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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 indicates 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.

Intervention Definition

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, Banthin, Selden, 1998). 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. Such legislation can be enacted at the federal or state level.

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.

Two federal initiatives have increased mental health parity, the 1996 Mental Health Parity Act (Solis, 2012) and the more comprehensive 2008 Mental Health Parity and Addiction Equity Act (Employee Benefits Security Administration, 2010). At the state level, forty-nine states and the District of Columbia (Cauchi, Landess & Thangasamy, 2011) have enacted some type of mandate legislation. In 2014, the Affordable Care Act will extend federal parity requirements to new health plans in individual and small group markets (Patient Protection and Affordable Care Act, 2010).

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.

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

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).

Economic Evidence

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.

The economic 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 and economic methods, and in research, practice, and policy related to mental health and mental illness.

Supporting Materials

Publication Status

Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe External Web Site Icon to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.

References

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.




Disclaimer

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.

Sample Citation

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