1. Mental Health Insurance Parity: A View from the States David L. Shern, Ph.D. President/CEO Mental Health America Academy Health Policy Conference February 5, 2008 Washington, D.C.

2. Overview of the Presentation Importance of Insurance Coverage for Mental Health and Substance Use Conditions Enactment of State Parity Laws Relative to the 1996 Federal Act Characteristics of State Laws Relationships to  Utilization  Outcomes

3. U.S. Has Highest Rates of Mental Illness U.S. has the highest prevalence rates (26%) in the world in a comparison of 14 developing and developed countries. (JAMA, 2004)

4. Mental Illness in Teens Mental Illness in Children and Adolescents Very Common  Anxiety Disorders – 13.0% (Median age of onset 11)  Mood Disorders – 6.2% (Median age of onset 30)  Disruptive Disorder – 10.3% (Median age of onset 11)  Substance Use – 2.0% (Median age of onset 20)  Any Disorder – 20.9% (Median age of onset 14) Substantial Delays in Receiving Treatment  Mood Disorders – 6 to 8 year latency  Anxiety Disorder – 9 – 23 year latency (PHS, 1999; Kessler et al, 2005, Wang et al 2005)

5. 5 The Impact of Behavioral Disorders Illustrated: Suicide is the Leading Cause of Violent Deaths Worldwide (World Health Organization, 2002 ) Homicide War Suicide

6. 6 In the United States A Person takes His/Her Life Approximately Every 16 Minutes

7. 7 The Impact of Behavioral Disorders Illustrated: The Disability Impact of Mental Illness Illness Related Disability--United States, Canada, and Western Europe, 2000 (World Health Organization, 2001)

8. Pincus HA. J Clin Psychiatry. 2001;62 Suppl 6:5-9; Schatzberg AF. J Clin Psychiatry. 2004;65 Suppl 12;3-4. Medical Condition Percent With Depression Prevalence of Depression in Medical Illness

9. Impact of Depression: Comorbitities Condition Annual Medical Costs per Patient Without Depression ($) Annual Medical Costs per Patient With Depression ($) Heart failure2.566.74 Allergic rhinitis3.278.46 Asthma3.7310.56 Migraine3.8215.47 Back pain11.6133.25 Diabetes13.0627.28 Hypertension13.3827.16 Heart Disease62.40110.94 Actual annual medical costs per patient based on claims data for 229,776 patients, 1995-1998. SOURCE: OCI 2001 Impact of Depression on Medical Cost

10. State Parity Laws 38 States/DC Have Enacted Some Form of Parity Law  5 Full or Best Parity  7 Good Parity  26 Limited Parity Laws  13 Mandate Coverage of MH Services  2 No Mandates or Parity

12. Variations in Parity Laws Best Parity Laws (5)  Applies to All Mental Health and Substance Use Condition  No exemptions for Small Employers or Cost Increases  Same Benefits as General Health Conditions Co-pays Limits Good Parity Laws (7)  Often Exclude Substance Use Conditions  Include Some Exemptions

13. Variations in Parity Laws (cont) Limited Parity Laws (26 States)  Apply to Select Groups Often Persons with Serious Mental Health Diagnoses (Schizophrenia, Bi-Polar Illness, etc.) Includes Exemptions Often Excludes Substance Use Conditions No Parity but Mandates MH Services (13) No Parity or Mandates (2)

14. Variable Estimates of Effect on Service Utilization in States Earlier Analyses by Sturm and Colleagues (2000, 2004, 2004)Showed Limited to No Effect on Utilization  Importance of Covering the ERISA Population  Effects of Managed Care More Recent Analyses by Harris et al. (2006)  Increase Utilization of Mental Health Services  Particularly for Individuals with Mild to Moderate Disorders  Perhaps Indicative of Greater Penetration of Parity Laws in more Recent Years

15. Mental Health America Ranking Study – Depression and Suicide Integrated Data from Several National Data Sets to Examine Relationships between System Characteristics, Depression and Suicide Rates  NSDUH, BRFSS, CDC Suicide Rates  MHA Parity Ratings for States

16. MHA State Ranking Study (cont.) Found Significant Difference between States Parity Rating and Mental Health Service Rates.  Best or Good Parity Law = 15.8%  Limited or No Parity Law = 13.4% Significant Negative Correlation between Mental Health Service Rate and Suicide Rate Significant Positive Correlation between Rates of Depression and Service Use Several Other Indicators or System Capacity Related to Decreased Rates of Suicide and Depression

17. Conclusions MHSU Conditions Prevalent, Disabling and Expensive State Parity Laws appear to have Increased Rates of Mental Health Service Use Utilization of Services may be Linked to Positive Health and Behavioral Health Status in the Population.