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
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.
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
A founding principle of hospice is that the patient and family is the unit of care; however, we lack national information on services to family members. Although Medicare certification requires bereavement services be provided, reimbursement rates are not tied to the level or quality of care; therefore, limited financial incentives exist for hospice to provide more than a minimal benefit.
To assess the scope and intensity of services provided to family members by hospice.
We fielded a national survey of hospices between September 2008 and November 2009.
A national sample of U.S. hospices with an 84 percent response rate (N=591).
Bereavement services to the family, bereavement services to the community, labor-intensive family services and comprehensive family services.
Most hospices provided bereavement services to the family (78%) and to the community (76%), but only a minority of hospices provided labor-intensive (23%) or comprehensive (27%) services to grieving family members. Larger hospice size was positively and significantly associated with each of the four measures of family services. We found no significant difference in provision of bereavement services to the family, labor-intensive services or comprehensive services by ownership type; however, non-profit hospices were more likely than for-profit hospices to provide bereavement services to the community.
Our results demonstrate substantial diversity in the scope and intensity of services provided to families of patients with terminal illnesses, suggesting a need for clearer guidance on what hospices should provide to exemplify best practices. Consensus within the field on more precise guidelines in this area is essential.
Hospice use in the United States is growing, but little is known about barriers that terminally ill patients may face when trying to access hospice care. This article reports the results of the first national survey of the enrollment policies of 591 US hospices. The survey revealed that 78 percent of hospices had at least one enrollment policy that may restrict access to care for patients with potentially high-cost medical care needs, such as chemotherapy or total parenteral nutrition. Smaller hospices, for-profit hospices, and hospices in certain regions of the country consistently reported more limited enrollment policies. We observe that hospice providers’ own enrollment decisions may be an important contributor to previously observed underuse of hospice by patients and families. Policy changes that should be considered include increasing the Medicare hospice per diem rate for patients with complex needs, which could enable more hospices to expand enrollment.
Consumer-directed health plans (CDHPs) hold the promise of reining in health spending by giving consumers a greater stake in health care purchasing, yet little is known about employers’ experience with these products. In examining the characteristics of those selecting a CDHP offered by one large employer, we found stronger evidence of selection than has been identified in prior research. Our findings suggest that in the context of plan choice, CDHPs may offer little opportunity to greatly lower employers’ cost burden, and they highlight concerns about the potential for risk segmentation and the value of conferring preferential tax treatment to CDHPs.
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.
We sought state-level factors associated with the adoption of medications to treat mental health conditions on state formularies for the AIDS Drug Assistance Program.
We interviewed 22 state and national program experts and identified 7 state-level factors: case burden, federal dollar-per-case Ryan White allocation size, political orientation, state wealth, passage of a mental health parity law, number of psychiatrists per population, and size of mental health budget. We then used survival analysis to test whether the factors were associated with faster adoption of psychotropic drugs from 1997 to 2008.
The relative size of a state’s federal Ryan White HIV/AIDS Program allocation, the state’s political orientation, and its concentration of psychiatrists were significantly associated with time-to-adoption of psychotropic drugs on state AIDS Drug Assistance Program formularies.
Substantial heterogeneity exists across states in formulary adoption of drugs to treat mental illness. Understanding what factors contribute to variation in adoption is vital given the importance of treating mental health conditions as a component of comprehensive HIV care.
Patients with cancer represent the largest diagnostic group of hospice users, with 560,000 referred for hospice in 2008. Oncologists rely on hospice teams to provide care for patients who have completed disease-directed treatment and desire to remain at home. However, 11% to 15% of hospice users disenroll from hospice, and little is known about their health care use and Medicare expenditures.
Patients and Methods
We used Surveillance, Epidemiology and End Results–Medicare data for hospice users who died as a result of cancer between 1998 and 2002 (N = 90,826) to compare rates of hospitalization, emergency department, and intensive care unit admission and hospital death for hospice disenrollees and those who remained with hospice until death. We also compared per-day and total Medicare expenditures across the two groups.
Patients with cancer who disenrolled from hospice were more likely to be hospitalized (39.8% v 1.6%; P < .001), more likely to be admitted to the emergency department (33.9% v 3.1%; P < .001) or intensive care unit (5.7% v 0.1%; P < .001), and more likely to die in the hospital (9.6% v 0.2%; P < .001). Patients who disenrolled from hospice died a median of 24 days following disenrollment, suggesting that the reason for hospice disenrollment was not improved health. In multivariable analyses, hospice disenrollees incurred higher per-day Medicare expenditures than patients who remained with hospice until death (higher per-day expenditures of $124; P < .001).
Hospice disenrollment is a marker for higher health care use and expenditures for care. Strategies to manage a patient's care and support family caregivers following hospice disenrollment may be beneficial and should be explored.
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.
From June 2003 through October 2004, the Food and Drug Administration (FDA) released five safety warnings related to antidepressant use and increased suicide risk in children. While researchers have documented a decline in antidepressant use in children over this time period, less is known about whether specific safety information conveyed in individual warnings was reflected in treatment patterns.
Thomson Marketscan claims data (2001–2005) for a national sample of privately insured children were used to construct treatment episodes (N=23,529). For each new episode of major depressive disorder, it was determined whether children’s treatment followed specific recommendations included in warnings released by the FDA. Treatment recommendations pertained to the use of the antidepressants paroxetine and fluoxetine and to patient monitoring. Treatment patterns were expected to change as the nature of risk information conveyed by the FDA changed over time.
The timing of FDA recommendations was associated with trends in the use of paroxetine and fluoxetine by children with major depressive disorder newly initiating antidepressant treatment. However, no evidence of increases in outpatient visits (i.e., monitoring) among depressed children initiating antidepressants was found.
Release of specific risk and benefit information by the FDA was associated with changes in prescribing, but not outpatient follow-up. These results suggest the FDA plays an important role in communicating information to the public and providers, but while public health safety warnings were associated with changes in some practice patterns, not all recommendations conveyed in warnings were followed.
Although private insurance typically covers many health care costs, the challenges faced by families caring for a sick child are substantial. These challenges may be more severe for CSHCN with mental illnesses than for other special needs children. Our objective is to determine whether families of privately insured children needing mental health care face different burdens than other families in caring for their children.
Patients and Methods
We use the 2005–2006 National Survey of Children with Special Health Care Needs (NS-CSHCN) to study privately insured children ages 6–17. We compare CSHCN with mental health care needs (N=4,918) to three groups: children with no SHCN (N=2,346), CSHCN with no mental health care needs (N=16,250), and CSHCN with no mental health care need but a need for other specialty services (N=7,902). The latter group is a subset of CSHCN with no mental health care need. We use weighted logistic regression and study outcomes across four domains: financial burden, health plan experiences, labor market and time effects, and parent experience with services.
We find that families of children with mental health care needs face significantly greater financial barriers, have more negative health plan experiences, and are more likely to reduce their labor market participation to care for their child than other families.
Families of privately insured CSHCN needing mental health care face a higher burden than other families in caring for their children. Policies are needed to aid these families in obtaining affordable, high quality care for their children.
mental health; health care services; CSHCN
In 2004, the Food and Drug Administration (FDA) directed pharmaceutical manufacturers to add a black box warning to antidepressants describing an increased suicide risk in children. We describe the events and evidence that led the FDA to act, the specific actions taken by the agency, and the changes in treatment patterns that followed. We then consider the outcomes of this case in the context of recent regulatory changes aimed at increasing the availability of information on the efficacy and safety of prescription medications.
In 2004, after an 18-month investigation, the Food and Drug Administration (FDA) directed pharmaceutical manufacturers to add a black box warning to antidepressants regarding an increased risk of suicidality in children. It has been suggested that news media reporting played a critical role in the sharp declines in pediatric antidepressant use that occurred concurrent with this investigation. Our objective was to evaluate the quality, content and overall impression conveyed in news coverage of this issue.
We collected all news stories on pediatric antidepressant use and suicidality published in a convenience sample of 10 of the highest circulation print newspapers in the U.S., the three major television networks and a major cable news network in 2003 and 2004 (N=167). Two researchers coded news articles using a nine-item instrument. Item inter-rater reliability was .84 or greater.
The quality of news reporting on key health messages included in FDA warnings was mixed. The overwhelming majority of news stories correctly described a risk of suicidality associated with pediatric antidepressant use as opposed to suicide itself. However, other key health messages highlighted in FDA warnings were often absent from news coverage. In terms of content, news stories, in particular television news, were more likely to include anecdotes of children harmed versus children helped by antidepressants while expert sources quoted were more likely to emphasize the benefits of antidepressants over their risks. However, the majority of news stories conveyed neither the overall impression that the risks of pediatric antidepressant use outweighed the benefits nor that the benefits outweighed the risks, and coverage became increasingly neutral over time.
Including key health messages in FDA safety warnings was not sufficient to ensure their communication to the public via the lay press, even though this information might have mitigated risks of pediatric antidepressant use.
pediatric depression; FDA; antidepressants; news media
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
Steep declines in pediatric antidepressant use were documented following the 2004 release of new safety information associating antidepressants with a risk of suicidality. We examine whether declines in pediatric antidepressant use were steeper among individuals with certain clinical or family characteristics. We find that declines in antidepressant use were associated with new (as compared to ongoing) treatment episodes. Also, although rates of antidepressant use were higher among children of college educated parents prior to risk disclosures, these children were more likely to forgo antidepressant medication than children of less educated parents after risk disclosures. We find that both children with and without psychiatric impairment experienced declines in antidepressant medication use following the risk warnings, although the decline occurred more quickly in the latter group. Our findings highlight the need for additional data to assess the effects of risk disclosures on treatment patterns and health outcomes.
FDA; black box; antidepressants; pediatric; suicidality