Despite the scientific and technological advances, numerous people still suffer needlessly from mental health and substance abuse disorders. Less than one-third of adults and children who suffer from these disorders receive any kind of treatment. There are numerous barriers to access and utilization of behavioral health services and challenges associated with the financing and coordination of mental health services, particularly for underserved populations.
Mental health is fundamental to general health and wellbeing. Mental health is the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. Yet in an era of technological and scientific advances, most Americans who suffer from mental health and/or substance abuse disorders go untreated. Approximately 20% of the population is affected by mental health or substance abuse disorders during any given year. Less than one-third of those affected will receive any type of treatment. Barriers to treatment include the lack of health insurance coverage, high cost of pharmaceuticals, and stigma surrounding mental illness.
While mental health and substance abuse disorders affect the entire population, there are subgroups of the population that disproportionately lack access to quality care and treatment. Among these subgroups are vulnerable populations, including the working poor, low income populations, racial and ethnic minorities, rural communities, and previously incarcerated individuals seeking community re-entry. In addition to the barriers to care that the general population faces, these vulnerable populations also face barriers due to lack of culturally and linguistically appropriate providers or geographically accessible providers, as well as transportation and childcare problems. These individuals may have a greater need for health and social support. In order to ensure healthy and productive lives for all Americans, efforts must be directed to support good mental health and to provide quality mental health services for those who need it.
The challenge is to create a mental health system that recognizes the importance of mental health to general health and one that supports the growing needs of vulnerable Americans. Mechanisms to address financial barriers to access include parity legislation and oversight of managed care and managed behavioral health care organizations. Congress passed and President Bill Clinton signed the Mental Health Parity Act of 1996, which imposed new federal standards on mental health coverage offered under employer-sponsored group health plans. Mental health parity acts fall within the scope of a broader set of laws that address mental health coverage. Specifically, the law prohibits employers from imposing annual or lifetime dollar limits on mental coverage that are more restrictive than those imposed on medical and surgical coverage. However, the law does not affect employers who do not offer mental health coverage and employers are also exempt if the law would result in excessive costs to them. To date, 46 states have enacted some type law that includes mental health "parity" or equal coverage laws, minimum mandated mental health benefit laws, and mandated mental health "offering laws" according to the National Council of State Legislatures (see http://www.ncsl.org/programs/health/mentalben.htm). There is considerable variation in mental health parity acts and mental health coverage laws. Some state laws affecting group plans are more comprehensive than the federal law in that they require parity not only in dollar limits but also in service limits or cost-sharing provisions. In addition, many of these also mandate that mental health benefits be included in all plans sold. Oversight of state-level public mental health systems by state mental health departments should work hand in hand with oversight of private insurers through insurance commissioners with the common goals of access and appropriate treatment. Public and private systems must be held accountable to address the need for continuity of care and coordination of services.
It has been suggested by some that because of its narrow scope and reductions in mental health benefits that employers have made to offset the required enhancements, compliance with the Mental Health Parity Act may have little effect on employees’ access to mental health services. A GAO report (2000) showed that:
- 87 percent of those that comply contain at least one other plan design feature that is more restrictive for mental health benefits than for medical and surgical benefits;
- About 65 percent of plans restrict the number of covered outpatient office visits and hospital days for mental health treatment beyond those for other health treatment; and
- Many employers may have adopted newly restrictive mental health benefit design features since 1996 specifically to offset the more generous dollar limits they adopted as a result of the federal law.
It is necessary to expand the federal mental health parity act by requiring that all limitations on the coverage for mental illnesses be equal to those for medical and surgical benefits. This provision would prohibit an insurance plan’s ability to impose arbitrary caps on spending limits, inpatient days and outpatient visits, and co-payments and other deductibles. Additionally, advocacy for state legislation that achieves full and comprehensive parity that includes protections for treatment for alcohol and substance abuse is critical. These provisions would require public and private health insurance plans to provide treatment for mental illness and substance abuse commensurate with that provided for other major physical illnesses and would require health plans to offer access to all effective and medically necessary medications. The National Advisory Mental Health Council (NAMHC) suggests that mental health parity has significant benefits on access to care (seehttp://www.nimh.nih.gov/publicat/nimhparity.pdf').
The Northern Manhattan Community Voices Collaborative (hereafter Community Voices) has been committed to increasing access to mental health care for the residents of Harlem and Washington Heights/Inwood. In 2000, Community Voices convened a workgroup of mental health providers, hospital administrators, community leaders, policy makers and consumers to identify solutions to a fragmented system of care. In 2001, after a series of round table discussions, the workgroup released a report, Mental Health: The Neglected Epidemic. The comprehensive assessment of key problems was concluded with a set of program and policy recommendations, including, initiatives to build the capacity of existing mental healthcare resources; activities to improve service coordination; demonstration programs to increase culturally relevant services; and community commitment to raise public awareness and education. The formation of the workgroup, resulting activities, and report, served as a catalyst for institutional policy changes. Among them, the integration of the collaborative model of mental health care in the ambulatory care centers of the hospital. As of today, the Ambulatory Clinics of the New York Presbyterian Hospital in northern Manhattan and one community health center of the Center for Community Health Partnerships, Columbia University Medical Center in Harlem have adopted this model and have made access to mental health services a possibility for hundreds of community residents.
More significantly, the workgroup provided an opportunity for health leaders and community members to collaborate and develop a unified “voice” to inform policies that undermined access to care for community residents. One of the key recommendations in the Community Voices Mental Report was for parity in the reimbursement of mental health services with other health services. The Report served as a tool for workgroup members, Community Voices staff, and other community leaders to participate in discussions concerning mental health parity with statewide policy makers. The Report prompted other community collaboratives to focus on the issue and it supported the efforts of statewide advocacy groups committed to mental health parity. As a result members of the workgroup, as well as Community Voices staff members, became intricately engaged in statewide and citywide discussions about the issue.
In January 2007, New York State Governor signed into law a bill requiring that commercial insurance policies cover mental health services similarly to the way they cover costs for other health treatment. New York now joins the other 22 states that have parity laws.
The new law should pave the way to improve care for those covered with commercial insurance. There is still more work to be accomplished for those covered by Medicare. However, this new law will provide a model for all payors to follow.
The Community Voices workgroup and the ensuing mental health report served as a critical vehicle to mobilize community resources towards improving mental health access. The leadership that emerged and the collective “voice” prompted change within organizations and institutions; and more importantly, it allowed community leaders and consumers to become active participants in the efforts to inform policy changes that would eliminate barriers to mental health care.
Many of the individuals who worked on developing the Report went on to make significant contributions in improving access to mental health care in northern Manhattan.