In a recently released article in Pediatrics, Dr. Kennedy-Hendricks and colleagues (10.1542/peds.2017-2618) examine the impact of the Mental Health Parity and Addiction Equity Act on mental health service use and spending among youth. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) became law on October 3, 2008, almost a decade ago, and took effect January 1, 2010.
The MHPAEA requires that all group health plans and health insurers who are providing both medical-surgical coverage and mental health/substance use coverage guarantee complete parity for limitations on treatment day and visit number and for all financial requirements, including deductibles, co-pays, out-of-network coverage and out-of-pocket caps. This means that mental health coverage cannot be more restrictive or more expensive than medical-surgical coverage. Since companies with less than 50 employees, and those whose group plans do not offer any mental health care at all, are exempt from the MHPAEA, the Act regulates mental health coverage but does not create access where there is none. However, the 2010 Affordable Care Act made mental health and substance use disorder care an Essential Health Benefit (EHB) for “non-grandfathered individual and small group plans” effectively including smaller plans under the MHPAEA.
MHPAEA was designed to plug loopholes in its predecessor, the Mental Health Parity Act (MHPA), which applied to group plans active on or after January 1, 1998. The MHPA only required comparable annual and lifetime dollar limits on mental health and medical coverage by group plans, and did not include substance use disorder coverage. It was extended six times, and many believe it had little effect on mental health coverage, as insurers were able to circumvent requirements by greater “cost-sharing” with patients and families. Hence Senators Domenici and Wellstone and others battled for the MHPAEA, which has a broader mandate, and hopefully, more impact. I was unaware of the MHPAEA’s history, and according to a survey done in 2014 by the American Psychological Association, only 4% of Americans are aware of the MHPAEA (2014 Mental Health Parity Survey). Interestingly in this same survey the barrier most frequently cited to mental health care was cost.
So the work by Dr. Kennedy-Hendricks and colleagues in this article is highly relevant and very timely, and aims to answer a question many of us frankly did not even know needed to be asked. The study population included children ages 3-8 years with mental health conditions in both large, self-insured plans and small group plans in 23 states who were enrolled continuously in health plans 2008-2012, and compares “pre-parity” (2008-9) with “post-parity (2011-12) expenditures for mental health care. A further comparison looks specifically at those whose spending was >85% of the total mental health spending distribution for the relevant years, versus all others. As you might expect, the Methods section is critical to full understanding of the study’s results, but (and this is key!) don’t be daunted by the details. Did the MHPAEA make a difference? Yes, it did, but the impact was much smaller than many might have hoped, and the dollar details are well explained. Even if you are not a “policy wonk” I think you will get a lot out of reading about the distribution of diagnoses and the costs associated with different aspects of mental health care. It’s an eye opener, and reading encouraged me to visit the AAP Advocacy Center Mental Health Care page to learn more and have a chance to make my voice heard on behalf of kids’ mental health.