Improving Mental Health and Addressing Mental Illness: Mental Health Benefits Legislation
Task Force Finding
The Community Preventive Services Task Force recommends mental health benefits legislation, particularly comprehensive parity legislation, based on sufficient evidence of effectiveness in improving financial protection and increasing appropriate utilization of mental health services for people with mental health conditions. There is also evidence that mental health benefits legislation is associated with increased access to care, increased diagnosis of mental health conditions, reduced prevalence of poor mental health and reduced suicide rates.
Evidence from a concurrent economic review indicated that mental health benefits expansion did not lead to any substantial increase in cost to health insurance plans, measured as a percentage of premiums.
Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.
Mental health benefits legislation involves changing regulations for mental health insurance coverage to improve financial protection (i.e., decreased financial burden) and to increase access to, and use of, mental health services including substance abuse services. Moving toward parity for mental health coverage is a key element of most mental health benefits legislation. Defined as having no greater restrictions for mental health coverage than physical health coverage (Employee Benefits Security Administration, 2010), parity can be considered on a continuum from limited to comprehensive. The latter requires coverage for a broad range of mental health and substance abuse disorders that places no greater restrictions on benefits (e.g., visit limits, treatment limits, annual dollar limits or deductibles) for mental health services than benefits for physical health services.
This review considered legislation and executive orders enacted at the state or federal level.
- Parity laws cover a continuum of benefits.
- Limited parity may cover specific mental health conditions, including substance abuse, or allow more restrictions in benefits compared to physical health (e.g., visit limits, copayments, deductibles, annual and lifetime limits).
- Comprehensive parity covers a broad range of mental health conditions, including substance abuse, with few or no restrictions.
- Mandate laws may or may not be parity laws. These laws require insurers or health insurance plans to do at least one of the following:
- Provide some specified level of mental health coverage, or in cases when mental health insurance was already being provided, meet a minimum benefits level.
- Offer the option of mental health coverage.
- Executive orders for mental health parity for government employees may be issued at the federal or state level.
In the United States, health insurance benefits for mental health services have been typically less than benefits for physical health services (American Psychological Association, 2010), resulting in potential financial burden for people with mental health conditions (Zuvekas et al., 1998).
A number of state and federal initiatives have aimed to address this issue by increasing parity for mental health coverage.
- At the state level, forty-nine states and the District of Columbia (Cauchi et al., 2011) have enacted some type of mandate legislation.
- At the federal level, the 1996 Mental Health Parity Act (Solis, 2012), the 2008 Mental Health Parity and Addiction Equity Act (Employee Benefits Security Administration, 2010), and the Affordable Care Act (Patient Protection and Affordable Care Act, 2010) have led to progressively stronger parity requirements.
About the Systematic Review
The Task Force finding is based on evidence from a systematic review of 30 studies reported in 37 papers (search period 1965 - March 2011). The effectiveness evidence is based on a systematic review of all available studies, conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to mental health and mental illness.
Results from the review showed favorable effects for the following outcomes.
- Access to care: median increase of 13.6 percentage points (8 data points reported in 3 studies)
- Financial protection: median decrease in out-of-pocket spending per user of 4.6 percentage points (7 data points reported in 2 studies)
- Appropriate utilization of mental health services: in general, studies reported that mental health benefits legislation increased the following:
- Visits to mental health specialists (3 data points reported in 3 studies)
- Receipt of recommended medication, therapy, or treatment duration modeled on evidence-based findings or standard guidelines (6 data points reported in 2 studies)
- Mental health visits for persons who need mental health care (5 data points reported in 5 studies)
- Morbidity: the percentage of those in poor mental health decreased, as measured by the Mental Health Inventory Scale (poor mental health = MHI-5 score <67; 1 study)
- In states that passed parity laws during the study period, there was a decrease of 3.2 percentage points in the proportion of people with poor mental health.
- In states with parity laws, a smaller proportion of people had poor mental health compared to people in states without parity laws (2.8 percentage points difference).
- Mortality: benefits legislation was associated with decreased suicide rates (2 studies)
Results were generally more favorable for comprehensive parity legislation than limited parity legislation (10 data points reported in 6 studies).
The economic review included 14 studies; 11 provided evidence on plan cost impacts and 3 provided evidence on other economic effects.
Change in cost to insurance plans was measured as a percentage of insurance premiums per person. Of the 11 studies that assessed the impact on plan costs, four were for the Federal Employee Health Benefits (FEHB) program, two were studies of state mandates, and five assessed plans of individual large employers.
- One of the plans assessed in three of the FEHB studies showed benefits legislation led to a 0.23% increase in annual premiums.
- In Oregon, all of the assessed plans had slight increases in their annual premiums; the highest was 0.60%. In Vermont, annual premiums for mental health and substance abuse decreased.
- Two of the large employers reported premium increases of 0.29% and 1.04%.
In summary, expanding mental health benefits has not lead to substantial cost increases for health insurance plans, measured as a percentage of premiums. Evidence of other economic effects, such as business and employment-related outcomes was limited.
- Analytic Framework [PDF - 120 kB]
- Evidence Gaps
- Summary Evidence Tables - Effectiveness Review [PDF - 504 kB]
- Summary Evidence Tables - Economic Review [PDF - 99 kB]
- Included Studies - Effectiveness Review
- Included Studies - Economic Review
- Search Strategy - Effectiveness Review
- Search Strategy - Economic Review
Sipe TA, Finnie RKC, Knopf JA, Qu S, Reynolds JA, Thota AB, Hahn RA, Goetzel RZ, Hennessy KD, McKnight-Eily LR, Chapman DP, Anderson CW, Azrin S, Abraido-Lanza AF, Gelenberg AJ, Vernon-Smiley ME, Nease DE, Community Preventive Services Task Force. Effects of mental health benefits legislation: a Community Guide systematic review [PDF - 1.01 MB]. American Journal of Preventive Medicine 2015;48(6):755-66.
Community Preventive Services Task Force. Recommendation for mental health benefits legislation [PDF - 137 kB]. American Journal of Preventive Medicine 2015;48(6):767-70.
Jacob V, Qu S, Chattopadhyay S, Sipe TA, Knopf JA, Goetzel RZ, Finnie R, Thota AB, and the Community Preventive Services Task Force. Legislations and policies to expand mental health and substance abuse benefits in health insurance plans: a Community Guide systematic economic review [PDF - 301 kB]. Journal of Mental Health Policy and Economics 2015; 18(1):39-48.
Read other Community Guide publications about Improving Mental Health and Addressing Mental Illness in our library.
Community Guide News
- Task Force Says Laws Help Increase Access to Mental Health Care
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American Psychological Association. Mental health insurance under the federal parity law. 2010. Available at URL: http://www.apa.org/helpcenter/federal-parity-law.aspx
Cauchi R, Landess S, Thangasamy A. State laws mandating or regulating mental health benefits. 2011. National Conference of State Legislatures. Available at URL: http://www.ncsl.org/issues-research/health/mental-health-benefits-state-laws-mandating-or-re.aspx
Employee Benefits Security Administration. Fact Sheet: The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). United States Department of Labor. 2010. Available at URL: http://www.dol.gov/ebsa/newsroom/fsmhpaea.html
Sarata A. Mental health parity and the patient protection and Affordable Care Act of 2010. Congressional Research Service, 2011. Available at URL: http://artowerhcc.com/artower/resources/BHA%20~%208.pdf.
Solis. 2012 Report to Congress: Compliance with the mental health parity and addiction equity act of 2008. Unites States Department of Labor. 2010. Available at URL: http://www.dol.gov/ebsa/publications/mhpaeareporttocongress2012.html
Zuvekas SH, Banthin JS, Selden TM. Mental health parity: What are the gaps in coverage? J Ment Health Policy Econ 1998;1:135–146.
The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.
The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Improving mental health and addressing mental illness: mental health benefits legislation. www.thecommunityguide.org/mentalhealth/benefitslegis.html. Last updated: MM/DD/YYYY.
Review Completed: August 2012
- Page last reviewed: June 3, 2015
- Page last updated: June 3, 2015
- Content source: The Guide to Community Preventive Services