Parity: Necessary, but Insufficientfor Mental Health Care

Mike Hogan, Ph.D.

Commissioner, NYS Office of Mental Health

50% of the population: no lifetime mental illness

50%--some MI in lifetime

20-25%--some MI within any year

10-15%--mild impairment

5-7%-- moderate impairment

5-9% (Kids) 3-5% (Adults) Severe Impairment

Who gets care:

--25% of all those with MI --50% of those with moderate/severe MI

Where care is given:

General Health System

Mental Health Specialists

Publicly Financed System

G

M

S

A Framework: Where Does Parity Have an Impact? Patterns of Mental Illness

and Mental Health Care

How Does Parity Relate? Coverage of People Receiving Care in NYS Public MH System

293484 Medicare59608 Duals26945 Medicare

103963 some private64189 uninsured67262 other/unk

Medicaid

DualsMedicare

Some private

Uninsured

Unknown

(294k)

(60k)

(27k)

(104k)

(64k)

(68k)

(2005; n=615,417)

Deep Benefit

Parity Needed

Coverage and Deep Benefit Needed

Why Parity is Necessary but Insufficient…

1. Equitable benefits are good if you have coverage, but don’t help the uninsured– People with mental illness are disproportionately

uninsured:• Most coverage is

employer based; unemployment is typical for people with SMI

• Onset of illness is frequently linked with transition off parents’ coverage

Why is Parity Insufficient?

• Not all plans are covered by parity requirements• State mandates in 38+/- states have widely

variable designs and apply only to state regulated plans

• ERISA pre-empts state regulation of self-insured plans and federal coverage requirements are weak

• Catastrophic and individual plans generally do not cover mental health treatment

• Medicare’s coverage is incomplete

Why is Parity Insufficient?

• Coverage under “parity” may still be limited– E.g. coverage of certain disorders, not others (as

in NYS’s “Timothy’s Law,” providing deep coverage for named disorders (e.g., schizophrenia, bipolar, ADHD) but not others (e.g. PTSD, eating disorders)

Why is Parity Insufficient?

• Your benefits exist, but you might not be able to access them– Under parity benefits, purchasers/insurers almost

universally turn to managed care (enrollment up from 70M in 1993 to 164M in 2002)

– Costs for mental health care in plans with generous benefits drop 30%-48% on conversion to managed care—mostly inpatient reductions

Why is Parity Insufficient?

• Many care needs of those with SMI (adults) or SED (children) extend beyond what health care provides, e.g.:– Adults: housing, employment support, crisis

respite, ACT?– Children/parents: parent coaching, residential

treatment, respite, wrap-around services

How Could Health Reform Address These Limits?

• Toward universal coverage• Coverage that bridges employer based policies,

Medicare and Medicaid

• Deep benefit: “Comprehensive collision coverage” vs. coverage only of the deductible

• Integration of benefits/resources with “the public system”:

• Medicaid• State hospitals, state subsidized services

• Fixed responsibility for care: “Who’s the $%#@?”

Thank You