Although the U.S. Congress was unable to reach an agreement on expanding mental health parity last fall, residents of more than two-thirds of the states were already covered under some form of parity legislation (Figure). But even before the ink had fully dried on the latest measures, some governors were looking at cuts in behavioral health care as a means of balancing their budgets.
In January, Illinois put its new plan into effect, bringing the number of states that have enacted some form of parity legislation, either for mental illness alone or for mental illness and substance abuse, to 37. Group health plans in Illinois are required to set equal co-payments and deductibles for nine mental illnesses and other types of disease. In addition, the plans must provide 45 days of inpatient treatment and 35 outpatient visits for mental illness every year, with no lifetime maximums. The law includes a sunset clause that goes into effect in 2005, when the department of insurance is required to report on the effects of the law.
Mississippi, Utah, Wisconsin, Alabama and South Carolina passed some form of parity law last year. In addition, several states improved their existing parity laws in 2001, expanding coverages to additional groups or requiring additional benefit levels. Other states, such as Massachusetts and Rhode Island, revised their older parity laws; but mental health care advocates say they expect to see fewer states adopt similar laws this year.
"It's not surprising after the sort of flurry we've seen in previous years," said Chris Koyanagi, policy director for the Bazelon Center for Mental Health Law in Washington, D.C., in an interview with Psychiatric Times. "It's natural to slow down. We've been going at it for the last several years. The closer we get to the group of states that are not very sympathetic, the fewer you are going to see added.
"The states that went out first [for parity] were states with low mental health utilization, states where the culture is such that people tend not to go to services. The impact [there] is less than in a state where people are anxious and there are more providers. In large rural areas, parity does not matter if there's no one to treat you. On the whole, parity laws have had less impact than people would have liked. And, every state has a certain number of large employers who are self-insured and not covered by the laws."
A handful of states have been reluctant to broach the subject of parity because of fears that increased costs associated with an expanded level of benefits will force employers to scale back benefits in all categories -- an argument that was used with some success during the Congressional debates last November and December. But the chair of the American Psychiatric Association's Joint Commission on Government Relations, Jeremy Lazarus, M.D., told PT that "employer flight" has been the exception rather than the rule.
"Employers have not been running for the hills," said Lazarus. "We're not seeing large groups of employers eliminating benefits. It's been a very small number, maybe 1% to 2%."
Lazarus said the APA will be pushing for more state parity laws this year, but he noted that physicians are beginning to focus on a less-publicized aspect of the debate.