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| Addiction Parity on the Horizon |
| Columns - Policy | ||||||||
| Written by Stephanie Muller | ||||||||
| Tuesday, 22 July 2008 | ||||||||
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The March 5 passage of the Paul Wellstone Mental Health and Addiction
Equity Act (H.R. 1424) was a significant victory for the addiction and
mental health communities, but before a bill can become a law, both
chambers of Congress (the House and the Senate) must agree upon the
exact same legislation before the bill can be sent to the President. Two bills — same issue, significant differences Currently, Congress is working to reconcile the differences between two bills on the same issue. The Senate passed a similar version of the House parity bill in September 2007. The Mental Health Parity Act (S. 558) was passed by unanimous consent, meaning that no official vote was taken because no Senator objected to the legislation. While this is good news for parity advocates, it is important to remember that there are significant differences between the House and Senate bills. The House bill, introduced by Reps. Jim Ramstad (R-Minn.) and Patrick Kennedy (D-R.I.) is largely supported by the addiction community, and includes more protections for people in need of treatment. Major differences in the bills are: • Clarity on preemption of state laws — H.R. 1424 includes very specific language that does not prevent states from passing stronger parity laws, if they so choose. Some legal experts have said that the language in S. 558 could still be used to override stronger state parity laws. • Out-of-network benefits — H.R. 1424 requires insurance companies to provide the same degree of out-of-network coverage for addiction treatment that is available for other medical conditions; S.558 only provides in-network coverage. The out-of-network parity is vital, especially for people who are living in rural or underserved areas, who will likely have difficulty accessing more specialized types of care. • Clarity on covered conditions — H.R. 1424 requires that insurance companies cover all disorders in the DSM-IV; S.558 does not. Without this provision, insurance providers may use arbitrary, non-scientific criteria to determine the scope of addiction or mental health conditions that are eligible for coverage. • Transparency — H.R. 1424 requires that insurance companies, upon request of claimants and their beneficiaries, provide information on medical necessity criteria and reasons for denials of reimbursement; S. 558 does not include this provision. Opponents of H.R. 1424 claim that parity is too expensive and will result in increased costs for consumers. An independent actuarial analysis of H.R. 1424 by Milliman, Inc., put estimated monthly premium increases at a rate of $0.03 - $2.40 per person, with significant long-term health care savings, due to people getting care early on in the disease process. Businesses and insurance companies also raised concerns with H.R. 1424 because the DSM-IV includes many “non-serious” conditions, such as caffeine addiction. However, H.R. 1424 would not prohibit insurance companies from using medical management techniques to determine whether a condition warrants coverage. The first federal parity bill was discussed in 1996, but later ended up applying to annual and lifetime limits for mental health only; not addiction. In 2001, the Federal Employee Health Benefits Program (FEHBP), the largest employer health care program in the United States, introduced parity for mental health and substance use disorders. The House has introduced parity bills in every session of Congress since 2001, and the Senate has introduced similar bills. These earlier attempts at parity failed, largely because they were opposed by the insurance industry and business groups. In an attempt to break this deadlock, Sens. Pete Domenici (R-N.M.) and Edward Kennedy (D-Mass.) consulted with stakeholders in the business and insurance industries to draft a bill that would ensure support from these two groups. The result was S.558, which is designed to require that group insurance plans covering 50 or more people do not provide coverage that discriminates against people with behavioral health disorders (as does H.R. 1424). Both bills require that the same co-pays, co-insurance, deductibles and treatment limitations that are applied to medical/surgical benefits also be applied to mental health and substance use disorder benefits. From a bill to a law A bill must go through a long and arduous process before becoming law; many bills never reach the President’s desk. The two parity bills, H.R. 1424 and S. 558, have made it further than most bills — having gone through committee and subcommittee reviews and “mark ups” (the process of offering amendments). Typically in a situation such as this, where each chamber has passed a bill on the same issue, a conference committee is convened to reconcile differences between the House and Senate versions. In this case, however, parity supporters in the House and Senate have said they will follow a less formal negotiating process. Although some senators have said they are not free to make changes to S.558, since it received the insurance industry’s blessing, others have urged their colleagues to work toward a compromise bill. At press time, Sens. Kennedy and Domenici had presented a compromise bill to House leadership. This proposed language adopts some provisions of the House bill (such as transparency and out-of-network coverage) and some from the Senate bill (such as not making scope of coverage based on the DSM-IV). It remains to be seen how this offer will be received by the leadership in the House and Senate, as well as insurance and business interests. Once a bill reaches the President, he or she can sign it, at which time it will become law. If the President opposes the bill, he or she may veto it; or, if he or she takes no action after the Congress has adjourned its second session, it is considered a “pocket veto” and the legislation dies. Congress may attempt to override the President’s veto, but this requires a two-thirds roll call vote of the members who are present, in sufficient numbers for a quorum. The Bush administration has indicated that it will sign a parity bill into law, if it is passed by Congress. If a bill is not passed this year, it can certainly be reintroduced in the next session of Congress. Daniel Guarnera, Government Relations Liaison for the National Association for Alcohol and Drug Addiction Counselors (NAADAC) and the National Association of Addiction Treatment Providers (NAATP), remains guardedly optimistic that a parity bill will pass this year. “We are thrilled with the historic support that parity has received in the past year, both in Congress and from advocates across the country,” Guarnera said. “We are committed to working with Congress to reach a strong compromise bill that can pass both chambers and be signed into law in 2008.” However, he warns that parity may get lost in the shuffle if a bill doesn’t pass this session. “We don’t want Americans to have to wait another year to access the treatment they need to recover,” Guarnera said. Two of parity’s strongest supporters, Sen. Domenici and Rep. Ramstad, are retiring and will not be in Congress to champion this issue next year. And depending on what happens in the November 2008 election, there may be a health care or health insurance reform movement that is far bigger than parity, and mental health and addiction groups will have to compete with every other area of the health care industry to be heard.” Guarnera said. “Parity has come so far — now is the time to end insurance discrimination and make sure people can access the care they need,” Guarnera added. Earlier this year, NAADAC and NAATP partnered to host Advocacy in Action!, — a conference that focused on legislative issues affecting addiction professionals and treatment providers. The two organizations provided briefings for participants, explaining to them how to discuss these issues with their elected officials to help convey the importance of addiction prevention, intervention, treatment and recovery efforts. NAATP President Dr. Ron Hunsicker was very pleased with the conference, stating, “I thought this set the stage for NAATP and NAADAC to work together in coming years on this event.” According to Hunsicker, the two organizations hold regular monthly conference calls to help further identify the issues they want to target. Asked what he thought about the potential for H.R. 1424 passing this year, Hunsicker said, “The real question is how serious the field is about getting a bill to the President this year. To get a bill to the President, we need to get behind a compromise.”
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