is to assess potential opportunities for and barriers to successful implementation of a community-based mental health system that integrates hospital and community mental health services into the general healthcare system. We examine 7066 sources in both English and Chinese: the academic peer-reviewed literature, the grey literature on mental health policies, and documents from government and policymaking agencies. Although China has proposed a number of innovative programmes to address its mental health burden, several of these proposals have yet to be fully activated, particularly those that focus on integrated care. Integrating mental health services into China's general healthcare system holds great promise for increased access to and quality improvement in mental health services, as well as decreased stigma and more effective management of physical and mental health comorbidities. This article examines the challenges to integrating mental health services into China's general healthcare system, especially in the primary care sphere, including: accurately estimating mental health needs, integrating mental and physical healthcare, increasing workforce development and training, resolving interprofessional issues, financing and funding, developing an affordable and sustainable mental health system, and delivering care to specific subpopulations to meet the needs of China's diverse populace. As China's political commitment to expanding its mental health system is rapidly evolving, we offer suggestions for future directions in addressing China's mental health needs.

Improving Data for Behavioral Health Workforce Planning: Development of a Minimum Data Set

The behavioral health workforce, which encompasses a broad range of professions providing prevention, treatment, and rehabilitation services for mental health conditions and substance use disorders, is in the midst of what is considered by many to be a workforce crisis. The workforce shortage can be attributed to both insufficient numbers and maldistribution of workers, leaving some communities with no behavioral health providers. In addition, demand for behavioral health services has increased more rapidly as a result of federal legislation over the past decade supporting mental health and substance use parity and by healthcare reform. In order to address workforce capacity issues that impact access to care, the field must engage in extensive planning; however, these efforts are limited by the lack of timely and useable data on the behavioral health workforce. One method for standardizing data collection efforts is the adoption of a Minimum Data Set. This article describes workforce data limitations, the need for standardizing data collection, and the development of a behavioral health workforce Minimum Data Set intended to address these gaps. The Minimum Data Set includes five categorical data themes to describe worker characteristics: demographics, licensure and certification, education and training, occupation and area of practice, and practice characteristics and settings. Some data sources align with Minimum Data Set themes, although deficiencies in the breadth and quality of data exist. Development of a Minimum Data Set is a foundational step for standardizing the collection of behavioral health workforce data. Key challenges for dissemination and implementation of the Minimum Data Set are also addressed.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Federal Parity and Access to Behavioral Health Care in Private Health Plans

OBJECTIVE

The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) sought to improve access to behavioral health care by regulating health plans' coverage and management of services. Health plans have some discretion in how to achieve compliance with MHPAEA, leaving questions about its likely effects on health plan policies. In this study, the authors' objective was to determine how private health plans' coverage and management of behavioral health treatment changed after the federal parity law's full implementation.

METHODS

A nationally representative survey of commercial health plans was conducted in 60 market areas across the continental United States, achieving response rates of 89% in 2010 (weighted N=8,431) and 80% in 2014 (weighted N=6,974). Senior executives at responding plans were interviewed regarding behavioral health services in each year and (in 2014) regarding changes. Student's t tests were used to examine changes in services covered, cost-sharing, and prior authorization requirements for both behavioral health and general medical care.

RESULTS

In 2014, 68% of insurance products reported having expanded behavioral health coverage since 2010. Exclusion of eating disorder coverage was eliminated between 2010 (23%) and 2014 (0%). However, more products reported excluding autism treatment in 2014 (24%) than 2010 (8%). Most plans reported no change to prior-authorization requirements between 2010 and 2014.

CONCLUSIONS

Implementation of federal parity legislation appears to have been accompanied by continuing improvement in behavioral health coverage. The authors did not find evidence of widespread noncompliance or of unintended effects, such as dropping coverage of behavioral health care altogether.

Communicating about Mental Illness and Violence: Balancing Stigma and Increased Support for Services

In the ongoing national policy debate about how to best address serious mental illness (SMI), a major controversy among mental health advocates is whether drawing public attention to an apparent link between SMI and violence, shown to elevate stigma, is the optimal strategy for increasing public support for investing in mental health services or whether nonstigmatizing messages can be equally effective. We conducted a randomized experiment to examine this question. Participants in a nationally representative online panel (N = 1,326) were randomized to a control arm or to read one of three brief narratives about SMI emphasizing violence, systemic barriers to treatment, or successful treatment and recovery. Narratives, or stories about individuals, are a common communication strategy used by policy makers, advocates, and the news media. Study results showed that narratives emphasizing violence or barriers to treatment were equally effective in increasing the public's willingness to pay additional taxes to improve the mental health system (55 percent and 52 percent, vs. 42 percent in the control arm). Only the narrative emphasizing the link between SMI and violence increased stigma. For mental health advocates dedicated to improving the public mental health system, these findings offer an alternative to stigmatizing messages linking mental illness and violence.

Federal Parity In The Evolving Mental Health And Addiction Care Landscape

The intent of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 is to eliminate differences between health insurance coverage of mental health and substance use disorder benefits and coverage of medical or surgical benefits. The Affordable Care Act significantly extended the reach of the Wellstone-Domenici law by applying it to new insurance markets. We summarize the evolution of legislative and regulatory actions to bring about federal insurance parity. We also summarize available evidence on how the Wellstone-Domenici law has contributed to addressing insurance discrimination; rectifying market inefficiencies due to adverse selection; and altering utilization, spending, and health outcomes for people with mental health and substance use disorders. In addition, we highlight important gaps in knowledge about how parity has been implemented, describe the groups still lacking parity-level coverage, and make recommendations on steps to improve the likelihood that the Wellstone-Domenici law will fulfill the aims of its architects.

Communication Strategies to Counter Stigma and Improve Mental Illness and Substance Use Disorder Policy

Despite the high burden and poor rates of treatment associated with mental illness and substance use disorders, public support for allocating resources to improving treatment for these disorders is low. A growing body of research suggests that effective policy communication strategies can increase public support for policies benefiting people with these conditions. In October 2015, the Center for Mental Health and Addiction Policy Research at Johns Hopkins University convened an expert forum to identify what is currently known about the effectiveness of such policy communication strategies and produce recommendations for future research. One of the key conclusions of the forum was that communication strategies using personal narratives to engage audiences have the potential to increase public support for policies benefiting persons with mental illness or substance use disorders. Specifically, narratives combining personal stories with depictions of structural barriers to mental illness and substance use disorder treatment can increase the public's willingness to invest in the treatment system. Depictions of mental illness and violence significantly increase public stigma toward people with mental illness and are no more effective in increasing willingness to invest in mental health services than nonstigmatizing messages about structural barriers to treatment. Future research should prioritize development and evaluation of communication strategies to increase public support for evidence-based substance use disorder policies, including harm reduction policies-such as needle exchange programs-and policies expanding treatment.

Mental Health Spending and Intensity of Service Use Among Individuals With Diagnoses of Eating Disorders Following Federal Parity

OBJECTIVE

The Mental Health Parity and Addiction Equity Act (MHPAEA) was intended to eliminate differences in insurance coverage for mental health and substance use disorder services and medical-surgical care. No studies have examined mental health service use after federal parity implementation among individuals with diagnoses of eating disorders, for whom financial access to care has often been limited. This study examined whether MHPAEA implementation was associated with changes in use of mental health services and spending in this population.

METHODS

Using Truven Health MarketScan data from 2007 to 2012, this study examined trends in mental health spending and intensity of use of specific mental health services (inpatient days, total outpatient visits, psychotherapy visits, and medication management visits) among individuals ages 13-64 with a diagnosis of an eating disorder (N=27,594).

RESULTS

MHPAEA implementation was associated with a small increase in total mental health spending ($1,271.92; p<.001) and no change in out-of-pocket spending ($112.99; p=.234) in the first year after enforcement of the parity law. The law's implementation was associated with an increased number of outpatient mental health visits among users, corresponding to an additional 5.8 visits on average during the first year (p<.001). This overall increase was driven by an increase in psychotherapy use of 2.9 additional visits annually among users (p<.001).

CONCLUSIONS

MHPAEA implementation was associated with increased intensity of outpatient mental health service use among individuals with diagnoses of eating disorders but no increase in out-of-pocket expenditures, suggesting improvements in financial protection.

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.

Litigation Provides Clues to Ongoing Challenges in Implementing Insurance Parity

Over the past twenty-five years, thirty-seven states and the US Congress have passed mental health and substance use disorder (MH/SUD) parity laws to secure nondiscriminatory insurance coverage for MH/SUD services in the private health insurance market and through certain public insurance programs. However, in the intervening years, litigation has been brought by numerous parties alleging violations of insurance parity. We examine the critical issues underlying these legal challenges as a framework for understanding the areas in which parity enforcement is lacking, as well as ongoing areas of ambiguity in the interpretation of these laws. We identified all private litigation involving federal and state parity laws and extracted themes from a final sample of thirty-seven lawsuits. The primary substantive topics at issue include the scope of services guaranteed by parity laws, coverage of certain habilitative therapies such as applied behavioral analysis for autism spectrum disorders, credentialing standards for MH/SUD providers, determinations regarding the medical necessity of MH/SUD services, and the application of nonquantitative treatment limitations under the 2008 federal parity law. Ongoing efforts to achieve nondiscriminatory insurance coverage for MH/SUDs should attend to the major issues subject to private legal action as important areas for facilitating and monitoring insurer compliance.

An audience research study to disseminate evidence about comprehensive state mental health parity legislation to US State policymakers: protocol

BACKGROUND

A large proportion of the US population has limited access to mental health treatments because insurance providers limit the utilization of mental health services in ways that are more restrictive than for physical health services. Comprehensive state mental health parity legislation (C-SMHPL) is an evidence-based policy intervention that enhances mental health insurance coverage and improves access to care. Implementation of C-SMHPL, however, is limited. State policymakers have the exclusive authority to implement C-SMHPL, but sparse guidance exists to inform the design of strategies to disseminate evidence about C-SMHPL, and more broadly, evidence-based treatments and mental illness, to this audience. The aims of this exploratory audience research study are to (1) characterize US State policymakers' knowledge and attitudes about C-SMHPL and identify individual- and state-level attributes associated with support for C-SMHPL; and (2) integrate quantitative and qualitative data to develop a conceptual framework to disseminate evidence about C-SMHPL, evidence-based treatments, and mental illness to US State policymakers.

METHODS

The study uses a multi-level (policymaker, state), mixed method (QUAN→qual) approach and is guided by Kingdon's Multiple Streams Framework, adapted to incorporate constructs from Aarons' Model of Evidence-Based Implementation in Public Sectors. A multi-modal survey (telephone, post-mail, e-mail) of 600 US State policymakers (500 legislative, 100 administrative) will be conducted and responses will be linked to state-level variables. The survey will span domains such as support for C-SMHPL, knowledge and attitudes about C-SMHPL and evidence-based treatments, mental illness stigma, and research dissemination preferences. State-level variables will measure factors associated with C-SMHPL implementation, such as economic climate and political environment. Multi-level regression will determine the relative strength of individual- and state-level variables on policymaker support for C-SMHPL. Informed by survey results, semi-structured interviews will be conducted with approximately 50 US State policymakers to elaborate upon quantitative findings. Then, using a systematic process, quantitative and qualitative data will be integrated and a US State policymaker-focused C-SMHPL dissemination framework will be developed.

DISCUSSION

Study results will provide the foundation for hypothesis-driven, experimental studies testing the effects of different dissemination strategies on state policymakers' support for, and implementation of, evidence-based mental health policy interventions.

The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders

BACKGROUND

The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between behavioral health and medical health insurance benefits among the commercially insured. This study determines whether MHPAEA was associated with increased BH expenditures and utilization among a population with substance use disorder (SUD) diagnoses.

METHODS

Claims and eligibility data from 5,987,776 enrollees, 2008-2013, were obtained from a national, commercial, managed behavioral health organization. An interrupted time series study design with segmented regression analysis estimated time trends of per-member-per-month (PMPM) spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance. The study sample contained individuals with drug or alcohol use disorder diagnosis during study period (N=2,716,473 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits; medication management; individual, group and family psychotherapy, and structured outpatient care); intermediate care utilization (day treatment; recovery home and residential); and inpatient utilization.

RESULTS

Starting at the beginning of the post-parity period, MHPAEA was associated with increased levels of PMPM total and plan spending ($25.80 [p=0.01]; $28.33 [p=0.00], respectively), as well as the number of PMPM assessment/evaluation, individual psychotherapy, and group psychotherapy visits, and inpatient days (0.01 visits [p=0.01]; 0.02 visits [p=0.01]; 0.01 visits [p=0.03]; 0.01days [p=0.01], respectively). Following these initial level changes, MHPAEA was also associated with monthly increases in PMPM total, plan, and patent out-of-pocket spending ($2.56/month [p=0.00]; $2.25/month [p=0.00]; $0.27 [p=0.03], respectively), as well as structured outpatient visits and inpatient days (0.0012 visits/month [p=0.01]; 0.0012days/month [p=0.00]).

CONCLUSION

MHPAEA was associated with modest increases in total, plan, and patient out-of-pocket spending and outpatient and inpatient utilization. These increases, while modest in magnitude, are larger in magnitude than increases detected among a sample of all enrollees (i.e. not only those with SUD diagnoses).

Was federal parity associated with changes in Out-of-network mental health care use and spending?

Background

The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act is to eliminate differences in insurance coverage between behavioral health and general medical care. The law requires out-of-network mental health benefits be equivalent to out-of-network medical/surgical benefits. Insurers were concerned this provision would lead to unsustainable increases in out-of-network related expenditures. We examined whether federal parity implementation was associated with significant increases in out-of-network mental health care use and spending.

Methods

We conducted an interrupted time series analysis using health insurance claims from self-insured employers (2007–2012). We examined changes in the probability of using out-of-network mental health services and, conditional on out-of-network mental health service use, changes in the number of outpatient out-of-network mental health visits and total out-of-network mental health spending associated with the implementation of federal parity in 2010.

Results

From 2007 to 2012, the proportion of individuals receiving any out-of-network mental health services each month declined dramatically from 18 to 12%, with a one-time drop of 3 percentage points at parity implementation (p < .01). Among out-of-network mental health service users, there was an increase in the number of visits per month (.12 visits; p < .01) and total spending per month ($49; p < .01) at parity implementation. Although there was a one-time increase in spending at parity implementation, this increase was accompanied by an attenuation of a trend toward increased spending growth, such that spending was back to original predictions by the end of our study period.

Conclusions

Despite concerns expressed by the health insurance industry when federal parity was enacted, out-of-network mental health spending did not substantially increase after parity implementation. In addition, use of out-of-network mental health services appears to have contracted rather than expanded, suggesting insurers may have implemented other policies to curb out-of-network use, such as increasing access to in-network providers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2261-9) contains supplementary material, which is available to authorized users.

Characterization of U.S. State Laws Requiring Health Care Provider Reporting of Perinatal Substance Use

BACKGROUND

State policies pertaining to health care provider reporting of perinatal substance use have implications for provider screening and referral behavior, patients' care seeking and access to prenatal substance use disorder treatment, and pregnancy and birth outcomes.

OBJECTIVES

This study sought to characterize specific provisions enacted in state statutes pertaining to mandates that health care providers report perinatal substance use, and to determine the proportion of births occurring in states with such laws.

METHODS

We conducted a systematic content analysis of statutes in all U.S. states that mentioned reporting by health care providers of substance use by pregnant women or infants exposed to substances in utero; inter-rater reliability was high. We calculated the number of states, and proportion of U.S. births occurring in states, with processes for mandatory reporting of perinatal substance use to authorities, and substance use disorder treatment provision for individuals who are reported.

RESULTS

Twenty states (corresponding with 31% of births) had laws requiring health care providers to report perinatal substance use to child protective authorities, and four states (18% of births) had laws requiring reporting only when a health care provider believed the substance use was associated with child maltreatment. About one-half of states (13) with any reporting law had a provision promoting substance use disorder treatment in the perinatal period.

CONCLUSIONS

Findings inform the ongoing debate about how health policies may be used to reduce the population burden of perinatal substance use.

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.

Increased Service Use Among Children With Autism Spectrum Disorder Associated With Mental Health Parity Law

Health care services for children with autism spectrum disorder are often expensive and frequently not covered under private health insurance. The 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was viewed as a possible means of improving access by eliminating differences between behavioral health and medical/surgical benefits. We examined whether the legislation was associated with increased use of and spending on mental health care and functional services for children with autism spectrum disorder compared to the period prior to implementation of the law. We used nationwide health insurance commercial group claims data to examine trends in service use and spending among children with autism spectrum disorder before and after implementation of the law. For such children, implementation was associated with increased use of both mental health and non-mental health services. These increases in use were not associated with higher out-of-pocket spending, which suggests that the law improved financial protection for families.

Federal parity law associated with increased probability of using out-of-network substance use disorder treatment services

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires commercial insurers providing group coverage for substance use disorder services to offer benefits for those services at a level equal to those for medical or surgical benefits. Unlike previous parity policies instituted for federal employees and in individual states, the law extends parity to out-of-network services. We conducted an interrupted time-series analysis using insurance claims from large self-insured employers to evaluate whether federal parity was associated with changes in out-of-network treatment for 525,620 users of substance use disorder services. Federal parity was associated with an increased probability of using out-of-network services, an increased average number of out-of-network outpatient visits, and increased average total spending on out-of-network services among users of those services. Our findings were broadly consistent with the contention of federal parity proponents that extending parity to out-of-network services would broaden access to substance use disorder care obtained outside of plan networks.

Uses of Research Evidence by State Legislators Who Prioritize Behavioral Health Issues

OBJECTIVE

Disseminating behavioral health (BH) research to elected policy makers is a priority, but little is known about how they use and seek research evidence. This exploratory study aimed to identify research dissemination preferences and research-seeking practices of legislators who prioritize BH issues and to describe the role of research in determining policy priorities. The study also assessed whether these legislators differ from those who do not prioritize BH issues.

METHODS

A telephone-based survey was conducted with 862 state legislators (response rate, 46%). A validated survey instrument assessed priorities and the factors that determined them, research dissemination preferences, and research-seeking practices. Bivariate analyses were used to characterize and compare the two groups.

RESULTS

Legislators who prioritized BH issues (N=125) were significantly more likely than those who did not to identify research evidence as a factor that determined policy priorities (odds ratio=1.91, 95% confidence interval=1.25-2.90, p=.002). Those who prioritized BH issues also attributed more importance to ten of 12 features of research, and the difference was significant for four features (unbiased, p=.014; presented in a concise way, p=.044; delivered by someone known or respected, p=.033; and tells a story, p=.030). Those who prioritized BH issues also engaged more often in eight of 11 research-seeking and utilization practices, and a significance difference was found for one (attending research presentations, p=.012).

CONCLUSIONS

Legislators who prioritized BH issues actively sought, had distinct preferences for, and were particularly influenced by research evidence. Testing legislator-focused BH research dissemination strategies is an area for future research.

The United States' Federal Parity Act and treatment of substance use disorders: Administrators' familiarity and perceptions of impact

BACKGROUND

The 2008 Wellstone and Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) aims to secure parity in private insurance coverage between behavioral and other medical disorders in the United States (U.S.). This legislation represents an important change in the operating field of substance use disorder treatment, but to date, its impact on treatment centers has not been widely examined. The current study measured the extent of center leaders' familiarity with the MHPAEA and their perceptions of its overall impact on their centers.

METHODS

Using a nationally representative sample of treatment centers in the U.S., we examined the extent of MHPAEA familiarity and its perceived impact as reported by treatment center leaders. We further employed logistic and ordered logistic regressions to determine personal and organizational characteristics associated with their reported familiarity and experienced impacts, including changes in the number of privately-insured clients seeking treatment and in the treatment coverage of those clients.

RESULTS

We found that dissemination of parity information was low. Only 36% of administrators reported high levels of familiarity and 16% used professional sources of information. The majority of administrators (71%) reported no impact of the legislation on their organization, but those that reported any impact were more likely to state positive impact. Greater parity knowledge and perceived positive impacts were associated with administrator and organizational characteristics indicative of greater access to industry-specific knowledge, a medical model orientation, and reliance on private insurance revenue.

CONCLUSION

This study demonstrates that dissemination of parity information is lacking and that the majority of leaders have yet to experience an impact of the MHPAEA. Leaders of centers with more sophisticated structures are most likely to be familiar with the legislation and perceive a positive impact. Research concerning the effective management of treatment centers, including environmental scanning techniques, continues to be needed.

Achieving Mental Health Care Parity Might Require Changes In Payments And Competition

One of the most prominent features of the Affordable Care Act has been the promotion of individual health plans chosen by consumers in the Marketplaces. These plans are subject to regulation and paid by risk-adjusted capitation, a set of policies known as managed competition. Individual health insurance markets, however, are vulnerable to what economists describe as efficiency problems stemming from adverse selection, and Marketplaces are no exception. Health plans have incentives to discriminate against services used by people with certain chronic illnesses, including mental health conditions. Parity regulations, which dictate coverage for mental health benefits on par with medical and surgical benefits, can eliminate discrimination in coverage but redirect discrimination toward hard-to-regulate tactics from managed care such as restrictive network design and provider payment. This article reviews policy options to contend with ongoing selection issues. "Better enforcement" of parity has less chance of success than more fundamental but feasible changes in the way plans are paid or in the way competition among plans is structured.

Health Plans' Early Response to Federal Parity Legislation for Mental Health and Addiction Services

OBJECTIVE

In 2008, the federal Mental Health Parity and Addiction Equity Act (MHPAEA) passed, prohibiting U.S. health plans from subjecting mental health and substance use disorder (behavioral health) coverage to more restrictive limitations than those applied to general medical care. This require d some health plans to make changes in coverage and management of services. The aim of this study was to examine private health plans' early responses to MHPAEA (after its 2010 implementation), in terms of both intended and unintended effects.

METHODS

Data were from a nationally representative survey of commercial health plans regarding the 2010 benefit year and the preparity 2009 benefit year (weighted N=8,431 products; 89% response rate).

RESULTS

Annual limits specific to behavioral health care were virtually eliminated between 2009 and 2010. Prevalence of behavioral health coverage was unchanged, and copayments for both behavioral and general medical services increased slightly. Prior authorization requirements for specialty medical and behavioral health outpatient services continued to decline, and the proportion of products reporting strict continuing review requirements increased slightly. Contrary to expectations, plans did not make significant changes in contracting arrangements for behavioral health services, and 80% reported an increase in size of their behavioral health provider network.

CONCLUSIONS

The law had the intended effect of eliminating quantitative limitations that applied only to behavioral health care without unintended consequences such as eliminating behavioral health coverage. Plan decisions may also reflect other factors, including anticipation of the 2010 regulations and a continuation of trends away from requiring prior authorization.

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.

Stigma and public support for parity and government spending on mental health: a 2013 national opinion survey

OBJECTIVE

The study examined attitudes among Americans about policies to require insurance parity for mental health and substance abuse benefits and to increase government spending on mental health treatment.

METHODS

A Web-based public opinion survey was conducted with a national sample (N=1,517). Analyses examined how sociodemographic characteristics, political affiliation, personal experience with mental illness, and attitudes toward persons with mental illness were associated with policy support.

RESULTS

Sixty-nine percent supported insurance parity, and 59% supported increasing government spending. Democrats were more supportive than Republicans or Independents. Personal experience was associated with higher support for both policies, and stigmatizing attitudes were associated with less support.

CONCLUSIONS

Most Americans favored policies to expand insurance and funding, but stigma was associated with lower support for both policies. This finding highlights the importance of developing robust antistigma efforts, particularly in an era when mental illness is increasingly linked to dangerousness in news media portrayals.

The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care

Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma's adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.

The effects of federal parity on substance use disorder treatment

BACKGROUND

In 2008, the US Congress enacted the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) requiring insurers to equalize private insurance coverage for mental health and substance use disorder services with coverage for general medical services.

OBJECTIVE

To examine the effects of MHPAEA on substance use disorder treatment.

STUDY DESIGN

We used a difference-in-differences design to compare changes in outcomes among plan enrollees in the years before and after implementation of federal parity (2009-2010) with changes in outcomes among a comparison group of enrollees previously covered by state substance use disorder parity laws.

METHODS

Insurance claims data from Aetna Inc health plans in 10 states with state parity laws were used to compare outcomes for plan enrollees in fully insured and self-insured health plans (N = 298,339).

RESULTS

In the first year of implementation, we found that federal parity did not lead to changes in the proportion of enrollees using substance use disorder treatment. We did find a modest increase in spending on substance use disorder treatment per enrollee ($9.99, 95% confidence interval, 2.54-18.21), but no significant change in identification, treatment initiation, or treatment engagement.

CONCLUSIONS

Inclusion of substance use disorder services in the federal parity law did not result in substantial increases in health plan spending. It will be critical to study results for year 2 after regulations affecting the management of care (eg, utilization review, network access) take effect.

Addressing public stigma and disparities among persons with mental illness: the role of federal policy

Stigma against mental illness is a complex construct with affective, cognitive, and behavioral components. Beyond its symbolic value, federal law can only directly address one component of stigma: discrimination. This article reviews three landmark antidiscrimination laws that expanded protections over time for individuals with mental illness. Despite these legislative advances, protections are still not uniform for all subpopulations with mental illness. Furthermore, multiple components of stigma (e.g., prejudice) are beyond the reach of legislation, as demonstrated by the phenomenon of label avoidance; individuals may not seek protection from discrimination because of fear of the stigma that may ensue after disclosing their mental illness. To yield the greatest improvements, antidiscrimination laws must be coupled with antistigma programs that directly address other components of stigma.