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By Robin Jay, BHC Editorial Director

This past week saw no deceleration in the fast-paced debates between the House and Senate regarding healthcare reform. Last Thursday, October 19, House Speaker Nancy Pelosi led a rally on the West Front of the Capitol to unveil H.R. 3962, the 1,990-pageAffordable Health Care for America Act. On Halloween, the GOP’s Rep. John Boehner, R-Ohio countered with a statement on his weekly radio and Internet address, saying Pelosi’s plan was “recklessly pursuing a government takeover.”

With all of this in mind, Behavioral Health Central sought the input of Mental Health America’s Vice President of Advocacy and Public Policy, Kirsten Beronio, to gather input on something not debated on the Capitol Hill Steps last Thursday:  What do the healthcare reform bills on the Congressional table have to say about behavioral healthcare?

“I think that there’s a misconception perhaps in the field, not among our members, but I hear periodically, ‘Oh, mental health is not being talked about in healthcare reform and we’re not being addressed.’ And I really think that’s a misconception. I think there are a number of good really positive previsions that have been included. The Parity and the coverage piece are just examples. There are a number of other places where mental health is specifically addressed and with regard to better care coordination, demonstration programs that incorporate mental health explicitly and workforce development programs that would really try to increase the workforce shortage problems that we face,” said Beronio. “so I think that it’s important that people recognize that there are important implications for mental health in this healthcare reform legislation and we need to push for enactment.

“We at MHA have been actually pleased with a number of the provisions that have been included in the major bills. We are pleased to see that in terms of the new initiative to cover the uninsured, mental health, substance abuse treatment was included in a list of key services that have to be covered for everyone getting coverage through this new federal initiative,” continued Beronio. “As just a kind of basic floor, they provide a set of parameters that the legislation would set up that would then be further flushed out in terms of what that really means, and what would really be covered in terms of mental health services by a kind of a commission or kind of a board that would be set up to make those determinations after the legislation was enacted. It’s modeled after a similar approach in Massachusetts [as discussed by BHC last week in an interview with Massachusetts State Congressman Peter Koutoujian] and we’ve pushed really hard to make sure that mental health and substance use conditions were addressed in that context.

“We’re pleased to see that they were addressed. Then, beyond that, to help ensure that that coverage is adequate, we pushed hard for Parity provisions to be included, so that although they aren’t really flushing out what particular services may be covered, that the principle that you can’t discriminate and have a lower level of coverage for mental health and substance abuse than for other conditions. The language is different in all three, so we’re right now trying to sort it out.

“I think the House provision is the most explicit in saying the principle of Parity should apply to coverage in the individual, small group and large group markets. Although the large group is already addressed in the existing Parity law, but just helpful to have that be very explicit. And then with the other bills, it’s a little bit less clear that it would apply universally, but I think the intent is to have at least in the finance package to have a Parity provision apply in any of the small group of individuals coming into this new program to cover the uninsured. Hopefully what they work in the Senate – they’re right now trying to combine both – the Senate bills will be very clear in that regard.”

If you haven’t had a chance to review news coverage of the House bill released last Thursday or the Senate response, here is an overview:

According to the House Rules Committee, the bill introduced by Nancy Pelosi would:

• result in a net deficit reduction of $104 billion over the 2010-2019 period
• impose a 5.4 percent tax on income over $500,000 for a single person or $1 million, for couples filing joint tax returns.
• impose a 2.5 percent tax on wholesale sales of medical devices, but exempts retail sales.
• expand the Medicaid program to those with incomes up to 150 percent of the federal poverty line
• subsidize coverage for families with incomes up to 400 percent of the federal poverty level
• set up a public insurance option, funded by $2 billion in federal start-up money and then paid for with enrollee premium payments.
• require some employers who do not offer insurance coverage to their workers to pay a penalty equal to 8 percent of their payroll costs. It exempts firms with annual payrolls below $500,000.
• require individuals to either obtain insurance coverage or pay a fee equal to 2.5 percent of their adjusted income above the income tax filing threshold
• set up a $10 billion reinsurance program for insurance plans which cover early retirees

On Halloween, in the GOP's weekly radio and Internet address, Rep. John Boehner, R-Ohio offered a response to the bill introduced by Pelosi. Boehner said that the Democrats "recklessly pursue a government takeover” of the healthcare system and offered his party's alternative.

“What Americans want are common-sense, responsible solutions that address the rising cost of healthcare and other major problems. Boehner’s address emphasized four tactics that he says will lower healthcare costs and expand access to quality care without a government-run health care system “that kills jobs, raises taxes on small businesses, or cuts Medicare for seniors,” said Boehner. These are the four tactics Boehner suggested:

• Let families and businesses buy health insurance across state lines.
• Allow individuals, small businesses, and trade associations to pool together and acquire health insurance at lower prices, the same way large corporations and labor unions do.
• Give states the tools to create their own innovative reforms that lower health care costs.
• End junk lawsuits that contribute to higher health care costs by increasing the number of tests and procedures that physicians sometimes order not because they think it's good medicine, but because they are afraid of being sued.

The Republican health care substitute to be offered during floor debate on Speaker Pelosi's plan will incorporate all or part of the following bills: Empowering Patients First Act, Improving Health Care for All Americans Act, Medical Rights and Reform Act, Help Efficient, Accessible, Low-Cost, Timely Healthcare Act, Small Business Fairness Act of 2009 and Health Insurance Access for Young Workers and College Students Act of 2009.

In our interview with MHA’s Beronio, we took a moment to talk specifically about the Mental Health Parity legislation that goes into effect in January – and how she feels the delay of regulations to the same month might impact the field and consumers.

“Unfortunately, I think it means less full implementation of the Parity law for this coming year,” said Beronio. “Of course, the plans are going to do what we expect – interpret it as narrowly as makes sense. MHA of course has been advocating for a full, very comprehensive approach to ensure that we don’t get into another situation like we did fallowing the ’96 Parity law, where it was interpreted very narrowly and only applying to annual and lifetime limits that couldn’t be different for mental health and for other conditions. And then what you saw was plans developing other ways to discriminate, so we hope that this time around, there’s not a lot of that gamesmanship that is allowed to go on and that we just do what we intended to accomplish. What we all have intended to accomplish, I believe, was that these conditions should not get a lower level of coverage of more restrictive treatment than other health conditions.

“So that means looking at things, interpreting the term treatment limitations to mean things beyond the list of examples included in the statute where they sighted numbers of out patient visits and numbers of in patient days covered, as examples of treatment limitations that could not be lower for mental health than for other conditions, or for mental health and substance abuse then for other conditions.

“But that goes beyond that if you’re talking about how you limit treatment. You need to look at things like utilization management on medications and how medical necessity determinations are being made and whether that’s being done in a fair way or whether there’s being more restrictive treatment being applied to these conditions; to look at networks of providers and whether you’re forcing by having a less robust network, you’re forcing people to go out of network, and therefore have higher out-of-pocket costs, which would then go to the requirement that financial requirements not be unequal.

“I think that if you really want to implement this in the correct way, you need to think about all of these different things, and I think the agencies are thinking along those lines as indicated in their request for information that came out in the spring that asked for comments and indicated that they were considering beyond just the actual examples included in the statute. I think that robust interpretation is going to be lost for this next year, so that’s unfortunate.”

To review our full interview with MHA’s Kirsten Beronio, click on the media player above or read the full transcript that follows:

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BHC: Thank you for joining us today, Kirsten. I understand you’re the Vice President of Advocacy and Public Policy at Mental Health America. Let’s talk about the different bills in Congress right now for healthcare reform and what Mental Health America’s position is regarding them.

Kirsten Bernio: Well, we have been actually pleased with a number of the provisions that have been included in the three major bills, if you can call them that, it’s changing daily, but we think about it in terms of three different bills because the House really tried to have kind of a joint effort among the committees of jurisdiction on their side and developed a tri-committee bill, although there were some differences coming out of the committees, and the House committee, the Education and Labor Committee and then your GN Commerce committee, considered was pretty much the same within some changes made by the committees and then on the Senate side, you have the Health Committee bill, which is the Health, Education, Labor and Pensions Committee bill and the finance committee bill, they developed two pieces of legislation that have significant differences, so we sort of think about this legislation at this point having three forms, the health committee, the finance committee and the tri-committee house bill.

And in all three, we are pleased to see that in terms of the new initiative to cover the uninsured mental health substance abuse treatment was included in a list of key services that have to be covered for everyone getting coverage through this new federal initiative as just a kind of basic floor, a set of parameters that the legislation would set up that would then be further flushed out in terms of what that really means, and what would really be covered in terms of mental health services by a kind of a commission or kind of a board that would be set up to make those determinations after the legislation was enacted. It’s modeled after a similar approach in Massachusetts and we’ve pushed really hard to make sure that mental health and substance use conditions were addressed in that context. We’re pleased to see that they were, and then beyond that, to help insure that that coverage is adequate, we pushed hard for Parity previsions to be included, so that although they aren’t really flushing out what particular services may be covered, that the principle that you can’t discriminate and have a lower level of coverage for mental health and substance abuse than for other conditions. We felt it important that that be addressed and included in the new federal initiative to cover the uninsured and have been pleased to see that all three pieces of legislation do address that issue in different ways. The language is different in all three, so we’re right now trying to sort it out.

I think the House prevision is the most explicit in saying the principle of Parity should apply to coverage in the individual, small group and large group markets. Although the large group is already addressed in the existing Parity law, but just helpful to have that be very explicit. And then with the other bills, it’s a little bit less clear that it would apply universally, but I think the intent is to have at least in the finance package to have a parity prevision apply in any of the small group of individuals coming into this new program to cover the uninsured. Hopefully what they work in the Senate – they’re right now trying to combine both – the Senate bills will be very clear in that regard.

BHC: It’s interesting that you mentioned the Massachusetts model. Last week, we had a story up with Massachusetts State Congressman Peter Koutoujian. Is that the model you’re speaking of, the universal one?

KB: Yes.

BHC: Okay.

KB: Their Universal Coverage Program, right.

BHC: You mentioned Parity. Let’s talk about that a little bit. For the large groups, the Parity legislation that will go into effect in January, how do you think that the delay of the regulations to January (they were supposed to come out in October) will impact the industry? They’ve been moved now to January, yet the large group plans have already tried to interpret the best they can since it’s currently open enrollment for their plans. How do you feel the delayed regulation might impact providers, payors and consumers ultimately?

KB: Well, unfortunately, I think it means less full implementation of the Parity law for this coming year. Of course, the plans are going to do what we expect – interpret it as narrowly as makes sense, and we of course have been advocating for a full, very comprehensive approach to ensure that we don’t get into another situation like we did fallowing the ’96 Parity law, where it was interpreted very narrowly and only applying to annual and lifetime limits that couldn’t be different for mental health and for other conditions. And then what you saw was plans developing other ways to discriminate, so we hope that this time around, there’s not a lot of that gamesmanship that is allowed to go on and that we just do what we intended to accomplish. What we all have intended to accomplish, I believe, was that these conditions should not get a lower level of coverage of more restrictive treatment than other health conditions.

So that means looking at things, interpreting the term treatment limitations to mean things beyond the list of examples included in the statute where they sighted numbers of out patient visits and numbers of in patient days covered, as examples of treatment limitations that could not be lower for mental health than for other conditions, or for mental health and substance abuse then for other conditions.

But that goes beyond that if you’re talking about how you limit treatment. You need to look at things like utilization management on medications and how medical necessity determinations are being made and whether that’s being done in a fair way or whether there’s being more restrictive treatment being applied to these conditions; to look at networks of providers and whether you’re forcing by having a less robust network, you’re forcing people to go out of network, and therefore have higher out-of-pocket costs, which would then go to the requirement that financial requirements not be unequal.

I think that if you really want to implement this in the correct way, you need to think about all of these different things, and I think the agencies are thinking along those lines as indicated in their request for information that came out in the spring that asked for comments and indicated that they were considering beyond just the actual examples included in the statute. I think that robust interpretation is going to be lost for this next year, so that’s unfortunate.

BHC: And so is there an understanding or a clarification that once those regs are released in January, if plans have interpreted the regulations too narrowly, do they not have to put in place the adjustments in the coming year?

KB: For the following year I think. I don’t know what the agencies are going to do in terms of enforcing these regulations. I kind of doubt that they will enforce them for this year that will already be underway. That seems unlikely to me. So that’s my concern, that they’re not -- that it’s going to be lost for at least a year.

BHC: Kirsten, going back to the Parity regarding healthcare reform, where hopefully Parity would apply to small group coverage, as well. What sort of consumer education do think we would need to do – because those who had, say, corporate coverage, are very much used to having very strict limitations regarding referrals and high copayments and very limited services. What sort of educating are we going to have to do for consumers so that they can properly utilize the benefits that they may have?

KB: Right. Well, we have underway an initiative here at Mental Health America to develop tool kits to help activate our leaders out in the states and communities to help bring that message, because it will be up to the individual consumers to really push for their rights when it comes down to it, because it may not be highly publicized that, “Oh yeah, you have a lot more access now then you used to.” So that is going to be a big focus of ours in the next year, absolutely.

BHC: When those tool kits are developed, we would love to provide access to them on Behavior Health Central.

KB: Oh great, I’ll make a note of that.

BHC: And Kirsten, is there anything else that you’d like to say on these topics before we close?

KB: Well, I just think that there’s a misconception perhaps in the field, not among our members, but I hear periodically, “Oh, mental health is not being talked about in healthcare reform and we’re not being addressed.” And I really think that’s a misconception. I think there are a number of good really positive previsions that have been included. The Parity and the coverage piece are just examples. There are a number of other places where mental health is specifically addressed and with regard to better care coordination, demonstration programs that incorporate mental health explicitly and workforce development programs that would really try to increase the workforce shortage problems that we face, so I think that it’s important that people recognize that there are important implications for mental health in this healthcare reform legislation and we need to push for enactment.

BHC: Kirsten, one last follow-up question. For the C-levels and the providers who are listening to this, what can they do to help push this along?

KB: The legislation or parity implementation?

BHC: Both. What actions can they take, one, to help make sure that their voice is heard regarding what their wishes are in their particular state, and two, how can they assist in the implementation to ensure that it’s done properly.

KB: I think it will be the implementation stage will be really critical. That’s where we’ll really have to do a lot of important advocacy around what should be covered in terms of mental health, to make sure that the benefit for the uninsured at the very least is comprehensive.

I think there will be a lot of pressure to keep costs down and to keep the benefit fare down to some extent. So I think that will be a critical phase, but in the mean time, we still have some big obstacles to overcome in the House and Senate, a lot of nervousness out among the public about changes. I think the approach that’s being taken is very incremental and that people should not be scared, but I think there are a lot of people that are scared. Just talking to patients, being reassuring, contacting members of Congress to say ‘we want healthcare reform’, there’s a big issue around Medicare payment that was a part of the Senate bill. They flooded out. I’m sure that that will be addressed. That has been addressed every year and I don’t think this is any different. So I would urge providers to not be discouraged by kind of some of the things that are going on in terms of trying to get the legislation through and trying to address the costs concerns around the legislation. I think it’s really important that this is our opportunity to get this done and it’s really, really important that we all step up and say we need to do this and not become fearful or become focused on more parochial concerns that I’m sure will be addressed.

BHC: Kirsten I really appreciate your time and your thoughts on these important issues.

KB: Thank you.

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