On Friday, October 3, 2008 the US House of Representatives approved the Emergency Economic Stabilization Act of 2008 [HR 1424]. The media focused on the $700 billion bailout package designed to salvage the nations economic crisis and few Americans noticed the Mental Health Parity and Addiction Equity Act of 2008 [HR 6983], that was one of the 20 attached bills that President Bush quickly signed into law a few days later (1).
For those of us in the Substance Abuse Treatment Community, the Parity and Equity Act generated more interest than the bailout. David Wellstone, son of the late Senator Paul Wellstone, who championed the Parity and Equity Act with Senator Pete Domenici (R. NM), was ecstatic. He noted that his father was one of the advocates of this legislation and had fought 12 long years for this moment after the 1996 passage of the Mental Health Parity Act.(2)
I believe that the battle to mandate treatment benefits for addictive disorders that are comparable with those provided for other chronic persistent medical disorders actually began in earnest 20 years ago. In 1987, psychiatrist Lewis L. Judd was named Director of the National Institute of Mental Health (NIMH), a post he held until 1990. (3) During Dr. Judds tenure he was instrumental in moving forward President George HW Bushs Proclamation 6158, designating the 1990s as the Decade of the Brain. (4) Six years later, Dr. Judds leadership resulted in Senators Wellstone and Domenicis championship of the Mental Health Parity Act which was signed into law by President Clinton in 1996. The Act banned discriminatory practices by insurance and health care providers from applying lower annual and lifetime spending limits for mental health treatment services. At NIMH, Dr. Judd provided the medical validation for this to occur through a three point strategy: prevalence, costs, and de-stigmatization of the mental illness. NIMH was able to demonstrate that more Americans experience some type of mental health disorder during their lifetimes than those who will experience a major physical illness like diabetes, heart disease, cancer or hypertension. Next, it was demonstrated that mental illnesses cost the American economy more losses than all physical illnesses. Finally, new medical technologies like brain imaging made it possible to objectively diagnose mental disorders thereby disproving the concept that symptoms of these conditions were merely improvised by those claiming to suffer mental illness. Unfortunately, much stigma still exists that symptoms of mental disorders are conjured up by unethical or lazy individuals to avoid basic life responsibilities. Through these efforts, Congress had to accept mental disorders to be biological conditions just like other medical diseases. As jubilant as Dr. Judd was at the passage of the Mental Health Parity Act of 1996, I was angered that it had excluded Substance Use Disorders and in some ways it was passed at the expense of substance use disorders. Dr. Judd acknowledged this but quickly pointed out that the huge stigma of mental illness in our society was much less than the stigma that exists regarding addiction. So much so that the Bill would not have had any chance of passage if it included substance abuse disorders in 1996. He then stressed the need for all to now work with Senators Wellstone and Domenici on a substance abuse parity act.
Dr. Judds projection of public stigma regarding substance use disorder is validated by the fact that it has taken 12 years since the Mental Health Parity Act to accomplish the enactment of the Mental Health Parity and Addiction Equity Act. This is especially disappointing since the Decade of the Brain actually demonstrated addiction and alcoholism to impact more Americans during their lifetimes than even mental health disorders. In fact, it revealed that Substance Use Disorder is Americas number one public health problems resulting in more deaths and medical complications than any other illness. Addiction also results in greater costs to American economy than mental illness and physical illness. Significantly, the discoveries during the Decade of the Brain validate chemical dependency, like mental disorders, results from neuro-cellular, neuro-chemical, and neuro-functional brain differences in those affected. It is biology and not a matter of intent or will power that robs an addict of their ability to control their use of substances, and further; this biological difference then conspires to get addicts using again when they try to stop.
Over the next dozen years, efforts on a federal substance abuse parity act morphed into the Mental Health Parity and Addiction Equity Act to include provisions that address loopholes in the original Mental Health Parity Act along with the establishment of equity for addiction treatment. The bill moved so slowly through congress that several states enacted their own substance abuse parity acts. By 2008, only Iowa and Wyoming had no parity provisions for substance abuse treatment, most states had some parity regulations while Connecticut, Maryland, Minnesota, Oregon and Vermont had the best parity laws. (5) Though most states had enacted their own parity acts, these still seemed to have minimal impact on treatment utilizations maybe because of vast differences between each states law and various loopholes that enabled insurance companies to still set some discriminatory limits for mental health and substance abuse treatment.
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 includes substance abuse treatment provisions and adds to the original Mental Health Parity Act of 1996 by banning differences in co-pays, deductibles, coinsurance, out of network coverage, out-of pocket expenses and various treatment limitations like caps on visits, limits on days, or limits on duration of treatment for mental health or addiction therapy. (6) Though buried in the Emergency Economic Stabilization Act of 2008, passage of the Mental Health Parity and Addiction Equity Act may prove to be the single most important occurrence in the history of chemical dependency treatment. Hopefully, it will start to erode the tremendous gap between treatment resources and those who want or need treatment for their substance use disorder by making such resources readily accessible through health insurance coverages. In addition, I sincerely hope that passage of this vital act will finally begin to reduce the great stigma about addiction and about those who are most vulnerable to its devastation.
The chemical dependency treatment community and those with substance use disorders owe a debt of gratitude to the late Senator Paul Wellstone, his son David, Senator Pete Domenici, and especially to Dr. Lewis Judd for their combined passions, perseverance, and their deep dedication to ending the discrimination in the treatment of mental health and addiction disorders.
Darryl S. Inaba, PharmD., CADC III
October 2008
References
1. Emergency Economic Stabilization Act of 2008
http://www.opencongress.org/bill/110-h1424/ show accessed 10/8/08).
2. (Frommer, F. (2008), After 12 years, Wellstone mental health parity act is law, Associated Press http://minnesota:publicradio.org/display/web/2008/10/303/parity_finalpassage/ accessed 10/8/08)
3. NIMH during the tenure of Director Lewis L. Judd, M.D. (1987-1990): the decade of the brain and the four national research plans http://www.faqs.org/abstracts/psychology-and-mental-health/NIMH-during-the- tenure-of-Director-Lewis-L-Judd-MD-1987-1990-the-decade-of-the-brain-and-the-four-na.html accessed 10/8/08)
4. Project on the decade of the brain (July 17, 1990), Presidential Proclamation 6158 http://www.loc.gov/loc/brain/proclaim.html accessed 10/8/08)
5. What have states done to ensure insurance parity (2008), Mental Health America, updated July 2008 http://www.mentalhealthamerica.net/go/parity/states accessed 10/8/08)
6. Mental health parity & addiction Equity is now law (Oct. 8, 2008), Occupational Health & Safety http://ohsonline.com/Articles/2008/10/8-Mental-Health-Parity-Act-is-Now-Law.aspx?p=1 accessed 10/9/08)