Mental Health and Mental Illness: Mental Health Benefits Legislation

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) 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.

The full CPSTF Finding and Rationale Statement and supporting documents for Improving Mental Health and Addressing Mental Illness: Mental Health Benefits Legislation are available in The Community Guide Collection on CDC Stacks.

Intervention

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.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 30 studies reported in 37 papers (search period 1965 — March 2011).

Study Characteristics

All of the included studies were conducted in the U.S.
Twenty-eight studies examined effects of state or federal mental health/substance abuse parity policies or legislation, and two examined effects of state-mandated coverage.
Six studies examined effects of comprehensive parity legislation or policies.
Most studies were conducted between 1990 and 2011 and used a nation-wide sample to examine effects of federal legislation or state mandates.

Summary of 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).

Summary of 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.

Applicability

Results should be applicable to the insured population across the U.S., with some evidence for specific outcomes on children, low-income and low-education groups, and employees of small employers. MHBL does not apply to the uninsured population.

Evidence Gaps

There is limited research investigating the effects of mental health benefits legislation on mental health outcomes. Specifically, more studies are needed to assess effects on morbidity (reduction of symptoms, relapse prevention, remission, and recovery), mortality, and quality of life
Further research is needed to clarify the role of mental health benefits legislation in reducing health-related disparities and improving mental health outcomes among important population subgroups (e.g., low socioeconomic status [SES] groups, racial and ethnic minorities, and individuals diagnosed with different types of mental illness).
There is limited evidence for those covered by public health insurance (e.g., Medicaid and Medicare). Further research is needed in these populations to confirm the effectiveness of mental health benefits legislation in improving mental health.
Evaluations of the effects of the 2008 federal legislation, the Mental Health Parity and Addiction Parity Act, are needed as this law contains more requirements for parity than the earlier 1996 Mental Health Parity Act.
Evaluations of long-term (more than three years) effects of mental health benefits legislation are needed.
Researchers reported a utilization outcome that often combined measures of inpatient and outpatient utilization. The desired direction for these types of utilization differs with various patient conditions; reporting them separately will better indicate that patients are receiving appropriate care. Another challenge in mental health is the determination of whether care provided is evidence-based or guideline-concordant. In addition, most studies reporting any utilization lacked measures of appropriateness of use, such as descriptions of provider type and patient need for mental health care.

Implementation Considerations and Resources

Challenges to effective implementation of MHBL include underutilization, access to services, and exemptions.

Underutilization:
- It is unclear to what extent MHBL reduces public stigma, a barrier to utilization of services.
- Low awareness of legislative provisions also may hinder service use by beneficiaries.
Access to Services:
- Limited numbers of mental health providers and inpatient beds restrict access to services, especially in rural areas.
- In some cases, covered services and treatments are not clearly defined in the legislation, allowing individual health plans to limit benefits provided for certain conditions or illnesses.
- Investigational treatments typically are not covered by insurance plans.
Exemptions:
- Larger employers often self-insure, and are therefore exempt from mental health insurance related state mandate laws because of the 1974 Employee Retirement Income Security Act (ERISA).
- Both employers with fewer than 50 employees and group health plans that demonstrate a mental health benefit related cost increase of 1% (MHPA) and 2% (MHPAEA) are exempt from the respective federal legislation.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.