| September 26, 2015

Lesson 5: Health Care Reform: The Mental Health and
Addiction Equity Act of 2008 and the Patient Protection
and Affordable Care Act of 2010



Sarata, A. K. (2011). Mental Health Parity and Patient Protection and Affordable
Care Act of 2010. Congressional Research Service. Retrieved from:
http://www. 1 docu me nts 1 health 1 M H parity&mandates. pdf

Garfield, R.L., Zuvekas, S.H., Lave, JR. & Donohue, JM. (2011). The impact of
national health care reform on adults with severe mental disorders.
American Journal of Psychiatry 168(5): pp. 486-494.

Bazelon Center for Mental Health Law (2014). Making the connection: Meeting
Requirements to Enroll People with Mental Illnesses in Healthcare

Coverage. Retrieved from /portals /0 /Where20We20Stand /Access20to

Making the connection: Meeting Requirements to Enroll People with Mental
Illnesses in Healthcare Coverage. Retrieved from 1 portals 10 IWhere20We20Stand IAccess20to
20Services 1 Health20Care20Reform I Maki ngtheCon nection. pdf

Health Care Cost Institute (HCCI) (February 2013). The Impact of the Mental
Health Parity and Addiction Equity Act on Inpatient Admissions. Issue
Brief #5, 1-10.
Iss ue- Brief. pdt.

National Alliance on Mental Illness (2015). Long road ahead: Achieving true
parity in mental health and substance use care. 1 Public-Policy
Reports IALong-RoadAhead 1201 5-ALongRoadAhead.pdf




The Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008. 1 10-6983

Patient Protection and Affordable Care Act of 2010. (for reference only)!HR3 590. pdf

King v Burkwell, 576          (2015). (slip opinion).!opinions!14pdf!14-114 goll.pdf.
(U.S.Supreme Court decision on health care subsidies).


This week’s lesson focuses on the most recent legislation affecting mental
health care and substance abuse treatment: the Wellstone-Domenici Mental
Health Parity and Addiction Equity Act of 2008 and the Patient Responsibility
and Affordable Care Act of 2010. We will review the historical evolution of
mental health parity, specific provisions of the 2008 and 2010 acts and the
impact of these acts on mental health care in the U.S.


John F. Kennedy’s Call to Action of 1963 pushed for mental and physical health
care parity but efforts to enact parity legislation did not gain true momentum
until the early 1990’s, when U. S. Senators Paul Domenici and Paul Wellstone
championed the cause. The two were driven by personal experience.

Domenici’s daughter was diagnosed with atypical schizophrenia, and
Wellstone’s brother was diagnosed with schizophrenia as well. Despite earlier
failed attempts at parity legislation, the two were successful in introducing a
parity bill as an amendment to Veterans Affairs, Housing and Urban
Development (VA-HUD) appropriations legislation and in 1996, President Bill
Clinton signed the Wellstone-Domenici Mental Health Parity Act (MHPA). The act
prohibited large group health plans from placing annual and lifetime limitations
on mental health care benefits. However, for the most part, the act benefitted
only those persons with severe and persistent mental illness–those persons
who would be most likely to have significant yearly and lifetime costs associated
with their illnesses. The law was further limited in scope because it lacked a



mandate for mental health benefits in health insurance plans, was applicable to
those plans that already provided mental health care benefits, did not provide
coverage for substance abuse treatment, had no rules for co-payments and
deductibles, and was applicable only to businesses with more than 50
employees. Furthermore, businesses who did not offer mental health care
benefits were exempt from the provisions of the Act, and the Act expired in
2001. Nevertheless, the Act was important shift toward parity (Barry, Huskamp,
& Goldman, 2010).

As momentum toward parity at the federal level grew, states were also moving
toward parity. As of November 30, 2000, 32 states had enacted mental health
and/or substance abuse treatment parity laws of some type. Twenty-seven of
these states enacted laws after the passage of the federal law, suggesting that
the MHPA actually set in motion parity legislation of those individual states.
Some states even enacted parity laws that were greater in scope than the MHPA.

At the federal level, there were repeated attempts to expand the mental health
parity benefits to a greater percentage of the population in the late 1990’s and
early 2000’s. However, until 2008, no further federal parity legislation was
passed except for repeated extensions of the MHPA of 1996. Nonetheless,
support for parity continued to grow. In 2002, President George W. Bush
established the President’s New Freedom Commission, whose charge it was to
conduct a comprehensive review of existing mental health services and make
recommendations for improvement. The New Freedom Commission report
outlined six main goals intending to assist persons with mental illness on their
road to recovery. Included was a goal to advance the “understanding that
mental health is essential to overall health.” The goal stressed the need to
address mental and physical health care “with the same urgency” and more
specifically, “the Commission strongly supports the President’s call for Federal
legislation to provide full parity between insurance coverage for mental health
care and for physical health care” (p.21).

Concurrently, support for parity grew as academic research on the cost of
mental health and substance abuse parity emerged, demonstrating that parity
would not “break the bank.” With considerable effort on the parts of Senators
Domenici, Enzi, and Kennedy (Edward) and Congressmen Ramstad and Kennedy
(Patrick), the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 (MHPAEQ) was approved as part of the Emergency



Economic Stabilization Act of 2008. The Act closed many of the loopholes left
by the expanded scope of the MHPA of 1996 and included substance use
disorders. The provisions were still applicable only to businesses with 50 or
more employees, and applied only to health plans that include both
medical/surgical benefits and mental health benefits. However, it now
prevented insurance companies from limiting mental health care by mandating
that mental health care parity be expanded to include deductibles, co-
payments, number of visits and days of coverage and out-of-network benefits.
This landmark bill dramatically affected mental health care benefits for millions
of people because, unlike the MHPA of 1996, the act applies to those in need of
mental health treatment who do not reach the annual and lifetime limitations.
Universal mental health care benefits (either physical or mental) were not
addressed in the MHPAEQ.

Health Care Reform and the Patient Protection and Affordable Care Act of 2010

Efforts to pass universal health care reform bills began as early as 1912 when
Teddy Roosevelt campaigned for national health insurance (he lost to Woodrow
Wilson). Presidents Truman, Kennedy, Carter and Clinton all supported
universal health care (see HI2iV6kbWBs&feature= player embedded

for a Kennedy speech on health care reform) but were defeated by opponents
including the American Medical Association, insurance companies, and health
care providers. Senator Ted Kennedy campaigned for universal health care
during his entire career, and was a key player in the passage of the Health
Insurance Portability and Accountability Act (HIPAA) in 1996, the State Children’s
Health Insurance Program (SCHIP) in 1997, the Medicare prescription drug law in
2003, and the Massachusetts health reform act in 2006. Secretary of State
Hillary Clinton and President Barack Obama both campaigned for universal
health care during the 2008 election campaign and Obama signed the Patient
Protection and Affordable Care Act (PPACA) (commonly referred to as
ObamaCare) in March 2010. In June 2012, the Supreme Court upheld the
constitutionality of the individual health care mandate, a central provision of the
PPACA. Twenty-eight states to date have challenged the constitutionality of the
PPACA. In June 2015, the Supreme Court upheld a central component of the act
that provides health care subsidies to individuals using the federal marketplace
to purchased insurance (if you are interested in reading the actual Supreme



Court decision, go to

Generally, the PPACA mandates health insurance for all adults, penalizes
companies who do not provide coverage, expands the pool of Medicaid-eligible
individuals, and provides subsidies to obtain insurance through “health benefits
exchanges” or the marketplace. Behavioral health care benefits “do not
substantially change behavioral health services offered under existing coverage
(Medicaid, Medicare and existing private plans that meet specified criteria”
(Garfield, Lave & Donohue, 2010, p. 1083). For any individual who gains
coverage under the PPACA, any plan in which they participate must provide
mental health and substance abuse benefits including the provision of
preventative care. “Qualified health plans” must comply with the MHPAEQ of
2008. Medicaid eligibility is expanded to include all individuals who are at
133 of poverty. However, those newly eligible individuals do not necessarily
receive the same Medicaid benefits of those individuals who are currently
eligible. Rather they will receive “benchmark” or “benchmark equivalent”
coverage that is equal to the Federal Employees Blue Cross/Blue Shield preferred
provider organization plan and the federal parity laws that apply to that
coverage. Certain individuals (disabled individual who do not qualify for 551,
children with serious emotional disturbance, and adults with mental disabilities
that significantly impair their ability to perform one or more activities of daily
living) can receive Medicaid benefits which are currently more expansive than
private health care plans. Medicaid currently covers short- and long-term care
for a mental or substance use disorder, case management, crisis intervention
and many supportive services (including housing assistance).

The MHPAEQ and the PPACA promise to significantly increase benefits and
reduce costs for thousands of persons with mental illness and substance abuse
disorders. However, the implementation of these acts is not straightforward and
several questions remain. Will penalties for non-compliance be enforced? What
loopholes, if any, exist to allow insurance companies to deny claims for mental
health and/or substance abuse costs? Are more people receiving mental health
care benefits than they were before the MHPAEQ and PPACA were enacted? With
changes in group insurance plan coverage and costs, is the price of mental
health care increasing or decreasing for those who were previously in plans that
offered mental health care benefits? What has been the impact of the PPACA on
states that did not expand Medicaid benefits?



Assignment and Group Discussion

Your response to the question below and your participation in the group
discussion will be worth 8 points.

Think about the implementation of the PPACA as it relates to mental health care.
Discuss its benefits for people who need mental health treatment, and
challenges to implementation. While you can discuss funding issues, please be
sure your discussion goes beyond that issue. Be sure to stay on the topic of
mental health care and provide research and/or data to back up your answer.
You can talk about the implications of the PPACA nationally or the specific
challenges within a particular state.

Again, please try to have your initial answers to the question on the Discussion
Board by Friday at 11 p.m. so that you can respond to others in the class by
Sunday evening.




Antos, J & Miller, T.P. (2010). A Better Prescription: AlE Scholars on Health Care
Reform. American Enterprise Institute, Washington, D.C. les/2 0 1 0/0212 3 /ABetterPrescription. pdf

Barry, C.L., Huskamp, H.A. & Goldman, H.H. (2010). A Political History of
Federal Mental Health and Addiction Insurance Parity. Milbank Quarterly
88(3): pp. 404-433.

Beronio, K., Po, R., Skopec, L., & Glied, S. (2013). Affordable Care Act Expands
Mental Health and Substance Use Disorder Benefits and Federal Parity
Protections for 62 Million Americans. ASPE Issue Brief, U.S. Department
of Health and Human Services, Office of the Assistant Secretary for
Evaluation and Planning. I health I reports 120 131 mentall rb mental.cfm

Garfield, R.L., Zuvekas, S.H., Lave, JR. & Donohue, JM. (2011). The impact of
national health care reform on adults with severe mental disorders.
American Journal of Psychiatry 168(5): pp. 486-494.

Garland, R.I., Lave, JR. & Donohue, JM. (2010). Health reform and the scope of
benefits for mental health and substance use disorder services.
Psychiatric Services 61(1 1): 1081 – 1086. /11 /1 081.

Hennessy, K.D. & Goldman, H.H. (2001). Full parity: Steps toward treatment
equity for mental and addictive disorders. Health Affairs 20(4): 58-67.

Koyanag, C. (2009). How will health reform help people with mental illnesses?

Bazelton Center for Mental Health Law. Washington, D.C. I LinkClick.aspx?fileticket=HJ7Q6AM8AHM3 D&ta

Patient Protection and Affordable Care Act of 201 O.

http:// Isourcefiles I HR3 590.pdf

The Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008.!congress ! bi Iitext.xpd?bill=h 110

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