That long wait is also familiar to the horde of players who came together to develop the legislation, including behavioral healthcare providers, insurers, and lobbyists for the business community and mental health patient population. Beginning in September 2007, the Senate passed its version of the bill, while the House passed its own legislation in March (March 10, p. 8). Then the issue was stalled as the two sides tried to reach consensus. In the end, it was the Senate versionthe Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008that made its way into the emergency economic package that both chambers approved last week. Without exception, those who worked on the bill said it passed because of old-fashioned relationship building and persistence.
There were mileposts along the way where accommodations were made and it became a shared enterprise, said Neil Trautwein, vice president and employee benefits policy counsel at the National Retail Federation. Trautwein also served as chairman of the Ad Hoc Coalition on Mental Health Parity, which brought together business leaders and insurers. It wasnt quite Stockholm, but the more we worked together, the greater sympathy of understanding grew and it became a question of how we moved the process forward to bring this understanding to the legislation, he said, referring to Stockholm syndrome, which is the psychological response seen when an abducted hostage shows signs of loyalty to the hostage-taker.
Trautwein said his group is glad the bill recognized the need to manage benefits in monitoring the quality of coverage (See chart). But the federation is equally pleased, Trautwein said, for what the final bill did not include, such as the House versions stipulation that plans must cover all mental illnesses and addiction disorders listed in the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders.
In a compromise, everybody doesnt get everything they wantand they didnt, said Mark Covall, executive director of the National Association of Psychiatric Health Systems. This is long overdue to cover these illnesses, he said of the legislation. I think also over the years it became clearer and clearer that the cost issue became less of a concern.
Providing mental healthcare and substance abuse coverage could actually end up helping employers as healthier employees make for a more productive workforce. People with untreated depression may be less productive at work and have greater absenteeism, said Jeffrey Borenstein, a psychiatrist who is the CEO and medical director at Holliswood Hospital, a 125-bed behavioral healthcare facility in New York. Borenstein also serves as president of the National Association of Psychiatric Health Systems. In addition to that, not treating psychiatric conditions can exacerbate other medical conditions. For example, if somebody has a heart attack, they are at greater risk of clinical depression. Not treating that depression is the greatest risk factor for the patient not to do well, than, say, the high blood pressure or the high cholesterol, he said.
Still, cost issues related to the legislation worried the U.S. Chamber of Commerce, according to Katie Strong, the chambers director of congressional and public affairs.
That was our primary concern: How can we achieve mental health parity legislation that would not have a negative effect on accessibility and affordability of employer-provided health benefits? Strong said, adding that the chamber also wanted to ensure that the legislation would lay out a federal standard so that states couldnt pass stronger legislation, and that small businesses of 50 or fewer employees would be exempted. Existing state parity laws that are stronger will remain in place.
Employer healthcare cost is also an important concern for the National Business Group on Health, which represents about 300 members, most of them Fortune 500 companies. Although the group has worked on the mental health parity issue for years, it took a neutral stance on the law because, philosophically, it opposes federal mandates of any kind.
We dont want a federal mandate restricting the employers flexibility of the design and implementation of their health plan, said Steven Wojcik, vice president of public policy at the National Business Group on Health. When you have a federal mandateeven if youre providing mental health and substance abuse coverage that go above and beyond what the law requiresyou have extra administrative requirements that take away resources that could be spent on providing employee health and productivity.
So instead, the group showed its support for employer-sponsored mental healthcare coverage when it created a behavioral health services tool kit for employers in late 2005. A year earlier, the group convened the National Committee on Employer-Sponsored Behavioral Health Services, which was funded by HHS Center for Mental Health Services. That committee reported 12 key findings, including statistics about cost and the consequences of absenteeism. In 2001, the committee found, mental health and substance abuse treatment costs totaled $104 billion and represented nearly 8% of total healthcare spending in the U.S. And it also said about 217 million days of work are lost each year because of a decline in productivity related to mental illness and substance-abuse disorders, which costs U.S. employers about $17 billion each year.
In talking about this legislation, each of the stakeholders involvedall of them seasoned professionals in their own industries and the workings of Capitol Hillsaid while the bill was significant for the millions who need this coverage, the process to create the legislation was noteworthy because it could serve as a model for healthcare reform.
We hope we can look to this as an example for reform discussions, but everybody has to give a little, said Strong of the U.S. chamber. When we reached this compromise, neither side was doing cartwheels down the hill.