A BRIEF HISTORY OF MENTAL HEALTH PARITY POLICY

The following is an excerpt from: The History of U.S. Federal Mental Health Policy, also posted on this blog.

The 1980's saw employers’ mental health insurance costs rise an average of 60 percent per year (England and Vaccaro, 1991; Washington Business Group on Health, 1996). The resulting typical benefit design--matching the minimums set fourth in the federal HMO Act and its amendments--was patently discriminatory. 

Compared to benefits for physical health therapies, benefits for behavioral health therapies typically had higher deductible, copayment and coinsurance requirements; lower limits on the number of outpatient visits and hospital days covered in a given year; and more austere care management guidelines. This remained the case even though it has never been clear whether managed behavioral health care produces more savings than is created by the initial expense reduction from imposing managed care on a system or population anew. (See Goldman et al. 1998, for example.)

The Mental Health Parity Act of 1996 (P.L. 104-204), which was signed by President Bill Clinton, began to correct these inequities by prohibiting disparate annual or lifetime limits on coverage for mental health and general health care. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which was signed by President George W. Bush and included in the Emergency Economic Stabilization Act of 2008 (PL 110-343), took this even farther. Primarily, it prohibits the discriminatory practices noted above. Moreover, in contrast to most state parity regimes, the Act extends parity requirements to all conditions in the latest issue of the Diagnostic and Statistical Manual of Mental Disorders (currently in its 5th edition), including addiction. Additionally, out of network parity is made compulsory.

Importantly, the Mental Health Parity and Addiction Equity Act (or MHPAEA) does not mandate mental health coverage. Instead it sets benefit parameters which are only in force IF mental health coverage is offered. Also worthy of note are two categories of exemptions. The first is of businesses with fewer than 50 employees. The second exemption applies to business that can show an actuarially certified 2 percent increase in healthcare costs in the first year, or a 1 percent annual increase thereafter (P.L. 110-343).

Post-Modern Political Honesty: Part II--How Did We End Up Here???

In Part I of this series, I suggested that honesty in political speech has crossed a threshold. Its moral value has been replaced with its argumentation value, resulting from continuously stretching the frequency and application of the same narratives to spin dishonesty. We have entered the era of post-modern political honesty.

How did we get here? From a macro perspective, globalization and technological advances have forced governments to become more transparent. The 1990s were years of foundational import in this regard. Mass use of the internet began-and exploded-during that decade, at the same time as Bill Clinton was leading the charge for globalization, most notably with the North American Free Trade Agreement.   (Much has been written on this topic by others.)


More transparency means, of course, that more can be questioned. And so it was. Initially, the United States' federal government responded to the increase in queries by digging in its heels (like most organizations would), also resisting change to the tropes that it typically employed to justify guarding information so closely. Politicians followed suit.

How easy the internet must have made it, for instance, for the media to collect - and confront Clinton with - ever more salacious details about his philandering. Yet he held fast to his denial. Of course, there was a bevy well-founded suspicion about the veracity of Clinton's claim of innocence. Added to the wave of on-camera 'gotcha' moments hitting many, the concern of most press secretaries - and even some politicians - was peaked. Their brainchild? Do more of the same; just increase the frequency and broaden the application. This shows considerable cognitive laziness, purposeful political cowardice, and a complete absence of creativity. For a while, if you were listening closely, thud after thud could be heard, as this 'approach' failed yet another spokesperson or politician.

The most well-known of these thuds came from Bill Clinton himself. The intensity of the media's investigation of his dalliances never abated, ultimately resulting in his infamous, syncopated, thumb-pointing, prime time denial of having 'sexual relations with that woman, Ms. Lewinski'.

The public's response went something like this. How absurd; he's probably lying. The political response was, of course, his impeachment. Otherwise said, the technology facilitated 'gotcha game', as Clinton called it, caused him to have to make this absurd-yet plausible-denial.


Plausible Deniability: popularized by Bill Clinton but used as a springboard by Hillary Clinton and Donald Trump.