National Nurses United

Mental Parity_Temp 11/24/09 6:54 PM Page 14 "In the federal law, you can simply say, 'We used to provide mental health insurance but we don't want to comply [with parity] so we won't provide any mental health insurance at all,'" Revelle explained. "The incentive in the federal law is to do nothing at all." Revelle thinks it's unlikely insurers will drop mental health coverage entirely, but others aren't so sure. Ron Manderscheid, director of mental health and substance use programs in SRA International's global health sector, a Washington, D.C.-based consultancy, said he wouldn't be surprised if insurers transfer their mental health benefits from managed care to employee assistance programs (EAP). Such programs offer access to therapists and other mental health professionals, but only for a very limited period of time, and only to a very small number of therapists—sometimes by phone. Since EAPs are not beholden to the same standards as health insurance plans, insurers can continue to limit the number of visits and apply unequal copa ys to those services. "This is all about what insurers think is a financial burden," Manderscheid said. "This is about whether they think they'll be left holding the bag, and some insurers will drop coverage. They'll invoke protective tactics, like saying that mental healthcare is not part of their health plan but part of an EAP ." There are already signs that insurers are moving at least partly to protect their bottom lines. John Kamilis, clinical director of CuraLinc Healthcare, an EAP provider, told HR.BLR.com, a human resources management website, that promoting your company's EAP instead of mental health coverage can defray costs associated with outright use of benefits. "If it is something we can deflect into the EAP, there is a cost savings for the company, because it is one less person who accesses its health benefits and one less claim filed," he told HR.BLR.com in October. But there's another problem with the law: Insurers, not healthcare providers, are allowed to determine what they'll consider medically necessary. Right now, insurers are advocating that they should be allowed to limit the number of diagnoses they have to cover under the new law. According to public comment letters sent to the departments of Labor, Health and Human Services, and Treasury, which are drafting the regulations, the American Benefits Council, a trade organization for employer-sponsored benefit programs, argued that the government ought to interpret "medical necessity" to mean that each insurer can decide for itself which conditions will be covered and which won't. "If this coverage is left open to interpretation, there will be extreme disparity from plan to plan, as well as state to state," countered the American Psychiatric Rehabilitation Association in its own public comment on the guidelines. "Consumers, enrollees, and employers must be able to understand what mental health diagnoses will be part of their coverage." In other words, letting insurers dictate what's covered will defeat the point of having a unified federal law at all. T he current terrain of mental healthcare access across the 50 states is already rocky. Some 46 states already have passed mental health parity laws that vary widely both in terms of mandated coverage and which conditions they require insurers to cover. Some limit coverage to serious mental illnesses such as schizophrenia and major depression. Others require insurers to treat every 14 REGISTERED NURSE diagnosis in the American Psychiatric Association's Diagnostic and Statistical Manual. Since legislators passed its law in 2005, patients in the state of Washington have benefited from one of the strongest state mental health parity laws in the country, mandating mental health services as well as prohibiting discriminatory pricing or limits to mental health coverage. "The federal law doesn't cover nearly everyone. It has huge holes and ev en where it covers something its requirements are weak," said Revelle. "If I were grading Washington's law on a scale of zero to 10, I'd give Washington's law a 10 and the federal law a three or four. That's how weak the federal law is." Revelle added that states with str onger mental health parity laws than what was required by the new federal law had to fight to protect their rules from getting superseded, but did ultimately win that battle. Despite insurers' warnings to the contrary, Revelle reports that no insurers have gone out of business in Washington state since the law began phasing in starting in 2005. And experts tell him that there's been no documented increase in health costs because of the la a sitw, uation he doesn't expect to change when the last of the law goes into effect next year. Still, patients in other states are not as fortunate. Unfortunately, now that Congress has passed a mental health parity bill, "the attitude now seems to be that this issue is dealt with, it's been taken care of. That's baloney," added Revelle. As of early November, the federal government still has not issued regulations interpreting the new law, even though they were supposed to have been issued by Oct. 3, 2009. Government agencies have delayed their release until the start of 2010. What that means in practice is that people with mental health issues will have to wait until 2011 to receive whatever benefits the law may eventually dole out. The reason? Insurers use the last quarter of the year to draw up their policies for members for the following calendar year. So at the end of 2009, they're writing policies for 2010. Without firm guidelines, insurers are now still free to interpret the law however they choose. "My biggest fear is that they'll interpret those laws to their advantage," said William Emmet, director of the Campaign for Mental Health Reform. "The new policies will have to be in compliance with the law and they've got to define what they think that means without benefit of regulations. That might mean that some things have to be undone." But whatever the government does, it's clear to people like Nancy Sharby that the solution does not lie with w atered-down, piecemeal laws attempting to hold private insurers accountable for mental health services, but with wholesale reform of the healthcare system through a national single-payer program that guarantees everyone a single, high-quality standard of care. "I have friends who are psych nurses, social workers, insurance brokers, and if I didn't ha all those pieces, I couldn't have gotten the ve services I did for my kids," she said. "It's insane. If you stay off cancer treatment, you die. Well, if you stay off antidepressants, you die, too. I think there should be a single-payer plan, because a third of the cost of healthcare is administrative overhead. But it would have to be a good plan, like the plan in Canada. It would have to be fabulous. If they tried to do something low budget it would be a disaster." n Heather Boerner is a freelance health writer in San Francisco. W W W. C A L N U R S E S . O R G OCTOBER 2009

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