President Obama made history on March 23rd with the historic signing of the Patient Protection and Affordable Care Act (PPACA). This health care reform legislation took some 70 years to successfully come to fruition. That makes the long battle to enact mental health parity seem like it occurred at the speed of light by comparison. Eighteen months ago, psychologists celebrated another historic signing. At that time the Paul Wellstone and Pete Domenici Mental Health Parity & Addiction Equity Act of 2008 was signed into law. Our joy then concentrated upon the thrill of success after slogging through more than a decade of hard work directed at finally ending decades of discrimination against those with mental disorders in private health insurance plans. Although the law was not a total panacea (managed care still has too much control of treatment), it represented a giant step forward in putting mental health benefits on a par with physical health benefits.
What we didn’t know eighteen months ago, however, was that the parity law would be the proverbial gift that keeps on giving. In fact, without the parity law in place when the debates about the recent health care reform bill were occurring, we might well be singing the blues today. The parity law not only established equality in health insurance between mental and physical health, but, perhaps of greater importance in a variety of ways, was the absolutely indispensable role parity played during the year after it was enacted. By virtue of the fact that the parity law was solidly in place, the PPACA’s handling of mental health and psychology benefits was most equitable. Mental health was handled as assumed components in all discussions about the bills rather than what might have been a more dismissive manner requiring a fight for every inch of inclusion, as had historically been the case prior to parity’s passage.
APA Practice Organization lobbyists participated actively in discussions around health care reform, with the goal of ensuring integration of psychological care in all health plans, not the most basic kind of inclusion as has always been the case in previous reform attempts. A key aspect of the just passed legislation was the extension of the mental health parity protections established into law in 2008. Not only are these protections extended to all plans in what are called the Exchanges, but mental health and substance use benefits are a part of the essential benefits package created by this legislation. For the 67 percent of adults and 80 percent of children who need mental health care that do not receive it, this victory cannot be understated. Additionally, the PPACA marks a leap forward towards the transition from an illness focus for the health care system to one which is preventive, collaborative, and patient-centered.
It is very important to understand that the prominence of mental health treatment and benefits in the new law is largely the consequence of all the debates, the lobbying, the battles, and the struggles to gain support from members of Congress that occurred during the ten years of construction of the mental health parity law. During those years, members of Congress of all stripes became sensitized not only to the significant incidence of mental disorders among Americans, but also to the value derived from providing treatment to those with mental health problems. During the parity debates, a substantial number of members of Congress developed a new set of beliefs about mental health. The stigma about mental disorders was diminished as more science based information was widely circulated across a broad spectrum of political ideologies. As more members of Congress understood the multi-faceted issues involved with mental health, parity legislation became the law of the land. Clearly, the mind-body connection if you will, and the attention it received by lawmakers would prove to be invaluable in all discussions about the inclusion of psychology/mental health in the bigger picture (overall healthcare reform) which followed almost immediately on heels of parity’s passage.
Imagine the obstacles we would surely have encountered in the halls of Congress and at the White House if parity legislation had not been enacted a short 18 months ago. Instead of fighting for the most fundamental sort of inclusion of psychology services in the bills that were written in both houses of Congress, we were able to start our discussions by focusing our energies on the integration of psychology with physical health services in order to remain consistent with the already enacted mental health parity law. There was no need to sell lawmakers on either the need for our services or the value of them. The recent ten year parity debate had filled in any holes that might have existed in these two areas much to our great benefit.
From the restoration of psychology reimbursement rates in Medicare, to increased recognition about the mental health problems in returning veterans, to acknowledging the importance of prevention matters in mental health, to the mental health parity law, psychology has made great strides in the past decade. I was privileged to attend the White House Conference on Mental Health in 2009 which was Chaired by Al and Tipper Gore. One of the main issues addressed at that time was the “stigma” of mental health treatment. It is very reassuring to recognize how far we have come on this matter on Capitol Hill. The progress can be measured in the PPCAC.
Overall the PPACA will benefit individuals with mental health disorders. First, it will expand access to health insurance coverage (through both private plans and Medicaid) and make it more affordable and quality-driven. A big improvement will involve setting standards for health insurance policies so as to protect consumers. In addition, the law will set minimum requirements regarding services that health plans must cover, including mental health and substance abuse services in that mandate.
Of note, for all of us, is a feature of the law that will encourage more coordinated primary care and specialty mental health care, promote preventive services, foster workforce development initiatives, and make other changes designed to improve the quality and availability of services that people receive.
As is always the case in the public policy realm, the enacting of legislation requires great patience. However, sometimes the impact of legislation can reach far greater than was originally envisioned. So it is in the case of the Parity Act. It has already proven to be essential in ways that extend beyond its original intent.