For most of us, attempting to follow the complexities of any legislation in the making is an exercise in frustration and confusion. The health care reform bills under current consideration are no exception. In fact, watching a bill become a law is often joked about as one of two processes you should never watch, the other is making sausage. Yet, these days you can’t pick up a newspaper or watch the evening news without being bombarded by evidence of lawmaking ad infinitum as pertains to health care reform.
If the march to a bill’s final passage seems long, laborious, and never ending, that’s because the actual process IS truly never ending. Yes, bills do become laws, but the process doesn’t end with the President’s signature in the Rose Garden. The actual signing of a bill into law is, metaphorically speaking, akin to a practitioner being granted the doctoral degree. While that is a great accomplishment, there still are many additional hurdles to jump over before one can hang out a professional shingle (internship, licensure, etc.). Even after licensure the process doesn’t end, practitioners must continually update their training through annual CE requirements in order to maintain their right to practice independently.
A good illustration of the long slog of lawmaking is the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) that will provide mental health services and substance abuse coverage to 113 million Americans.
We all rejoiced when this historic measure was finally enacted a year ago (after more than a ten year battle until passage). But our work is not done on this measure. The current phase in the process is every bit as critical as the initial ten years because it is here that the rubber meets the road, so to speak. It is at this juncture that the new law is scrutinized down to the last detail and the working federal rules and regulations are stipulated.
Vigilance is the keyword during this stage in order to insure that the intent of the legislation does not get lost in the interpretations of the rule writers. The Federal rules and regulations are the actual enforceable laws authorized by the legislation enacted by Congress.
While the MHPAEA was clearly landmark legislation requiring years of laborious planning, debate, compromise and reconciliation in Congress, the work of creating the federal rules and regulations, some would call these the real laws behind Acts, happens largely unnoticed in the offices of the government agencies rather than the halls of Congress.
With regard to the MHPAEA, the following Federal Agencies: Health and Human Services, Department of Treasury and the Department of Labor are the regulatory agencies empowered to create and enforce rules—regulations—that carry the full force of a law. After passage of the MHPAEA, the three above agencies were instructed to issue regulations before January 1, 2010, the effective date for the Act. HHS Secretary Kathleen Sibelius has already postponed the date of issuing regulations to sometime in January. It is essential that the regulations are issued for many reasons. However, the fundamental reason for issuance of rules is to avoid misinterpretation of the law when it is implemented and, in the case of the MHPAEA, to ensure access to critical mental health and addiction services as prescribed in the law.
The essential role of the rules and regs is to enforce the law. The Department of Labor insures compliance for ERISAregulated health plans, Health and Human Services oversees compliance for all other health plans, and Treasury exacts tax penalties for noncompliance. All three departments will jointly enforce the law.
This process of creating and enacting federal regulations is generally referred to as the “rulemaking” process. Rulemaking requires the highest level of nitty gritty detail, a virtual treasure trove for Bruno Klopfer’s “dd” types. In the case of the MHPAEA, for instance, the APAPO had an opportunity to respond to six questions developed by the federal rulemaking agencies. The APAPO responded to these questions with a twenty-three page letter sent to the agencies last May. Included in that letter was a comprehensive response to the six questions the agencies raised in a formal Request for Information, as well as a response to questions raised by the employer and insurer community regarding whether a group plan may have separate but equal financial requirements for mental/substance use benefits was offered.
In this phase of the process, psychology is specifically concerned that the agencies take special care to address issues such as scope of services, medical management, treatment limitations, and the use of “separate but equal” deductibles.
Of note, a recently published study examining California’s experience with its own state parity law (on the books since 2000) could be valuable to the success of the MHPAEA. The study, by researchers at Mathematica Policy Research and the Substance Abuse and Mental Health Services Administration (SAMHSA), used data from interviews and focus groups to draw conclusions about the success and failures of the California law from 2000 to 2005. Among the findings: • Costs associated with parity were in line with, or even below, the projections.
• Most health plans responded to the parity law by lifting limits on the annual number of days allowed for inpatient treatments and the number of visits allowed for outpatient treatment. • Concerns arose over the use of “medical necessity” clauses to authorize treatments and control costs. Medical necessity is typically defined as the need to supply a service for a condition that could endanger life or cause significant illness, suffering or disability and for which there is no adequate, less costly alternative available. • Consumers also complained about being referred to lists of mental-health providers only to find out that providers on the list were not taking new patients. • Health insurance providers felt the list of diagnoses covered under the parity law was arbitrary in excluding certain diagnoses. • Some doctors reported that they chose a parity diagnosis for a patient in order to ensure insurance coverage although it wasn’t the most accurate diagnosis. Some doctors said they had little flexibility to change a client’s diagnosis if he or she improved because they believed the health plan would then stop providing coverage for continuing care or care for a lesser diagnosis. • Nearly half of Californians polled in focus groups were unaware of the parity law.
Most, if not all, of these findings are well known to professional psychologists. Now, though, there is a public context, in which to actually examine these issues. We are hopeful that the rules and regs phase of the MHPAEA will create binding language that will insure the best outcomes for the new law as it was intended. We are well aware that the “medical necessity” criterion is one that is in dire need of very careful regulation, and recognize it is one of the thorniest issues in the entire area mental health benefits. Psychology’s public policy team will have their hands full in insuring that these matters continue to be kept front and center in the minds of lawmakers who have a vested interest in the MHPAEA. After all, we are most cognizant of the fact that the job continues long after a law is born. Keep your eye on the ball and continue your support for our efforts so that we are better able to make headway on these matters.
Finally, though it is not in the province of federal rules, but very important nevertheless, a strong suggestion made by the authors of the California parity study should be noted which encouraged the use of public education campaigns to accompany the introduction of the federal parity law, underscoring that the effort could yield another benefit. The authors correctly pointed out that enhanced public education may also lead to reduced stigma associated with mental illness. We have made progress in this area, but there is still further room for growth. Here’s to a productive 2010 for all of us.