This Congressional session marks the first time that both houses of Congress have passed legislation regarding mental health parity. Last fall, the Senate adopted the Mental Health Parity Act and, in March the House passed the Paul Wellstone Mental Health and Addiction Equity Act. The two bills differ in language which has stalled the final passage of the legislation. The difference lies in the definition of mental illness. The Senate bill is silent on the matter which would allow for insurers to define the definition of mental illness. The House bill relies on the Diagnostic and Statistical Manual (DSM) to explicitly define mental health and substance abuse conditions.
The difference in the bills and the impediment to progress is all about money. Most health insurance plans do not formally define the conditions which they cover. They use the term "medically necessary" to define the scope of coverage. They do not use the ICD or DSM to define conditions. Coverage may be denied if, in the opinion of the insurer, a condition would not improve with treatment or if the treatment is not considered appropriate or effective or is experimental. The House bill which uses the DSM relies on that manual's definition of the 300 or so disorders which includes some that may not require intervention and may not effect functional abilities and capacities.
The battle about money between the two bills has some long range implications. Will insurers design benefits for mental health conditions control and balance costs and restrict access to care? They likely would if the legislation required treatment of the all inclusive DSM conditions. Insurance plans may be designed to discourage people with serious and chronic mental health conditions from enrolling by using prohibitive cost sharing techniques. If that was the case, then the Mental Health Parity Act would be an empty vessel. There would be people who remain uncovered by insurance simply because the required coverage would be of no benefit to them. The Federal Employee Health Benefits Program of 2002 established parity, but disallowed treatment for conditions which were not serious. The analysis of the claims conducted for this program showed that treatment was directed towards serious mental health conditions.
The House model based on the DSM criteria could backfire and force insurance companies into the stance of raising the bar to force disenrollment of individuals with serious and chronic mental health conditions. The solution will be found in brokering the House and Senate versions to prevent exclusion of entire categories of problems due to the high costs associated with those conditions and to use the concepts of "medically necessary care and treatment" to focus resources on the serious and chronic mental health and substance abuse conditions. For Mental Health Parity to exist as functional coverage we need to find a solution which allows insurance resources to be used for those mental health and substance abuse conditions which cause impairment, disability and suffering.