The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act prohibits commercial group health plans from imposing spending and visit limitations for mental health and substance abuse services that are not imposed on medical-surgical benefits. Controversially, the Act also restricts the use of managed care tools that apply to the behavioral health benefit in ways that differ from their application to the medical-surgical benefit. The only precedent for this approach is Oregon’s state parity law, implemented in 2007. The goal of this study is to estimate the effect of Oregon’s parity law on expenditures for mental health and substance abuse treatment services.
We compared expenditures for individuals in four Oregon commercial plans from 2005 through 2008 to a matched group of commercially insured individuals in Oregon who were exempt from parity. Using a difference-in-differences analysis, we analyzed the effect of comprehensive parity on spending for mental health and substance abuse services.
Increases in spending on mental health and substance abuse services following Oregon’s parity law were due almost entirely to a general trend observed among individuals with and without parity. Expenditures per enrollee for mental health and substance abuse services attributable to parity were positive but did not differ significantly from zero in any of the four plans (range: +$12.15 to +$25.49, p>0.05 for each comparison).
Behavioral health insurance parity that places restrictions on how plans manage mental health and substance abuse services can improve insurance protections without substantial increases in total costs.
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires commercial group health plans offering coverage for mental health and substance abuse services to offer those services at a level that is no more restrictive than for medical-surgical services. The MHPAEA is notable in restricting the extent to which health plans can use managed care tools on the behavioral health benefit. The only precedent for this approach is Oregon's 2007 state parity law. This study aims to provide evidence on the effect of comprehensive parity on utilization and expenditures for substance abuse treatment services.
A difference-in-difference analysis compared individuals in five Oregon commercial plans (n=103,820) from 2005–2008 to comparison groups exempt from parity in Oregon (n=19,633) and Washington (n=39,447). The primary outcome measures were annual use and total expenditures.
Spending for alcohol treatment services demonstrated statistically significant increase in comparison to the Oregon and Washington comparison groups. Spending on other drug abuse treatment services was not associated with statistically significant spending increases, and the effect of parity on overall spending (alcohol plus other drug abuse treatment services) was positive but not statistically significant from zero.
Oregon's experience suggests that behavioral health insurance parity that places restrictions on how plans manage the benefit may lead to increases in expenditures for alcohol treatment services but is unlikely to lead to increases in spending for other drug abuse treatment services.
Parity; Health Economics; Health Policy; Alcohol Treatment; Substance Abuse Treatment; Managed Care
“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.
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 (MHPAEA). In one 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.
Overall, parity in Oregon was associated with a slight increase (0.5% to 0.8%) in initiations with masters-level specialists, and relatively little change for generalist physicians, psychiatrists and psychologists. Patients are particularly sensitive to distance for nonphysician specialists.
Our results suggest that the MHPAEA 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.
This article chronicles the political history of efforts by the U.S. Congress to enact a law requiring “parity” for mental health and addiction benefits and medical/surgical benefits in private health insurance. The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity (MHPAE) Act of 2008 is to eliminate differences in insurance coverage for behavioral health. Mental health and addiction treatment advocates have long viewed parity as a means of increasing fairness in the insurance market, whereas employers and insurers have opposed it because of concerns about its cost. The passage of this law is viewed as a legislative success by both consumer and provider advocates and the employer and insurance groups that fought against it for decades.
Twenty-nine structured interviews were conducted with key informants in the federal parity debate, including members of Congress and their staff; lobbyists for consumer, provider, employer, and insurance groups; and other key contacts. Historical documentation, academic research on the effects of parity regulations, and public comment letters submitted to the U.S. Departments of Labor, Health and Human Services, and Treasury before the release of federal guidance also were examined.
Three factors were instrumental to the passage of this law: the emergence of new evidence regarding the costs of parity, personal experience with mental illness and addiction, and the political strategies adopted by congressional champions in the Senate and House of Representatives.
Challenges to implementing the federal parity policy warrant further consideration. This law raises new questions about the future direction of federal policymaking on behavioral health.
parity; insurance; mental health; substance abuse
Congress is considering enactment of comprehensive parity legislation. The intent of parity is to equalize private coverage of behavioral and general medical care, thereby improving efficiency and fairness in insurance markets. One issue is whether to extend parity to substance abuse (SA) benefits. In the past, inclusion of substance abuse has been a hurdle to passage of parity. We examine the politics of SA parity, compare coverage trends for substance abuse and mental health, and assess the rationale for equalizing benefits. We conclude that the justification for SA parity is as compelling as it is for mental health parity.
OBJECTIVE: To determine the impact of parity in mental health benefits on the marginal prices that consumers face for mental health treatment. DATA SOURCES/DATA COLLECTION: We used detailed information on health plan benefits for a nationally representative sample of the privately insured population under age 65 taken from the 1987 National Medical Expenditure Survey (Edwards and Berlin 1989). The survey was carefully aged and reweighted to represent 1995 population and coverage characteristics. STUDY DESIGN: We computed marginal out-of-pocket costs from the cost-sharing benefits described by policy booklets under current coverage and under parity for various mental health treatment expenditure levels using the MEDSIM health care microsimulation model developed by researchers at the Agency for Healthcare Research and Quality. Descriptive analyses and two-limit Tobit regression models are used to examine how insurance generosity varies across individuals by demographic and socioeconomic characteristics. Our analyses are limited to a description of how parity would change the marginal incentives faced by consumers under their existing plan's cost-sharing arrangements for mental and physical health care. We do not attempt to simulate how parity might affect the level of benefits, including whether benefits are offered at all, or the level of managed care that affects the actual benefits that plan members receive. Rather, we focus only on the nominal benefits described in their policy booklets. PRINCIPAL FINDINGS: Our results show that as of 1995 parity coverage would substantially reduce the share of mental health expenditures that consumers would pay at the margin under their existing plan's cost-sharing provisions, with larger changes for outpatient care than for inpatient care. Because current mental health coverage generally becomes less generous as expenditures rise, while coverage for other medical care becomes more generous (due to stop-loss provisions), the difference in incentives between current mental health coverage and the assumed parity coverage widens as total expenditure grows. We also find that the impact of parity on marginal incentives would vary greatly across the privately insured population. CONCLUSIONS: Based on the large variation in the impact of parity on marginal incentives across the population under current plan cost-sharing arrangements, changes in the demand for mental health treatment will likely also vary across the population.
The bulk of mental health services for people with depression are provided in
primary care settings. Primary care providers prescribe 79 percent of
antidepressant medications and see 60 percent of people being treated for
depression in the United States, and they do that with little support from
specialist services. Depression is not effectively managed in the primary care
setting. Collaborative care based on a team approach, a population health
perspective, and measurement-based care has been proven to treat depression more
effectively than care as usual in a variety of settings and for different
populations, and it increases people’s access to medications and behavioral
therapies. Psychiatry has the responsibility of supporting the primary care
sector in delivering mental health services by disseminating collaborative care
approaches under recent initiatives and opportunities made possible by the
Affordable Care Act (ACA).
antidepressants; primary care; collaborative care
To study the financial impact of state parity laws on families of children in need of mental health services.
Privately insured families in the 2000 State and Local Area Integrated Telephone Survey National Survey of Children with Special Health Care Needs (CSHCN) (N=38,856).
We examine whether state parity laws reduce the financial burden on families of children with mental health conditions. We use instrumental variable estimation controlling for detailed information on a child's health and functional impairment. We compare those in parity and nonparity states and those needing mental health care with other CSHCN.
Multivariate regression results indicate that living in a parity state significantly reduced the financial burden on families of children with mental health care needs. Specifically, the likelihood of a child's annual out-of-pocket (OOP) health care spending exceeding $1,000 was significantly lower among families of children needing mental health care living in parity states compared with those in nonparity states. Families with children needing mental health care in parity states were also more likely to view OOP spending as reasonable compared with those in nonparity states. Likewise, living in a parity state significantly lowered the likelihood of a family reporting that a child's health needs caused financial problems. The likelihood of reports that additional income was needed to finance a child's care was also lower among families with mentally ill children living in parity states. However, we detect no significant difference among residents of parity and nonparity states in receipt of needed mental health care.
These results indicate that state parity laws are providing important economic benefits to families of mentally ill children undetected in prior research.
Parity; mental health; CSHCN; economic burden
The impact of parity coverage on the quantity of behavioral health services used by enrollees and on the prices of these services was examined in a set of Federal Employees Health Benefit (FEHB) Program plans. After parity implementation, the quantity of services used in the FEHB plans declined in five service categories, compared with plans that did not have parity coverage. The decline was significant for all service types except inpatient care. Because a previous study of the FEHB Program found that total spending on behavioral health services did not increase after parity implementation, it can be inferred that average prices must have increased over the period. The finding of a decline in service use and increase in prices provides an empirical window on what might be expected after implementation of the federal parity law and the parity requirement under the health care reform law.
In this paper, we argue that mental illness touches everyone's lives, and that mental health care is a core activity of primary care. The increasing move towards a primary care-led National Health Service has now created a climate where primary care can move beyond providing a gatekeeper function for secondary care specialist services. Primary care is also sufficiently mature as a discipline to commission, develop, and deliver integrated patient-focused mental health services grounded in the culture and built on the strengths of primary care. We discuss examples of integrated approaches to mental health care, and highlight the potential tensions created by new ways of working. We also suggest that any changes need to be accompanied by carefully negotiated adjustments to the way primary and secondary healthcare professionals conceptualise their roles and responsibilities, and must be underpinned by new ways of learning together.
Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care—elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.
chronic disease management; addiction; primary care; linkage; addiction treatment; chronic care model; recovery
OBJECTIVE: To determine whether state-level parity legislation has led to an increase in utilization of mental health services. DATA SOURCES: Healthcare For Communities (HCC), a multi-site nationally representative study sponsored by the Robert Wood Johnson Foundation that tracks health care system changes for mental health and substance abuse treatment. Information on state-level parity legislation was provided by state offices of the National Alliance for the Mentally Ill (NAMI); local and state market data come from the Area Resource File; information on other health mandates from Blue Cross/Blue Shield. STUDY DESIGN: Two-stage regressions are used to estimate the effect of state parity legislation on use of any mental health services, use of specialty mental health services, and number of specialty visits in the past year. In the first stage, we predicted the probability that a state decides to pass parity legislation as a function of state health care market indicators and previous legislative activity. The fitted probability is used in the second stage to determine the effect of this legislation on access and utilization. PRINCIPAL FINDINGS: State parity legislation is not associated with a significant increase in any of our measures of mental health services utilization. These results are robust to various specifications of the models. CONCLUSIONS: Those states that are able to pass parity legislation do not experience significant increases in the utilization of mental health services. This may be due in part to a loss of coverage for those people most at risk for mental health disorders. The results could be very different, however, if strong federal legislation were passed.
Provisions in the Affordable Care Act (ACA) are likely to expand access to substance use disorder treatment for low-income individuals. The aim of the study was to provide information on the need for substance use disorder treatment among individuals who may be eligible for Medicaid under the ACA.
The 2008 and 2009 National Survey on Drug Use and Health provided data on demographic characteristics, health status, and substance use disorders for comparison of current low-income Medicaid enrollees (N=3,809) with currently uninsured individuals with household incomes that may qualify them for Medicaid coverage beginning in 2014 (N=5,049). The incomes of the groups compared were 138% of the federal poverty level (133% provided in the ACA plus a 5% income “disregard” allowed by the law).
The rate of substance use disorders among currently uninsured income-eligible individuals was slightly higher than the rate among current Medicaid enrollees (14.6% versus 11.5%, p=.03). Although both groups had significant unmet need for substance use disorder treatment, the treatment rate among those who needed treatment was significantly lower in the income-eligible group than in the currently enrolled group (31.3% versus 46.8%, p<.01). When the analysis excluded informal care received outside the medical sector, treatment rates among those with treatment needs were much lower in both groups (12.8% in the income-eligible group and 30.7% among current enrollees).
Findings suggest that Medicaid insurance expansions under the ACA will reduce unmet need for substance use disorder treatment.
To assess the impacts of recent state mental health parity legislation on perceived quality of health insurance coverage, perceived access to needed health care, and use of mental health specialty services by individuals with likely need for mental health care.
The study sample came from two waves of a national household survey first fielded in 1997–1998 and then in 2000–2001. The analysis used a subset of the sample.
The study took the Difference-in-Difference-in-Difference approach to investigate changes in self-perceived quality of health insurance coverage and access to needed health care, and use of mental health specialty care by the group with mental disorders (relative to those without) in states with parity legislation of different comprehensiveness (relative to the nonparity states) in the years after the law (relative to before the law).
Overall, there were no significant or consistent effects of the parity legislation. Descriptive statistics showed significant changes in some (but not all) outcome variables, but these results disappeared in detailed statistical analyses by controlling for important covariates.
The null findings of the effects of state mental health parity mandates suggest that under ERISA (Employee Retirement Income Security Act), the scope of state parity legislation may have been restricted because of large proportion of self-insured employers. Furthermore, comprehensiveness of state legislation appears to be related to the traditional level of use of mental health specialty care, which becomes another confounder for the potential policy effects.
Mental health parity legislation; health care access; insurance coverage; mental health specialty care
The Patient Protection and Affordable Care Act (ACA) institutionalized Medicaid as a significant and permanent structure in the U.S. health care system. About half of the 32 million Americans expected to gain health insurance coverage under the ACA will be covered under Medicaid. While it is clear general internists will be significantly impacted by Medicaid-related health care reform provisions, its ultimate effect is unclear since these new opportunities also come with some new potential burdens. There are four main areas of impact for general internists to consider: (1) coverage expansions and reimbursement; (2) multiple payers and fragmented coverage; (3) primary care workforce and infrastructure capacity; and (4) delivery model changes.
Despite the high prevalence of mental health concerns, few young adults access treatment. While much research has focused on understanding the barriers to service access, few studies have explored unbiased accounts of the experiences of young adults with mental health concerns. It is through hearing these experiences and gaining an in-depth understanding of what is being said by young adults that improvements can be made to interventions focused on increasing access to care.
To move beyond past research by using an innovative qualitative research method of analyzing the blogs of young adults (18–25 years of age) with mental health concerns to understand their experiences.
We used an enhanced Internet search vehicle, DEVONagent, to extract Internet blogs using primary keywords related to mental health. Blogs (N = 8) were selected based on age of authors (18–25 years), gender, relevance to mental health, and recency of the entries. Blogs excerpts were analyzed using a combination of grounded theory and consensual qualitative research methods.
Two core categories emerged from the qualitative analysis of the bloggers accounts: I am powerless (intrapersonal) and I am utterly alone (interpersonal). Overall, the young adult bloggers expressed significant feelings of powerlessness as a result of their mental health concerns and simultaneously felt a profound sense of loneliness, alienation, and lack of connection with others.
The present study suggests that one reason young adults do not seek care might be that they view the mental health system negatively and feel disconnected from these services. To decrease young adults’ sense of powerlessness and isolation, efforts should focus on creating and developing resources and services that allow young adults to feel connected and empowered. Through an understanding of the experiences of young adults with mental health problems, and their experiences of and attitudes toward receiving care, we provide some recommendations for improving receptivity and knowledge of mental health care services.
Young adult; mental health; mental health services; life experiences; blogging; qualitative research
Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO.
Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners.
About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents.
Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce.
Health plans; Managed care; Treatment providers; Demographics; Substance abuse; Mental health
Inadequate physician training and involvement in addictions treatment are barriers to integrating mental health and addiction services in public behavioral health care. The authors designed and implemented the Dual Diagnosis Physician-infrastructure Assessment Tool (DDPAT) to quantify statewide dimensions of this workforce problem.
The DDPAT examined institutional dual diagnosis capability and physician workforce, training backgrounds, and clinical roles across Indiana’s 30 community mental health centers (CMHCs), six psychiatric hospitals, and 13 addiction treatment centers.
All treatment centers and 75% of physicians responded. Sixty-nine percent of all treatment centers and 97% of CMHCs reported dual diagnosis capability. However, 29% of physicians treated both mental illness and addictions, and only 8% had certification in an addiction specialty. Overall workforce shortages, particularly of younger psychiatrists, contextualized these findings.
The DDPAT identified multiple deficiencies in the physician workforce with respect to dual diagnosis and addictions care in Indiana. The DDPAT may be useful for characterizing similar trends in other states.
Kurt Vonnegut was one of the most influential novelists of the late 20th Century. His wry views of people and organizations are applicable to the today's efforts to use science to improve the effectiveness of substance use treatment programs. His 1963 book, Cat's Cradle pointed to the potentially disastrous consequences of the development of science for science's sake. Moving to more current viewpoints, in 2009 the young writer and medical doctor Josh Bazell published Beat the Reaper, a novel that discusses modern medical care and pharmaceutical treatments with sarcasm and wit. Currently we are witnessing many developments to incorporate evidence-based practices into addiction treatment, ranging from Institute of Medicine overviews to the organization the Substance Abuse and Mental Health Services Administration, fielding the National Registry of National Registry of Evidence-based Programs and Practices for preventing and treating substance abuse and mental health disorders, legislative initiatives, efforts to upgrade the treatment workforce and, most recently, health care reform. There are signs that these and other efforts are upgrading the effectiveness of treatments for addiction. Yet the checks and balances of every effort to create change make for a field that shows halting and peripatetic development. “Top-down” reforms are watered down by “bottom-up” approaches, and vice-versa. Several concrete steps can be taken to improve the magnitude and speed of change in the field. We cannot change human nature, but we can improve addiction treatment.
The Patient Protection and Affordable Care Act of 2010 (ACA) will increase insurance coverage for US citizens and for breast and cervical cancer screening through insurance expansions and regulatory changes. The primary objective of this study was to estimate the number of low-income women who would gain health insurance after implementation of the ACA and thus be able to obtain cancer screening. A secondary objective was to estimate the size and characteristics of the uninsured low-income population and the number of women who would still need National Breast and Cervical Cancer Early Detection Program (NBCCEDP) services.
We used the nationally representative 2009 American Community Survey to estimate the determinants of insurance status for women in Massachusetts, assuming full implementation of the ACA. We extrapolated findings to simulate the effects of the ACA on each state. We used individual-level predicted probabilities of being uninsured to generate estimates of the number of women who would gain health insurance after implementation of the ACA and to predict demand for NBCCEDP services.
Approximately 6.8 million low-income women would gain health insurance, potentially increasing the annual demand for cancer screenings initially by about 500,000 mammograms and 1.3 million Papanicolaou tests. Despite a 60% decrease in the number of low-income uninsured women, the NBCCEDP would still serve fewer than one-third of the estimated number of women eligible for services. The NBCCEDP-eligible population would comprise a larger number of women with language and literacy-related barriers to care.
Implementation of the ACA would increase insurance coverage and access to cancer screening for millions of women, but the NBCCEDP will remain essential for the millions who will remain uninsured.
While parity (number of children) reportedly is related to tooth loss, the relationship between parity and dental caries has not been extensively investigated. We used path analysis to test a theoretical model that specified that parity influences dental caries levels through dental care, psycho- social factors, and dental health damaging behaviors in 2635 women selected from the NHANES III dataset. We found that while increased parity was not associated with a greater level of total caries (DFS), parity was related to untreated dental caries (DS). The mechanisms by which parity is related to caries, however, remain undefined. Further investigation is warranted to determine if disparities in dental caries among women are due to differences in parity and the likely changes that parallel these reproductive choices.
parity; dental caries; health disparities; path analysis
American Indian/Alaska Native youth represent the strength and continued survival of many Nations and Tribes. However, they currently experience numerous health disparities and challenges, including the highest rate of suicide among 15 to 24 year-olds in the United States. Our comprehensive review of the literature on the mental health of AI/AN youth highlighted seven focal causes of behavioral health disparities: 1) high levels of violence and trauma exposure and traumatic loss, 2) past and current oppression, racism, and discrimination, 3) underfunded systems of care, 4) disregard for effective indigenous practices in service provision, policy, and funding, 5) overreliance on evidence-based practices, 6) lack of cultural competence among systems of care and providers, and 7) barriers to care. Seven policy recommendations that recognize the importance of moving beyond exclusive reliance on western models of care and that seek to foster transformation of individuals, families, communities, behavioral health service systems of care, and social structures are presented, supported, and discussed.
Adolescent; Alaska Native; American Indian; Behavioral Health; Evidence-Based Intervention; Historical Trauma; Mental Health Services; Native American; Policy
The Patient Protection and Affordable Care Act (ACA) of 2010 is landmark legislation designed to expand access to health care for virtually all legal U.S. residents. A vital but controversial provision of the ACA requires individuals to maintain health insurance coverage or face a tax penalty—the individual mandate. We examine the constitutionality of the individual mandate by analyzing relevant court decisions. A critical issue has been defining the “activities” Congress is authorized to regulate. Some judges determined that the mandate was constitutional because the decision to go without health insurance, that is, to self-insure, is an activity with substantial economic effects within the overall scheme of the ACA. Opponents suggest that Congress overstepped its authority by regulating “inactivity,” that is, compelling people to purchase insurance when they otherwise would not. The U.S. Supreme Court is set to review the issues and the final ruling will shape the effectiveness of health reform.
health reform; Affordable Care Act; Constitution; individual mandate; Commerce Clause; nursing
The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries’ financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children.
Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending.
The apparent increase in the rate of children’s mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children’s mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant.
Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services.
health care costs; health insurance; mental health; substance abuse/use; managed care
Oncologists, practice managers, manufacturers, and patient advocates must stay involved at the federal and state levels to ensure appropriate access to necessary services and quality treatment are maintained for patients with cancer.
The Patient Protection and Affordable Care Act (ACA) will have lasting effects on oncology coverage and, perhaps, on oncology practice as well. The ACA ushers in a new class of insured individuals; approximately 25 million will purchase insurance through the exchanges, and Medicaid will expand by 12 million beneficiaries over the next 10 years. Essential health benefits (EHBs), which are required in all qualified health plans (QHPs) sold in the exchanges, will define the coverage available to the newly insured population and could lead to the development of new definitions and standards for medical necessity. This article will discuss effects of the ACA EHB requirements on oncology coverage, as well as the state and federal options and responsibilities as they relate to coverage of and access to oncology services within the QHPs in the exchanges.