[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE PAUL WELLSTONE MENTAL HEALTH AND ADDICTION EQUITY ACT OF 2007
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
ON
H.R. 1424
__________
JUNE 15, 2007
__________
Serial No. 110-57
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
U.S. GOVERNMENT PRINTING OFFICE
42-868 PDF WASHINGTON DC: 2008
---------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092104 Mail: Stop IDCC, Washington, DC 20402�090001
COMMITTEE ON ENERGY AND COMMERCE
JOHN D. DINGELL, Michigan, JOE BARTON, Texas
Chairman Ranking Member
HENRY A. WAXMAN, California RALPH M. HALL, Texas
EDWARD J. MARKEY, Massachusetts J. DENNIS HASTERT, Illinois
RICK BOUCHER, Virginia FRED UPTON, Michigan
EDOLPHUS TOWNS, New York CLIFF STEARNS, Florida
FRANK PALLONE, Jr., New Jersey NATHAN DEAL, Georgia
BART GORDON, Tennessee ED WHITFIELD, Kentucky
BOBBY L. RUSH, Illinois BARBARA CUBIN, Wyoming
ANNA G. ESHOO, California JOHN SHIMKUS, Illinois
BART STUPAK, Michigan HEATHER WILSON, New Mexico
ELIOT L. ENGEL, New York JOHN B. SHADEGG, Arizona
ALBERT R. WYNN, Maryland CHARLES W. ``CHIP'' PICKERING,
GENE GREEN, Texas Mississippi
DIANA DeGETTE, Colorado VITO FOSSELLA, New York
Vice Chairman STEVE BUYER, Indiana
LOIS CAPPS, California GEORGE RADANOVICH, California
MIKE DOYLE, Pennsylvania JOSEPH R. PITTS, Pennsylvania
JANE HARMAN, California MARY BONO, California
TOM ALLEN, Maine GREG WALDEN, Oregon
JAN SCHAKOWSKY, Illinois LEE TERRY, Nebraska
HILDA L. SOLIS, California MIKE FERGUSON, New Jersey
CHARLES A. GONZALEZ, Texas MIKE ROGERS, Michigan
JAY INSLEE, Washington SUE WILKINS MYRICK, North Carolina
TAMMY BALDWIN, Wisconsin JOHN SULLIVAN, Oklahoma
MIKE ROSS, Arkansas TIM MURPHY, Pennsylvania
DARLENE HOOLEY, Oregon MICHAEL C. BURGESS, Texas
ANTHONY D. WEINER, New York MARSHA BLACKBURN, Tennessee
JIM MATHESON, Utah
G.K. BUTTERFIELD, North Carolina
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
_________________________________________________________________
Professional Staff
Dennis B. Fitzgibbons, Chief of
Staff
Gregg A. Rothschild, Chief Counsel
Sharon E. Davis, Chief Clerk
Bud Albright, Minority Staff
Director
(ii)
Subcommittee on Health
FRANK PALLONE, Jr., New Jersey, Chairman
HENRY A. WAXMAN, California NATHAN DEAL, Georgia,
EDOLPHUS TOWNS, New York Ranking Member
BART GORDON, Tennessee RALPH M. HALL, Texas
ANNA G. ESHOO, California BARBARA CUBIN, Wyoming
GENE GREEN, Texas HEATHER WILSON, New Mexico
Vice Chairman JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado STEVE BUYER, Indiana
LOIS CAPPS, California JOSEPH R. PITTS, Pennsylvania
TOM ALLEN, Maine MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin MIKE ROGERS, Michigan
ELIOT L. ENGEL, New York SUE WILKINS MYRICK, North Carolina
JAN SCHAKOWSKY, Illinois JOHN SULLIVAN, Oklahoma
HILDA L. SOLIS, California TIM MURPHY, Pennsylvania
MIKE ROSS, Arkansas MICHAEL C. BURGESS, Texas
DARLENE HOOLEY, Oregon MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York JOE BARTON, Texas (ex officio)
JIM MATHESON, Utah
JOHN D. DINGELL, Michigan (ex
officio)
C O N T E N T S
----------
Page
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 1
Hon. Nathan Deal, a Representative in Congress from the State of
Georgia, opening statement..................................... 2
Hon. Lois Capps, a Representative in Congress from the State of
California, opening statement.................................. 3
Hon. Heather Wilson, a Representative in Congress from the State
of New Mexico, opening statement............................... 5
Hon. Tammy Baldwin, a Representative in Congress from the State
of Wisconsin, opening statement................................ 6
Hon. Mike Ferguson, a Representative in Congress from the State
of New Jersey, opening statement............................... 7
Hon. Jan Schakowsky, a Representative in Congress from the State
of Illinois, opening statement................................. 8
Hon. Sue Wilkins Myrick, a Representative in Congress from the
State of North Carolina, opening statement..................... 9
Hon. Hilda L. Solis, a Representative in Congress from the State
of California, opening statement............................... 10
Hon. John Sullivan, a Representative in Congress from the State
of Oklahoma, opening statement................................. 10
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 11
Hon. Jim Matheson, a Representative in Congress from the State of
Utah, opening statement........................................ 12
Hon. Marsha Blackburn, a Representative in Congress from the
State of Tennessee, opening statement.......................... 13
Hon. Tom Allen, a Representative in Congress from the State of
Maine, opening statement....................................... 14
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 14
Hon. John D. Dingell, a Representative in Congress from the State
of Michigan, prepared statement................................ 15
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, prepared statement.............................. 16
Witnesses
Hon. Patrick J. Kennedy, a Representative in Congress from the
State of Rhode Island.......................................... 17
Prepared statement........................................... 19
Hon. Jim Ramstad, a Representative in Congress from the State of
Minnesota...................................................... 21
Prepared statement........................................... 23
James E. Purcell, president and chief executive officer, Blue
Cross & Blue Shield of Rhode Island............................ 24
Prepared statement........................................... 27
Answers to submitted questions............................... 85
Edwina Rogers, vice president, health policy, the ERISA Industry
Committee...................................................... 32
Prepared statement........................................... 33
Answers to submitted questions............................... 94
Marley Prunty-Lara, board member, Mental Health America.......... 36
Prepared statement........................................... 38
James A. Klein, president, American Benefits Council............. 40
Prepared statement........................................... 42
Answers to submitted questions............................... 77
Howard H. Goldman, M.D., professor of psychiatry, University of
Maryland School of Medicine.................................... 46
Prepared statement........................................... 48
Answers to submitted questions............................... 67
H.R. 1424, THE PAUL WELLSTONE MENTAL HEALTH AND ADDICTION EQUITY ACT OF
2007
----------
FRIDAY, JUNE 15, 2007
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 12:13 p.m., in
room 2123, Rayburn House Office Building, Hon. Frank Pallone,
Jr., (chairman) presiding.
Present: Representatives Green, Capps, Allen, Schakowsky,
Solis, Matheson, Deal, Wilson, Ferguson, Myrick, Sullivan,
Murphy, Burgess, and Blackburn.
Staff present: Carrie Annand, Yvette Fontenot, Christie
Houlihan, Purvee Kempf, Jodi Seth, Bridgett Taylor, Lauren
Bloomberg, Nandan Kenkeremath, and Chad Grant.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. I call the hearing of the subcommittee to
order.
Good morning. Today, we are holding a hearing on H.R. 1424,
the Paul Wellstone Mental Health and Addiction Equity Act of
2007. My colleagues and the chief sponsors of H.R. 1424,
Congressman Patrick Kennedy of Rhode Island and Jim Ramstad of
Minnesota, are here with us this morning. Thank you for being
here.
To their great credit, they have been the most vocal
proponents in Congress for requiring parity in insurance
coverage of mental health conditions; and together they have
crisscrossed the country to bring national attention to their
cause and develop support for the legislation. To date, they
have garnered 268 cosponsors and have demonstrated that this is
not a partisan issue; and I want to thank them again for all
they have done.
To establish the pressing need for this legislation, we
will be hearing from witnesses about the current problems
individuals confront when they seek insurance coverage for
mental health and addiction treatment services. It will be made
clear that, in spite of widespread recognition that mental
illness and substance abuse are treatable illnesses, there
exists glaring inequities between health insurance coverage for
mental health and that for other medical conditions.
Health insurance plans often impose stricter treatment
limits and higher out-of-pocket expenses on mental health care
than on care for other illnesses. This discrimination prevents
many from getting the treatment they need to function normally.
As a Nation, we can no longer afford to ignore this disparity
in coverage, because the cost to families and to society in
general is simply too high.
On February 26 I hosted a forum in Trenton, NJ, on mental
health parity with Congressman Kennedy, mental health
professionals, advocates and individuals who experienced
discrimination when they sought mental health services for
themselves or their families. Their stories demonstrated to me
the pain and anguish that accompanies mental illness when it
goes untreated. Their personal accounts reveal that denying
treatment for a mental illness can be just as life threatening
as denying surgery to a cancer or heart patient.
The inequities extend across all age groups. For instance,
it is estimated that over two-thirds of children with mental
health conditions do not get the treatments they need.
In my own State of New Jersey, we have what is considered a
limited mental health insurance parity statute. It requires
that all biologically based mental illnesses be covered on a
par with all other illnesses. It does not provide parity for
what have been called nonbiological-based such as post-
traumatic stress disorder, substance abuse, and eating
disorders. Fortunately, thanks to the efforts of advocates and
enlightened legislators, a measure for full parity has cleared
many hurdles and is making its way towards passage in the New
Jersey State Legislature.
But many other States are moving on their own towards more
comprehensive coverage and now 26 mandate mental health
coverage with full parity. I believe that any legislation we
pass on the Federal level should recognize the value of these
stronger State laws and serve as a Federal floor of covered
benefits, beneath which no State law should sink.
The Kennedy-Ramstad bill recognizes this by not preempting
existing State laws with greater protections. This sets that
legislation apart from the Senate bill sponsored by Senators
Kennedy and Enzi, legislation that is certainly a major step
forward but not quite as comprehensive. Of course, I haven't
figured out yet, there are two Kennedys here on two sides of
the aisle, but we won't get into that too much.
The Kennedy-Ramstad bill also sets a high standard by
requiring coverage of disorders offered to Members of Congress
and their staffs through the Federal Employees Health Benefits
Program. Our witnesses today will report on the costs
associated with providing this more comprehensive mental health
parity.
Employers have experienced cost increases of less than 1
percent as a result of implementing full parity laws. In fact,
it appears that the cost of doing nothing is far greater for
individuals, families, our health care system, and economy; and
this will also be discussed in more detail by our witnesses.
In conclusion, it seems that almost every day a major news
story breaks that has as its root an untreated mental health
problem. A college student shoots his classmates, a mother
drowns her own children, kidnapping, suicides, drug and alcohol
addiction. The next day's story is about the State's
deteriorated mental condition--I should say about the subject's
deteriorated mental condition, which many people knew about,
and the failure or inability of that person to get mental
health counseling and treatment.
By putting mental health on a par with other conditions, we
will be improving the availability and affordability of health
care for those with mental health and substance abuse
conditions. This will not only reduce these horrific public
incidents but also the everyday pain and anguish of many of our
constituents and their families who suffer in silence.
I want to thank our witnesses and our Members for coming
today and look forward to their comments. But I really couldn't
conclude without thanking both of you. I saw when I--I know Jim
wasn't able to come that day in Trenton. He tried, but he
wasn't able to. But Patrick was there, and it was--the fact
that Patrick was willing to tell his own story so effectively,
the fact that so many other people were there to back him up.
If I could just use that Trenton example of how Patrick and Jim
have been going around the country, raising attention, both
media and otherwise, to this. It is really because of your
efforts and your willingness to do that and spend so much time,
that we are at the point I think where we are going to be able
to pass this and send it to the President. You really should be
very proud, both of you, of what you have done; and I mean that
sincerely. Thank you.
I will yield now to the ranking member, Mr. Deal.
OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF GEORGIA
Mr. Deal. Thank you, Mr. Chairman.
I want to thank our colleagues for taking time out of their
schedules to be with us. I realize this is a piece of
legislation both of you have worked on for a very long time,
and we appreciate your presence.
During last year we had hearings in the subcommittee on
mental illness, and we discussed not only the prevalence of the
problem and the treatment for mental illness but also the
difficulty some patients had in accessing care. We heard
compelling testimony about the debilitating effects of some of
these illnesses, in addition to the advances in research. It
became clear to me that improvements should be made to increase
the access to mental health services, and I am glad we are
taking the opportunity to today to explore that issue.
While I do believe people suffering from mental health
disorders do need access to the appropriate type and level of
treatment, legislation should be balanced in how it addresses
this serious problem. I have always been concerned about the
impact of insurance coverage requirements on the cost of health
insurance. While no one mandate may increase the cost of
insurance in a sizable way, they can have a cumulative effect
of making coverage prohibitively expensive. I am sure this will
be a point of discussion in the testimony of our witnesses, and
I certainly look forward to hearing your thoughts on this
issue.
I would also be concerned with any legislation which had
the unintended consequence of employers not providing any
coverage for all for other serious mental illnesses. Another
troubling consequence could be, because employer-sponsored
insurance is voluntary, increasing mandates could lead
employers to stop offering benefits altogether. I realize these
are reservations often raised in regards to legislation like
the bill before us, and I hope that the witnesses can shed some
light on these issues.
Improving access to mental health treatment is certainly a
worthy goal. However, as we seek this target, there are a
number of questions which must be addressed, such as what
diseases and disorders ought to be covered in legislation and
the broader impact of these changes on the insurance market.
For this reason, I think this will be a good hearing, and we
will give the opportunity to the committee to explore these
issues in more detail.
My son happens to be a superior court judge in our State
and handles the drug court for the two counties that our
circuit is composed of. He was in town yesterday, along with
mental health court advocates and family courts and drug courts
from our State; and one of the things that they obviously all
face is not only funding problems to keep those alternatives,
which are very, very successful--in fact, the recidivism rate
coming through the drug court has been 5 percent or less for a
number of years now.
We are attempting and have begun the process of a mental
health court, but it has huge problems of being able to obtain
necessary funding. So it is a very broad picture, and I thank
both of you for your time and efforts to be here today.
Thank you, Mr. Chairman.
Mr. Pallone. Thank you.
I recognize the gentlewoman from California, Mrs. Capps.
OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Mrs. Capps. Thank you, Chairman Pallone.
The ranking member just made a comment about mental health
court that prompted my interest, so I am going to be contacting
him.
Thank you, Chairman, for holding this important hearing. I
am very proud to be a cosponsor of the Paul Wellstone Mental
Health and Addiction Equity Act of 2007, and I will be even
prouder when it is passed by Congress and signed into law. That
is when we will truly honor the memory of its namesake.
It is so fitting today that our first two witnesses are the
bill's co-authors. Last month, it was also encouraging to take
part in Mental Health Parity Day and meet with the men and
women across the country who dedicate themselves to improving
the lives of others. Really at the heart of this bill and this
discussion today is the fact that there exists an unreasonable
difference in the way we treat mental health conditions as
opposed to all other health conditions. To a health
professional--and there are a few of us in this subcommittee
and many across the country that know that there should be no
distinction in the importance of treating any state of ill
health, whether it be heart disease, kidney disease, brain
disease or a mental health disease. All parts of the body,
including the mind and the brain, are vital to our ability to
function; and it is so sad that there has existed this
distinction for mental health because of stigma and
misunderstanding.
H.R. 1424 will begin to finally break down barriers for
accessing life-saving mental health treatment. And I say life-
saving deliberately, because as we are going to hear from these
witnesses today, mental health conditions can indeed be just as
life-threatening as other health conditions. We must put an end
to the discrimination being practiced by insurers when they
offer coverage for some health conditions and not others. And I
know that some people today might refer to the Senate
compromise on mental health parity. But frankly, I don't feel
it goes far enough.
I strongly support the passage of language in H.R. 1424,
which our dedicated colleagues and champions for mental health,
Patrick Kennedy and Jim Ramstad, have worked so hard for so
long to perfect.
Many employees aren't as fortunate as Members of Congress
and our staff, who have access to Federal health benefits. Many
employees have no choice at all which insurance plan they may
access. They are lucky to have one, and so they take it without
questioning. When someone gets a job and is offered health
insurance, they pretty much have to take what the company has
chosen for them. And it is not fair, I believe, to say, well,
we are going to cover some parts of your health care, but we
will pick and choose which parts of your body to cover. I
believe that is bad for business. I know it is bad health care.
So again, I look forward to discussing the bill before us,
and I am excited for the prospects of finally passing this
legislation during this session of Congress. I yield back.
Mr. Pallone. Thank you. The gentlewoman from New Mexico,
Mrs. Wilson.
OPENING STATEMENT OF HON. HEATHER WILSON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF NEW MEXICO
Mrs. Wilson. Thank you, Mr. Chairman. And I also wanted to
thank my colleagues, Mr. Kennedy and Mr. Ramstad, for your
leadership on this issue, and for being willing to take up the
charge over such a long period of time and make it personal to
people, as I think that getting beyond the stigma of mental
illness is part of what we need to do to make sure that we
achieve parity, so that diseases of the brain are treated in
the same way and thought of in the same way as diseases of the
heart or the lungs or the kidneys or anything else.
I come to this debate, and I have been a supporter in the
past, a cosponsor in the past of the mental health parity
legislation here in the House really based on my experience as
the former cabinet secretary for child welfare in the State of
New Mexico, where on any night we had about 1,600 kids in
foster care. And generally, they were physically healthy and
emotionally a wreck. And we aren't talking about kids who are a
little bit depressed on the bus on the way to school. We are
talking about severe mental illness among children. And getting
those children adopted is hard enough, but making sure that
they still have access to the necessary medical and insurance
coverage is certainly a challenge. And mental health parity
would go a long way to helping families be able to get the care
that they need for their children.
There is a different version of this bill, and Mrs. Capps
just mentioned it, that was introduced in the Senate. It was
introduced and has been supported for a long time by my
colleague, the senior Senator from New Mexico, Pete Domenici.
And that bill does represent I think--it is an agreement--
represents an agreement that was developed over a period of
about 2 years between--again in negotiations with various
stakeholders in the mental health community and so on. I
actually have a slight preference for the Senate bill, but I
would like to see this bill get to conference so that we can
get something done and move forward.
Again, I thank my colleagues from Rhode Island and
Minnesota for your leadership on this issue, and I thank the
chairman for holding this hearing today. Thank you.
Mr. Pallone. Thank you. Ms. Baldwin of Wisconsin.
OPENING STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF WISCONSIN
Ms. Baldwin. Thank you, Mr. Chairman. And I am very, very
encouraged by the fact that we are holding this hearing today.
I am proud to be an original cosponsor of H.R. 1424, the House
Mental Health Parity bill, and I am delighted that this
committee is holding this hearing and the bill's two main
sponsors are here with us today. Congressmen Kennedy and
Ramstad, you have shown such tremendous leadership on this
issue, and I thank you both for that.
All Americans deserve access to affordable, comprehensive
health care to meet both their physical and mental needs, and I
believe that Americans should be provided with comprehensive
coverage for mental health services. Mental illness and
substance abuse are tangible, treatable health problems, just
like hypertension, cancer, heart disease. Yet millions of
hardworking men and women still find that their health plans
place strict limits on coverage for mental health benefits.
I am very much looking forward to our discussion with our
witnesses today, and I hope that we can take this opportunity
to dispel some misconceptions about mental health parity. Often
we hear those opposed to parity say that requiring mental
health parity will increase utilization of mental health
benefits and mental health costs. But we know from experience
in States which already have mental health parity laws that
this is not the case. And I look forward to hearing our
witnesses talk more about that.
Lastly, I wanted to share an excerpt from a letter that I
recently received from a constituent. Her name is Lisa, and she
is from Madison, Wisconsin. Lisa is a registered nurse and a
survivor of mental illness. Specifically, she has an eating
disorder. And she writes, and I quote, ``I strongly believe I
would not have suffered from a severe eating disorder for 7
years, putting myself, my friends, and my family through hell
had I had parity of insurance coverage.'' There are many causes
and contributing factors to each sufferer's eating disorder,
and it does not develop overnight. I was one of the lucky ones
to have even some health insurance for treatment of my serious
eating disorder. However, it was grossly inadequate, geared
more towards stabilizing the resultant physical consequences,
and not the underlying cause. Only those who themselves can
afford or whose families can afford this great expense have a
good chance of recovery.
Unfortunately, Lisa's story is not unique. As we will hear
today, millions of Americans face horribly restrictive barriers
when they seek care for mental illness. This is not right, and
this is why we need to ensure that every American has access to
adequate mental health care by ensuring mental health parity.
And again, thank you to the witnesses today. I look forward
to the testimony. Thank you, Mr. Chairman.
Mr. Pallone. Thank you. Mr. Ferguson.
OPENING STATEMENT OF HON. MIKE FERGUSON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Ferguson. Thank you, Mr. Chairman. Thanks for convening
this hearing and for your leadership on this issue. This
legislation will undoubtedly deliver much needed treatment and
care to thousands and thousands of people for which it is long
overdue. I particularly want to thank Mr. Ramstad and Mr.
Kennedy, our colleagues and friends, for joining us. There are
few people in this body who don't have enormous respect and
have noticed the incredible leadership and sacrifices that you
have both made on behalf of this cause. I have had an
opportunity to work with you on many different issues, but on
this issue you two have no equal, except maybe each other, in
your leadership and the work and devotion that you have made
toward this issue. And you have our admiration for that.
Addiction and mental illness are afflictions that have long
been stigmatized and brushed aside by our society and our
institutions. And I would submit that every family, every
family has been touched by mental illness in some way, large or
small, in some way or another. And for too long people have
been told that they must fend for themselves while battling
these diseases. Those battling their debilitating effects have
not been able to receive the stability of care that is
available when adequate insurance coverage is in place. And the
Paul Wellstone Mental Health and Addiction Equity Act is an
idea whose time had come a long time ago. And it is time to
deliver what people battling addiction and mental illness have
long needed and wanted, and that is help.
I have been a cosponsor of mental health parity efforts in
the past. I am happy to be here today to add my support as a
cosponsor during this Congress. And I look forward to the
testimony of our witnesses and both of our panels today, and
certainly look forward to working with my colleagues on this
committee on both sides of the aisle to pass this important
legislation.
I yield back. Thank you, Mr. Chairman.
Mr. Pallone. Thank you. The gentlewoman from Illinois.
OPENING STATEMENT OF HON. JAN SCHAKOWSKY, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF ILLINOIS
Ms. Schakowsky. Thank you, Mr.Chairman. I too want to thank
our wonderful panel of witnesses for sharing their experience
and expertise with us, particularly those witnesses who are
willing to share their personal experience, including of course
Representatives Kennedy and Ramstad, whose leadership has been
informed by personal experience. And you do honor to our friend
Paul Wellstone. He and his wife Sheila were great personal
friends of mine, and I know he will be very proud when this
bill is signed--or would have been very proud when this bill is
signed into law.
The courage that you two demonstrate telling your personal
stories of struggle and hope will serve as models for others
who have been touched by mental illness. And what family has
not been? Each of you serve as proof that with adequate support
and appropriate treatment people with mental illness can live
to their full potential and make unique contributions to
society.
Your stories also point to the tremendous value of mental
health treatment. We have come a long way in our understanding
and treatment of mental illness, but the barriers to obtaining
coverage remain. Approximately 15 percent of Americans are
affected by a clinically significant mental disorder in any
given year, with 2 to 3 percent experiencing a severe mental
illness. Many of them are struggling to access effective
treatment that could greatly reduce their suffering and
increase their participation in occupational, educational,
social and civic realms.
Science has dispelled several myths that have been used to
justify unequal coverage of mental disorders and mental health
treatments. The arguments that mental illnesses are not real
illnesses and mental health treatments are not real treatments
have been dispelled by research into mental disorders and their
treatment. Growing evidence also suggests that the myth that if
mental health care were available as a standard benefit then
everyone would use it and it would bankrupt the system, and
that has been dispelled by economic analyses and actual
experience.
Today we know that mental disorders are real and complex,
with biological, psychological, and social contributors.
Rigorous scientific evaluations have found a range of mental
health treatments to be effective, including numerous
medications and psychotherapies sometimes showing greater
effectiveness than many medical treatments. For example, there
is a 90 percent cure rate for panic disorder, which is a very
debilitating condition. A variety of mental disorders actually
have a number of effective treatment options available, making
cost-effective choices possible.
Several studies and the experience of numerous States have
demonstrated that the provision of mental health parity results
in only modest cost increases. Illnesses such as schizophrenia,
bipolar disease, major depression, anorexia nervosa, alcohol
dependence, and many other disorders are potentially life-
threatening conditions that can cause serious impairment and
tremendous suffering for affected individuals and their
families and friends. These illnesses are not moral or personal
failures, and affected individuals should not be punished for
suffering from them.
The time has long passed that we do this. I am so proud to
be a supporter of H.R. 1424, and look forward to its passage
and this discussion of it today. Thank you.
Mr. Pallone. Thank you. Mrs. Myrick of North Carolina.
OPENING STATEMENT OF HON. SUE WILKINS MYRICK, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NORTH CAROLINA
Mrs. Myrick. Thank you, Mr. Chairman, for holding the
hearing today. And I also thank our colleagues for all their
hard work and their willingness to speak out. This issue of
mental health insurance parity is not a new one, and I think
this hearing is a good opportunity for members to have
questions answered about how it will impact of course the
insurance market, but also the lives of the patients who have
the brain disease.
For some time I have emphasized the need for Americans to
realize that severe mental illnesses are really brain diseases,
diseases that impact your brain rather than your heart or your
kidneys. They are diagnosable, treatable, and biological in
nature.
There are several fronts in the battle to recognize and
treat these diseases. There is the awareness fight, which has
been very difficult, to help people realize that diseases like
bipolar, schizophrenia, depression aren't moral failings; they
are diseases that can be treated once they are diagnosed. There
is a scientific fight in which experts attempt to map the
different changes in the brain and the genome and that impact
the onset and the severity of the illnesses, and there is the
treatment fight. These diseases are expensive and frustrating
and often difficult to diagnose and treat. Doctors don't always
have the latest scientific treatment standards at hand to treat
each patient with the right dose or the right medicine or the
cocktail or the right therapy. And from personal experience, we
have had that experience in our family of trying to find the
right way to do it. Patients with a mental illness aren't
always willing to seek help from professionals. And then of
course there is always the question of insurance and how much
does it cost.
Untreated mental illness costs our country billions of
dollars each year. It costs patients the ability to work,
function in society. It costs our families a lot of heartache,
and bleeds so much from our public system in the forms of
homelessness, incarceration, illegal drug use. The list goes
on.
It should also be noted that those who have health
insurance, but lack sufficient mental health coverage,
sometimes bankrupt themselves and their families, and they
eventually end up on Medicaid. And we know that that costs us a
lot over the long run.
In many ways, having a severe mental illness is no less
serious than having cancer, and oftentimes it poses a more
serious threat to the patient's life and ability to function.
But let's not underestimate the gravity of the decision to
create a Federal mental health parity structure. The health
insurance market is notoriously complicated, and those who have
a brain disease and don't have insurance don't benefit from
mental health parity mandates. That is a whole 'nother issue.
And if there is any incentive for insurance providers to drop
coverage based upon the perceived expense or imposition of
parity laws, those who have some mental health coverage may
eventually find themselves without it. And that is why I am
glad we are having the hearing today to discuss all these
options.
It is also important to note States have control over their
benefits as well and a lot of employee plans under their
jurisdiction, and we need to look into that as well. I know the
agreement that is reached on the Senate side. I think it is
very important they have that kind of agreement, especially
with the problems that we have today. And so I want to hear
from people relative to the House bill and what that brings as
well. And again I thank the gentlemen from Rhode Island and
Minnesota for all your years of dedication.
Thank you, Mr. Chairman.
Mr. Pallone. Thank you. Ms. Solis.
OPENING STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Ms. Solis. Thank you, Mr. Chairman. And I really appreciate
the fact that you are having this hearing, and want to welcome
Congressman Kennedy and Congressman Ramstad also. I know you
guys, both of you, have worked so tirelessly on this issue, at
least in the last 7 years that I have been here in the House,
and I want to thank you for continuing the fight that Senator
Wellstone began. And I did have the pleasure of working with
him shortly. But as a State legislator, because even in the
State of California back in 1999, we passed a mental health
parity bill for this same reason that you are here today. And I
would just say that it works, it works well, it is something
that is proven. And for a district like mine, where we have so
many young people that we are finding in the juvenile justice
system and then eventually leading into the county jail system,
and I know Congressman Kennedy knows fully well what that
means. And in many terms our sheriff there, Lee Baca, has said
that he is really not a caretaker for criminals, but more of a
caretaker of the mentally ill. And it is unfortunate, but that
is a fact and it is a reality, and we as a country need to do
something about it.
And I am particularly concerned because of communities of
color. Because the ratio of suicide for Latinos, Latinas, and
Asian American women is very high, and we are not doing enough
to detect that early on and providing tools for their families,
and also for school districts, where I think intervention
really needs to take place as well.
So I am very happy to be a cosponsor of the bill, and look
forward to hearing from both of you, and can't wait to see a
signature from the President on the bill. Thank you, and I will
yield back the balance of my time.
Mr. Pallone. Thank you. Mr. Sullivan of Oklahoma.
OPENING STATEMENT OF HON. JOHN SULLIVAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OKLAHOMA
Mr. Sullivan. Thank you, Mr. Chairman. And I would like to
thank Congressman Kennedy and Congressman Ramstad for
testifying today on H.R. 1424, the Mental Health Addiction
Equity Act of 2007, and I am pleased to be an original
cosponsor of this very important legislation. At the end of
March, Congressman Kennedy and I held a field hearing in Tulsa,
Ok, to examine the effects of mental health disorders on
Tulsans and the need for mental health and addiction parity.
Hearing from families, scientific experts, businesses in Tulsa,
all of whom have been affected by mental health disorders,
drove home the point that mental illness touches many lives and
the need for mental health parity could not be more important.
My home State of Oklahoma currently ranks No. 1 in the
Nation in the number of people struggling with mental illness
and addiction disorders, almost one-fourth of the population of
the State. While many States, including Oklahoma, already have
mental health parity laws in place, it is vital that Congress
enact Federal legislation which levels the playing field for
the 54 million Americans suffering from mental illnesses. The
simple fact is mental illnesses are biologically-based brain
disorders, and need to be treated by insurance companies like
any other physical illness.
According to the Government Accountability Office, nearly
90 percent of health plans impose financial limitations and
treatment restrictions on mental health and addiction care.
This legislation, which would help an estimated 113 million
Americans receive fair mental health and addiction treatment,
requires group health plans that offer mental health and
addiction benefits to do so on the same terms as they do for
other diseases. This means closing the loopholes in the past
laws that have allowed insurance companies to continue to
charge higher copayments and deductibles to individuals seeking
mental health treatment, and eliminating annual caps on
inpatient/outpatient care.
One of the most important aspects of this bill is that it
ensures that the health plans must cover the same range of
mental illnesses and addictions that Members of Congress and
other Federal employees and their dependents receive under the
Federal Employee Health Benefit Plan.
And a lot of people talk about this as costing a lot of
money, which is not true. The economic cost of untreated mental
illness in America is more than $100 billion each year, and the
cost of addiction is $400 billion each year. Mental health
parity will bring these costs down and offer new hope to
millions of Americans suffering from mental illness.
I look forward to hearing your testimony, and also I want
to say that you two are doing something that really is going to
help people's lives. We vote on a lot of stuff around here, and
this is truly going to have an impact on millions of people's
lives. You guys are heroes. You are doing a great job. Thank
you.
I yield back.
Mr. Pallone. Thank you. I recognize our vice chairman, Mr.
Green.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman. I would like to ask
unanimous consent to place a full statement into the record,
and I will just paraphrase it to save time.
One, like my colleagues, I want to thank our colleagues
from Rhode Island and Minnesota for being so diligent in
working on this bill for so many years. I am proud to be a
cosponsor of it. And I will just briefly talk about the need
for it.
Sixty percent of employers in my district that provide
insurance come under Federal law and not State law. We have 26
States who have full mental health coverage, but a number of
other ones only have partial, which includes the State of
Texas. And I was proud as a State senator to even get that much
in the late 1980s.
I am glad the bill uses a DSM-IV, so that doctors and not
insurance companies will make the decision on illnesses. In our
experience in the Houston area, with the Katrina evacuees
traumatized, it is so needed to make sure we have mental health
services available, whether you are in New Orleans or Houston
or anywhere else in the country, particularly in a disaster.
And I will say a caveat, in an earlier career, before I ran
for Congress, I did mental health work as an attorney. And it
is half mental health work and half counseling to find
reasonable placement and family for my clients. And seeing the
clients who were in the public system, as opposed to the few
who had private insurance, it was so amazing.
And so that is why this bill is so important, and I yield
back my time.
Mr. Pallone. Thank you. Mr. Burgess.
Mr. Burgess. Thank you, Mr. Chairman. I want to welcome our
colleagues, thank them for being here. In the interests of
time, I am going to submit my statement for the record, reserve
time for questions.
Mr. Pallone. Thank you. The gentleman from Utah.
OPENING STATEMENT OF HON. JIM MATHESON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF UTAH
Mr. Matheson. Well, thanks, Mr. Chairman, and I am so glad
you are holding this hearing today. And I really want to first
just extend my appreciation to our colleagues, Mr. Ramstad and
Mr. Kennedy. I appreciate your leadership on this issue and
your commitment, and I hope we can make progress. I know you
do, too. I look forward to hearing from both panels, actually,
and I hope we can get some insight that will help this
committee move forward. I also hope that we hear
recommendations on how best to achieve a balance between the
important goal of mental health parity, and also assuring that
we continue to improve access for all Americans to affordable
and comprehensive health care.
As you know, Mr. Chairman, I am an original cosponsor of
this bill, and have been a cosponsor in previous Congresses as
well. I look forward to seeing if this committee can pass
legislation in this area. I believe the provision of mental
health care is an important responsibility of health care
plans. And mental health care should not be treated in a
significantly different manner than other illness, and those
who suffer from mental illness should be able to obtain
necessary services and medications.
It was in 1999 the Surgeon General reported mental health
illnesses are largely biologically based disorders, similar to
other medical conditions. And the Surgeon General has reported
that mental health treatments are highly effective. It is
simply common sense to cover these treatments so that those who
suffer from these illnesses can return to being fully
productive members of our society.
It is my hope this committee will work on this tough
legislation. I think it is a crucial step forward in the fight
to assure every American's access to high quality health care.
And I appreciate the time, Mr. Chairman, and I will yield back.
Mr. Pallone. Thank you. The gentlewoman from Tennessee.
OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TENNESSEE
Mrs. Blackburn. Thank you, Mr. Chairman. Thanks for holding
the hearing, and welcome to all of our witnesses that are here
with us today. And I do want to thank our colleagues for their
willingness to work on the legislation and to come before us
today.
When I was in the State senate and dealing with issues that
came before us in judiciary committee, I started to look at
some of the root causes for teen violence, for gangs, for
abusiveness, for the drug court problems that we had. And
repeatedly as I delved into that root cause it came back to
some form of mental illness and mental health. And as I studied
a little bit more on the issue and I moved on to Congress I
certainly became aware of the cost to our health care system.
When you look at it in aggregate of what it costs the American
health care system with emergency room visits, and days lost
from work, and additional costs to the criminal justice system,
we are talking hundreds of billions of dollars.
This is not an isolated problem. It is not a segmented
problem. Many times it is the basis for other forms of health
and wellness. And currently 46 States have some type of mental
health coverage that is enacted into law. And they vary
considerably, including equal coverage or a minimum mandated
mental health benefit, depending upon the State. And 26 States
have laws that require some type of mental health parity or
something that is broader than the Mental Health Parity Act
passed in 1996. And some laws apply primarily to serious mental
illness and may not assure coverage for current circumstance.
Many private market health plans also include some type of
mental health benefit on a voluntary commercial basis, not
necessarily required by State or Federal laws.
Now while this seems like a patchwork, indeed what it does
show is an awareness over the past couple of decades that there
is a connection between the physical and the mental health. As
we move forward on this discussion, I hope that we are going to
keep an eye toward what happens in the free market and look for
a decision of how to cover mental health benefits as we can
leave options to the insurer and the insured. So I am looking
forward to discussing how a Federal mandate requiring that
mental health coverage be given parity does not usurp personal
freedom and unnecessarily trump State laws that are currently
in existence.
Thank you again to our witnesses and to our Chairman, and I
yield back.
Mr. Pallone. Thank you. Mr. Allen of Maine.
OPENING STATEMENT OF HON. TOM ALLEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MAINE
Mr. Allen. Mr. Chairman, thank you for calling this
important hearing on mental health parity. And to our
colleagues, Patrick Kennedy and Jim Ramstad, thank you for your
courage and your determination to drive this issue. You are
doing it extraordinarily well.
Through this piece of legislation, we have an opportunity
to improve the lives of millions of Americans suffering from
mental illness and addictions, and I believe we must work
together to strengthen current law to improve access to mental
health treatment and services.
The effects and implications of mental illness are broad.
Poor mental health manifests itself as more than an emotional
condition. It can also cause or exacerbate physical conditions,
such as substance abuse, obesity, and heart disease. If our
goal is to reduce health care spending and improve health care
outcomes, covering treatment for mental illness differently
than physical illness is illogical and ineffective.
Mental illness and addictions left untreated increase
indirect societal costs. Lack of access to mental health
treatment due to lack of insurance coverage costs our economy
more than $100 billion a year through absenteeism, turnover and
retraining expenses, lower productivity, and increased medical
costs.
Treatment of mental illness has come a long way. Mental
health providers deliver better care for patients through use
of evidence-based practices and, as we have heard and will hear
today, improved coverage for mental health does not greatly
increase total health care spending.
Many States, including my home State of Maine, have acted
independently to provide individuals with more comprehensive
mental health benefits. The Paul Wellstone Mental Health and
Addiction Equity Act appropriately allows States to continue to
provide exemplary care to their citizens. States that go above
and beyond Federal requirements should not be held back.
I look forward to working with my colleagues to create a
strong mental health parity bill that truly ensures equal
coverage for physical and mental illness. I thank our witnesses
and, Mr. Chairman, yield back the balance of our time.
Mr. Pallone. Thank you. Mr. Murphy,
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Murphy. Thank you, Mr. Chairman, for holding this
important meeting. And I appreciate Mr. Kennedy and Mr. Ramstad
for being here, too, for through this issue we have developed
real friendships and respect for the work you have done. I
speak here also as the co-chair of the Mental Health Caucus and
as the only child and family psychologist serving in Congress,
and as a person who has held in my arms those patients who have
tried to commit suicide while waiting for an ambulance or have
gone to their funerals. But I have also gone to their
graduations and received notes from them when they have had
their children as their life has turned around. And it is
important to know that these are very real instances, despite
what those who may oppose this bill continue to send out false
information that it is not treatable, it is a matter of fantasy
and pretend, or that its costs outweigh the benefits.
I tell you from a person who has studied this throughout my
life, and as a practicing psychologist for over 25 years, and
has written books and published articles on the subject, mental
illness is real. It is debilitating. It costs money. And it can
cause health care costs to double when it is untreated.
Mental illness can be treated successfully, oftentimes
better than many other medical problems. And to do so is cost-
effective. When a factory looks at buying a machine for its
assembly line, it doesn't just look at the direct costs of what
that machine is, but it also looks at what it would cost to buy
a cheaper machine when it is less effective, less efficient,
less safe. We also need to put this same sort of reasoning when
it comes to buying health care plans. We can all buy something
cheaper up front, but it will cost more in the long run for
employee training, absenteeism, presenteeism, workers comp
costs, injuries, and deaths.
We also need to know that mental illness is not something
that one treats just by encouraging one to pull themselves up
by their bootstraps on one extreme, nor is it something where a
person is doomed to victimhood all their life with some sad
lifelong sentence. Indeed, it is something that we can treat,
but we cannot treat it if we remain mired in the Salem witch
trials mentality of centuries gone by where we think if we
ignore something or torture something that somehow it will get
better.
This is an opportunity to change the direction of health
care to save money and to save lives. It is both cost-effective
and compassionate. I can think of no better marriage of ideas
from all levels than looking at an issue of mental health
parity. Many Fortune 500 companies have examined it, have
concluded that it saves money for them, and we need to deal
with this in a rational way, finally, to help those who
otherwise we place behind the shadows of victimhood. And it is
time that we stop ignoring them. To all of those people we need
to reach out our hearts, we need to understand this carefully,
and we need to pass this bill.
Thank you, Mr. Chairman.
Mr. Pallone. Thank you. I believe that concludes the
members' opening statements.
Any other statements for the record will be accepted at
this time.
[The prepared statements of Mr. Dingell and Ms. Eshoo
follow:]
Prepared Statement of Hon. John D. Dingell, a Representative in
Congress from the State of Michigan
I welcome all of our witnesses here today to help shed
light on the issue of Mental Health Parity and specifically
H.R. 2414 introduced by Representatives Patrick Kennedy and Jim
Ramstad. The devotion and passion that they have shown on this
issue is truly impressive.
More than 54 million Americans, about 20 percent of
Americans, have a mental disorder in any given year. And 22
million Americans struggled with drug and alcohol dependence in
2005. Fewer than 8 million, however, sought treatment for their
mental disorders and less than 10 percent of Americans sought
treatment for their substance abuse problems.
Part of the reason for this is the lack of health
insurance or an absence of coverage for mental health or
substance abuse disorders. People cannot afford to pay the
costs associated with seeking medical care without insurance so
they forgo necessary treatment. Not only does this lack of
treatment have detrimental effect on the individual but it also
has ripple effects on their families, our community and
economy.
Inadequately-treated mental illness and substance abuse
not only harm a person's mental and emotional health, but it
can also lead to other serious chronic and acute medical
conditions. For example, studies indicate depression greatly
increases the risk of developing heart disease and makes a
person four times more likely to have a heart attack. And
untreated alcoholism can lead to chronic diabetes. At the
economic level, employees who are depressed are twice as likely
to miss work for health reasons as employees who are not
depressed, and be less productive when on the job. In addition,
there is a 23 percent unemployment rate among American adults
with depression, compared to 6 percent of the general
population.
Despite the effects of mental illness and substance abuse,
these disorders can be addressed with treatment. Eighty percent
of those who seek treatment for clinical depression are
successful. Behavioral healthcare treatments and psycho-
pharmacological treatments for panic and bipolar disorders
range in the 80 percent success rate, while treatments for
schizophrenia, depression, and obsessive-compulsive disorders
range in the 60 percent success rate.
When one considers all of this information, we understand
how important it is that people have access to the same health
care coverage to treat their mental health problems as they do
to treat their physical health problems.
I applaud this legislation for taking the simple step of
requiring health plans to impose no more restrictive treatment
limitations and financial requirements in its mental health and
substance abuse benefits than are applied in its medical and
surgical benefits. In addition, this legislation ensures the
right of States to further protect their citizens. It's a
question of fairness.
----------
Prepared Statement of Hon. Anna G. Eshoo, a Representative in Congress
from the State of California
Mr. Chairman, thank you for holding this important hearing
on H.R. 1424, the Paul Wellstone Mental Health and Addiction
Equity Act. The fact that this bill has 268 bipartisan
cosponsors in the House is a testament to the wide support and
need for mental health parity legislation.
Representatives Patrick Kennedy and Jim Ramstad are our
Nation's champions of this legislation and I thank them for
their extraordinary leadership. I was proud to host them in my
congressional district this year for a field hearing on the
need for mental health and addiction parity. This issue is
critically important to my constituents and I'm proud to be an
original cosponsor of H.R. 1424.
Mental health and addiction disorders touch nearly every
family in America. They account for over one-fifth of all lost
days of work or school productivity, and they affect children,
teenagers, adults and seniors. Approximately 54 million
Americans suffer from mental illnesses, and 26 million from
addictions. A high percentage of Americans are battling co-
occurring mental illnesses and addictions.
Mental illnesses and addictions have historically not been
well understood. Because their visible symptoms are changes in
personality and behavior, mental health disorders have often
been perceived as personal or moral failings. New technologies
developed in the last few decades such as MRI's and PET scans
have allowed scientists to peer inside the brain and clearly
establish the physiological and biological basis of these
diseases. The mapping of the human genome has also illustrated
that strong genetic markers for mental disorders and addictions
exist. In spite of these facts, public health policy has not
kept up with science.
Most Americans face barriers to mental health care and
addiction treatment not encountered in accessing other forms of
health care. According to a 2000 report published by the
Government Accountability Office, most employer-sponsored
health plans include more expensive financial requirements
(such as copayments and deductibles), treatment limitations
(such as limits on the number of covered outpatient visits or
days in the hospital), or excluded diagnoses related to mental
health or addiction disorders.
H.R. 1424 will improve the health of Americans by granting
greater access to mental health and addiction treatment and
prohibit health insurers from placing discriminatory
restrictions on treatment. Specifically, the bill prohibits
treatment limits or the imposition of financial requirements on
mental health and substance-related disorder benefits in group
health plans which are not similarly imposed on substantially
all medical and surgical benefits in any category of items or
services under such plans.
The legislation also requires the Comptroller General to
study the effect of the bill on various aspects of the health
care system, including the cost of and access to health
insurance coverage, the quality of health care, Medicare,
Medicaid, and State and local mental health and substance abuse
treatment spending, as well as spending on public services.
I look forward to the testimony of our witnesses.
----------
Mr. Pallone. So we will now turn to our panel, with our two
Congressmen and sponsors of this legislation, and we will begin
with Mr. Kennedy.
STATEMENT OF HON. PATRICK J. KENNEDY, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF RHODE ISLAND
Mr. Kennedy. Thank you, Mr. Chairman. First, thank you, Mr.
Chairman, and Ranking Member Deal, and all the committee
members for your very, very generous comments regarding myself
and Mr. Ramstad. They were very generous, and believe me, are
reciprocated many times over for many of you who we worked with
on the hearings that we did around the country. We couldn't
have done those hearings without your support and the work that
you did in organizing them for us as we traveled the country.
And as evidenced by your opening statements, you basically
stole our thunder, because you basically told the story of why
we need this bill better than we could really say it ourselves.
Each of you laid out in your own statements very
effectively why we need this legislation, and I think it is
very poignant that you all addressed this in very different
ways, from economic arguments, to how it affects the criminal
justice system, to how it affects our health care system, how
it affects a whole panoply of areas in our society.
I thought Mrs. Blackburn's comment that this is not an
issue that can be isolated and segmented, but it affects all of
society was right on target. Ranking Member Deal's point, with
his son running the drug courts, was right on target.
The fact of the matter is this is a public health issue
that we have criminalized. And our court system has become
the--we have basically--as Sheriff Baca said in the words of
Ms. Solis, I run the largest mental health clinic in the
country. I run the Los Angeles County jails. That was in the
words of Sheriff Baca.
In our health care system, as was mentioned by Mr. Murphy,
in terms of the costs, we had the head of our emergency rooms
often talk about up to 80 percent of the costs on any given
weekend in our Trauma 1 centers, the costs of those patients,
where those patients were there because of drugs and alcohol.
But they were never transparently there for drugs and alcohol,
they were there because of auto accidents that were as a result
of drugs and alcohol. They were there as a result of gun
shootings and fights, all of which were the result of drugs and
alcohol. They were there as a result of other accidents that
were a result of drugs and alcohol. And all of those accidents,
and so forth, were written up as contusions, lacerations,
concussions and intubations, all of which get reimbursed by
insurance. And of course they are all symptoms of a deeper
problem which doesn't get covered by insurance. And that brings
us back to why we need prevention. And that is why we need this
bill passed. Because if we had the real issue covered, we could
avoid those other costs that are so acute and end up bringing
people to the emergency room far too often, adding so much cost
to our health care system.
And then of course I think Mr. Murphy said it so well in
terms of the costs to our business community. He made the
analogy with the machine in a business. Making that same
analogy, someone may say, well, it will cost more to implement
parity. Of course we have here today someone who will testify
to the fact that it won't. But the fact is even if it does, as
Mrs. Blackburn said, we haven't taken it into account in terms
of the overall savings in the aggregate, how it will save us
money in the aggregate. And he said, well, if you put in a
machine in a business that turns out more widgets, but it costs
more to put it in, but in the net of the business you make more
money, do you ask how much it cost to put the machine in if at
the end of the day you make more money? No. Because you are
looking at the bottom line. And so if it costs more to put
these benefits in but at the end of the day you get a better
return on your investment because you get better productivity
from your workers, isn't that worth the investment? And that is
what we heard in Pittsburgh, from Alberto Colombi from PPG in
Pittsburgh.
And then we heard, from those out in San Francisco, we
heard from Kevin Hines, who has survived a jump from the Golden
Gate Bridge. Every year we have 34,000 Americans, twice the
number of Americans that are murdered, twice the number of
Americans that are murdered attempt--or actually successfully
take their lives. To think that we see the news every night and
see the number of people that are murdered, to think that twice
that number actually successfully take their lives every year.
And this was one gentleman who actually tried but failed. He is
getting married this fall, Kevin Hines is. And he is happy now
because he is getting treatment. And he is a sign of success.
And you know what, 90 percent of the people who attempt
suicide are suffering from a mental disorder that is treatable.
That is treatable. We could avoid those suicides in 90 percent
of the cases where the mental illness is treatable. And that is
an avoidable cost that could be addressed if we had mental
health parity.
And finally, this is an issue fundamentally of civil
rights. Nobody chooses to be born with a particular genetic
makeup or a brain anatomy any more than they choose to be born
with a particular skin color or gender. And so nobody deserves
to be denied opportunities based upon such immutable
characteristics.
And so when everyone here starts to talk about the cost of
extending this coverage, let me just tell you about the story
of Amy Smith. She is a young woman who said that for 40 years
she was wandering the streets, muttering to herself, in and out
of jails, because she suffered from schizophrenia and
addiction. She said finally one day she got access to
treatment. Now she holds down a job and she pays taxes. But she
says I lost the opportunity to live my life, to live out my
dreams as an American because I didn't get access to treatment.
And that is a cost of our current system that you can't measure
when you consider the costs of not having parity.
You can't measure that in financial terms. But that is a
cost that you have to consider when you are taking it into
account. You also have to consider the cost in the loss of
lives. And when you think about cost-effectiveness you have to
think about telling people like Amy Smith and millions like her
when you think about keeping health care costs down, are they
going to have to pay with their lives to keep the health care
costs down? Because that is what you are essentially going to
have to say if you say we don't want mental health parity
because it costs too much. If you do that, you might as well
say to cancer patients why not roll back coverage for cancer
patients because that will also bring down costs. And I don't
think any of you up there would want to roll back coverage for
cancer. Because essentially you would have to be doing the same
thing for cancer as you would do for mental health if you were
to decide that you don't want to cover mental health parity.
Because effectively you would be asking to be doing the same
thing.
Jim and I have both been the beneficiary of mental health
treatment, and we are both here because of it. And we are
fortunate to be covered under the Federal Employees Health
Benefit Plan. And if it is good enough for Members of Congress,
it ought to be good enough for the rest of the country. And
that is what this legislation says. And I hope that you have a
chance to pass it out of this committee in the near future.
Thank you.
[The prepared statement of Mr. Kennedy follows:]
Testimony of Hon. Patrick J. Kennedy, a Representative in Congress from
the State of Rhode Island
Chairman Pallone, Ranking Member Deal, and my
distinguished colleagues, thank you for inviting me to testify
today, and, especially, for your commitment to ending insurance
discrimination.
And of course, I must single out my great friend and the
strongest champion for Americans with mental illnesses and
addictions, Jim Ramstad. For years he has led this fight,
leaning into the stiff wind of his own leadership without
regard for the political consequences, speaking up for what he
knows is right. We all owe him a debt of gratitude, nobody more
than I. Jim, it has been an honor to stand with you in these
efforts, and a greater privilege to be your friend.
This issue is first and foremost one of fundamental
fairness. Marley Prunty-Lara, who you will hear from, paid her
health insurance premiums just like everyone else. But when she
got sick and needed her insurance coverage, she didn't get it.
That is just not fair. And it nearly cost Marley her life.
There is no way to justify denying Marley, and millions of
others, the full benefit of the health insurance they pay for.
In the attached exhibit, you can see the visual evidence
that these diseases are physiological brain disorders. Some
brain diseases, like Parkinson's, affect the motor cortex, the
basal ganglia, the sensory cortex, and the thalamus. Other
brain diseases, like depression, affect the limbic cortex,
hypothalamus, frontal cortex, and hippocampus.
There is no way to justify providing full coverage to
treat certain structures of the brain, but to erect barriers to
the treatment of other structures.
This discrimination is not only unjustifiable, it is
enormously costly. Representative Ramstad and I have traveled
across this country holding informal field hearings on this
subject--14 in total.
We've heard from chiefs of police, like Sheriff Baca in
Los Angeles who says he runs the largest mental health provider
in the United States: the L.A. County Jail. According to the
Justice Department, more than half of inmates in jails and
prisons in this country have symptoms of a mental health
problem. Two-thirds of arrestees test positive for one of five
illegal drugs at the time of arrest, according to the National
Institutes of Health.
That's a cost of our insurance discrimination.
We've heard from hospital presidents and emergency room
doctors, like Dr. Victor Pincus. He said that 80 percent of the
trauma admissions at Rhode Island Hospital, a level-one trauma
center, were alcohol and drug related. Eighty percent.
The physical health care costs go beyond the emergency
room. Research shows, for example, that a person with
depression is four times more likely to have a heart attack
than a person with no history of depression. Health care use
and health care costs are up to twice as high among diabetes
and heart disease patients with co-morbid depression, compared
to those without depression, even when accounting for other
factors such as age, gender, and other illnesses. Not
surprisingly then, one study found that limiting employer-
sponsored specialty behavioral health services increased the
direct medical costs of beneficiaries who used behavioral
healthcare services by as much as 37 percent.
These are costs of our insurance discrimination.
In our field hearings, we've heard from enlightened
business leaders and insurance executives who understand that
skimping on mental health and addiction treatment only winds up
driving up other costs. That's why Bob Hulsey from the Williams
Companies in Tulsa, Rep. Sullivan's district, said of parity,
``I absolutely believe that it helps the business.''
Rick Calhoun, an executive in the Denver office of CB
Richard Ellis, a Fortune 500 company, made a similar point. Mr.
Calhoun said that the cost of treating mental illness is 50
percent of the cost of not treating it. As he said, ``This is a
no-brainer. How could we not cover it?''
Untreated mental health and addiction cost employers and
society hundreds of billions of dollars in lost productivity.
The World Health Organization has found that these diseases are
far and away the most disabling diseases, accounting for more
than a fifth of all lost days of productive life. Depressed
workers miss 5.6 hours per week of productivity due to
absenteeism and presenteeism, compared to 1.5 hours for non-
depressed workers. Alcohol-related illness and premature death
cost over $129.5 billion in lost productivity per year.
These are the costs of our insurance discrimination.
All of these costs are preventable, and wasteful. But none
are as tragic as the individual costs. We heard testimony from
anguished parents like Kitty Westin and Tom O'Clair, who had to
bury their children because their mental illnesses and
addictions went untreated.
We heard testimony from people like Amy Smith, who said
when she runs into people she knew 25 years ago, they're
stunned she's still alive. She was in and out of jail and
emergency rooms, unable to connect with other people, muttering
to herself on the street, and unemployed. For 45 years, she
says, she was a drain on society. Then she finally got the
treatment she needed and now she's a taxpayer, holding down a
good job.
Amy Smith lost decades of her life because she didn't get
treatment. If you want to know the costs of our insurance
discrimination, Amy Smith can describe them: ``I would have
been able to pursue my dreams for my life, which were things
like driving a car, or holding down a real job, or getting
married, or volunteering in the community, any of those things.
I think my life would have been a lot different if I had had
those services a lot earlier.''
So many Americans have lost their dreams, lost years, and
even lost their lives--unnecessarily. In Palo Alto we met Kevin
Hines. He is a gregarious, outgoing person and is engaged to be
married this summer. In 2001 he jumped off the Golden Gate
Bridge, one of very few to survive that fall. Thirty-thousand
people succeed where Kevin fortunately failed and take their
own lives each year. How many of them would, like Kevin, be
starting families, contributing to their communities, holding
jobs, and realizing their potential if only they had access to
treatment?
Mr. Chairman, I'm happy to provide the transcripts from
the field hearings I have referenced to be included in the
record of this hearing, as well as our report, ``Ending
Insurance Discrimination: Fairness and Equality for Americans
with Mental Health and Addictive Disorders.''
We will hear arguments that, even if worthwhile,
equalizing benefits is just too costly. The truth, however, is
that the cost of doing the right thing and equalizing benefits
between mental health and addiction care on the one hand and
other physical illnesses on the other hand is negligible. This
is not speculation.
In 2001, we brought equity to mental health and addiction
care in the Federal Employees Health Benefits Program (FEHBP),
which covers 9 million lives, including ours as Members of
Congress. A detailed, peer-reviewed analysis found that
implementing parity did not raise mental health and addiction
treatment costs in the FEHBP. Since our bill specifically
references the FEHBP to define the scope of our bill, this
analysis provides strong evidence that our legislation will
similarly have negligible impact on costs. This finding is
consistent with virtually every study of state parity laws as
well.
But frankly, the very fact that we need to debate how much
it costs to end insurance discrimination is offensive. Nobody
is asked to justify the cost-effectiveness of care for diabetes
or heart disease or cancer. Tell Marley Prunty-Lara, Kitty
Westin, Tom O'Clair, Amy Smith, or Kevin Hines, or the millions
of others who live with these diseases that to keep health care
costs down for everyone else, they will not have to pay with
their lives. Why them?
People might say that there is a component of personal
responsibility here, especially with addiction. That's true.
I'm working hard every day at my recovery, and it's reasonable
to ask of me. But it's also true that we don't deny insurance
coverage to people genetically predisposed to high cholesterol
who eat fatty foods. We don't deny insurance coverage to
diabetics who fail to control their blood sugar.
At the end of the day, this is about human dignity and
whether we deliver on the promise of equal opportunity that is
at the heart of what it means to be American. Nobody chooses to
be born with particular genetics and anatomy, any more than
they choose to be born with a particular skin color or gender.
And nobody should be denied opportunities on the basis of such
immutable characteristics. Anybody who pays their health
insurance premiums is entitled to expect their plan to be there
when they get sick, whether the disease is in their heart,
their kidneys, or their brain.
Unlike any other country in the world, this one was
founded on principles--the ideas of equality and freedom and
opportunity. The history of America is the history of a country
striving to live up to those self-evident truths. In pursuit of
those values we've fought a civil war, chipped away at glass
ceilings, expanded the vote, renounced immigration exclusion
laws, and recognized that disabilities need not be barriers.
Led by one of our own colleagues, a generation of peaceful
warriors forced America to look in a mirror and ask itself
whether its actions matched its promise, and they changed
history.
It is time, once again, to ask that question: are our
actions matching our promises? And once asked, the answer is
clear. Jim and I know, personally, the power of treatment and
recovery. We are able to serve in Congress because we have been
given the opportunity to manage our chronic diseases. Every
American deserves the same chance to succeed or fail on the
basis of talent and industriousness. That's the American Dream,
and it shouldn't be rationed by diagnosis.
Thank you.
----------
Mr. Pallone. Thank you so much. Mr. Ramstad.
STATEMENT OF HON. JIM RAMSTAD, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF MINNESOTA
Mr. Ramstad. Thank you, Chairman Pallone, Ranking Member
Deal, distinguished committee members and friends all. Thank
you for holding this important hearing, and thank you for your
kind and supportive comments.
On July 31, 1981, I woke up from my last alcoholic blackout
under arrest for a variety of offenses, woke up in a jail cell
in Sioux Falls, SD, and I am alive and sober today only because
of the access that I had to treatment. Too many people don't
have that access to treatment that Patrick Kennedy and I had.
It is a national disgrace that 270,000 Americans had the doors
slammed shut to the treatment centers last year alone. It is a
national tragedy that last year alone 150,000 of our fellow
Americans died as a direct result, as a direct result of
chemical addiction. Nobody knows as an indirect result how many
heart failures, how many liver failures, how many other causes,
how many accidents that weren't documented.
It is also a national tragedy that 34,000 Americans, as
Patrick mentioned, committed suicide last year as a direct
result of depression. And it is a national crisis, really a
crisis that untreated addiction and mental illness, according
to SAMHSA, cost our economy over $550 billion last year alone.
When you think of the costs, as I know you all do, that
can't be measured in dollars and cents, the human suffering,
the broken families, the shattered dreams, the ruined careers,
destroyed lives and so on. It is time to end the discrimination
against people suffering the ravages of mental illness and
chemical addiction. It is time to end the higher copayments,
higher deductibles, out-of-pocket costs, and limited treatment
stays, discriminatory barriers to treatment that don't exist
for other diseases.
According to the GAO, 90 percent of health plans currently
impose financial limitations and treatment restrictions on
mental health and addiction care that are not imposed on other
illnesses. Ninety percent of plans impose these discriminatory
barriers that they don't impose on other illnesses. It is
really time to treat mental illness and chemical addiction
under the same rules as other medical illnesses. Because if you
believe what the American Medical Association espoused back in
1956, that addiction and mental illnesses are a disease, then
you can't justify discriminating against those diseases.
The Paul Wellstone Mental Health and Addiction Equity Act
will give Americans suffering from addiction and mental illness
greater access to treatment by prohibiting health insurers from
putting discriminatory restrictions on treatment. It will end
the discrimination against people who need treatment for mental
illness or chemical addiction. And we have all the empirical
data in the world to show that increasing access to treatment
is not only the right thing to do, but it is a cost-effective
thing to do. And I would be happy to share any of the 20-some
studies that we have that independently corroborate the fact
that parity, where it has been employed, with respect to the
Federal Employees Benefit Plan, for example, and you are going
to hear testimony, I believe, in the second panel, actually
saves dollars. This doesn't cost dollars, as those critics
would maintain. We have got the proof, the empirical data,
including all the actuarial studies, to prove that equity for
mental health and addiction treatment will save billions of
dollars nationally, while not raising anyone's premiums not
more than one-half of 1 percent.
Let me put it to you this way. For the price of a cheap cup
of coffee a month, 16 million people in health plans could
receive treatment for their mental illness or chemical
addiction. That is right from the Milliman & Roberts study, an
independent actuarial firm. Furthermore, it is well documented
that every dollar spent on treatment saves $12 in health care
and criminal justice costs alone. And that study doesn't even
take into account savings in social services, lost
productivity, absenteeism, injuries in the workplace, and so
forth. And you are going to hear from a CEO today how much
money was saved and how cost-effective parity was in his
experience. And we heard that at hearing after hearing across
the country from employers, enlightened employers who have
already enacted parity and who have already brought parity into
their plans and who are saving money.
Let me conclude by repeating as strongly as I can, it is
time to end the discrimination against people who need
treatment for mental illness and addiction. It is time to
prohibit health insurances from placing discriminatory
restrictions on treatment. It is time to provide greater access
to treatment. It is time to get this bill to the President who,
by the way, endorsed parity in 2002 in Albuquerque, NM, in a
speech there when he was with Senator Domenici.
It is time to pass the Paul Wellstone Mental Health and
Addiction Equity Act. The American people really can't afford
to wait any longer.
Thank you again, Mr. Chairman.
[The prepared statement of Mr. Ramstad follows:]
Statement of Hon. Jim Ramstad, a Representative in Congress from the
State of Minnesota
Chairman Pallone, Ranking Member Deal, thank you for
holding this important hearing.
On July 31, 1981, I woke up in a jail cell in Sioux Falls,
SD, under arrest as the result of my last alcoholic blackout.
I'm alive and sober today only because of the access I had
to treatment, as well as the grace of God and support of many
recovering people the past 25 years. I'm living proof that
treatment works and recovery is possible.
But too many people don't have access to treatment. It's a
national disgrace that 270,000 Americans were denied addiction
treatment last year. It's a national tragedy that last year
alone, 150,000 of our fellow Americans died from chemical
addiction and 30,000 Americans committed suicide from
depression. And it's a national crisis that untreated addiction
and mental illness cost our economy over $550 billion last
year.
And think of the costs that can't be measured in dollars
and cents--human suffering, broken families, shattered dreams,
ruined careers and destroyed lives.
It's time to end the discrimination against people
suffering the ravages of mental illness and chemical addiction.
It's time to end the higher copayments, deductibles, out-of-
pocket costs, and limited treatment stays--discriminatory
barriers to treatment that don't exist for other diseases. It's
time to treat mental illness and chemical addiction under the
same rules as physical illness.
The Paul Wellstone Mental Health and Addiction Equity Act
will give Americans suffering from addiction greater access to
treatment by prohibiting health insurers from placing
discriminatory restrictions on treatment.
It will end the discrimination against people who need
treatment for mental illness or chemical addiction.
Expanding access to treatment is not only the right thing
to do; it's also the cost-effective thing to do. We have all
the empirical data, including actuarial studies, to prove that
equity for mental health and addiction treatment will save
billions of dollars nationally while not raising premiums more
than one half of one percent. In other words, for the price of
a cheap cup of coffee per month, 16 million people in health
plans could receive treatment for their mental illness or
chemical addiction.
Furthermore, it's well-documented that every dollar spent
on treatment saves up to $12 in health care and criminal
justice costs alone. That does not even take into account
savings in social services, lost productivity, absenteeism and
injuries in the workplace.
Let me conclude by repeating as strongly as I can: It's
time to end the discrimination against people who need
treatment for mental illness and addiction. It's time to
prohibit health insurers from placing discriminatory
restrictions on treatment. It's time to provide greater access
to treatment. It's time to pass the Paul Wellstone Mental
Health and Addiction Equity Act.
The American people cannot afford to wait any longer for
Congress to act.
----------
Mr. Pallone. I want to thank you again. You explained
everything so well why we need to pass this bill. It certainly
is our intention to move on it as quickly as we can. And my
understanding is, we don't have any questions because I don't
think there is anything we can ask you. You basically said it
all.
Mr. Kennedy. If I could say the sooner that you can move on
it, I know the Senate is going to be moving on unanimous
consent. Obviously, we have an opportunity to set the bar if we
move on it before they do.
There has--many of you on both sides of the aisle have made
the point on State's rights which I think is a really strong
point. States ought to have the opportunity to experiment and
certainly should not be preempted by the Federal Government,
and we would have a much stronger position going into it if we
were to pass our bill first, I think.
Mr. Pallone. I know it has got to go to several committees,
but it is already out of two of them, right, is my
understanding.
OK. We are going to try our best, and I agree with you on
the preemption. That was certainly brought home to me when we
had the hearing in Trenton. That was maybe 50 percent of the
debate that day, if I remember. So really, thank you again; we
appreciate it.
Mr. Burgess. I would ask unanimous consent if Mr. Ramstad
would make that Millerman & Roberts study available to the
committee.
Mr. Ramstad. Thank you. I would be happy to.
Mr. Pallone. Welcome. Thank you for being here. Starting
from my left is Mr. James Purcell, who is president and chief
executive officer of Blue Cross and Blue Shield of Rhode
Island.
Ms. Edwina Rogers, who is vice president of health policy
for the ERISA Industry Committee. Then we have Ms. Marley
Prunty-Lara; I don't know if I am pronouncing it properly. And
then we have Mr. James Klein, who is president of the American
Benefits Council. And, finally, Dr. Howard H. Goldman, who is a
professor of psychiatry at the University of Maryland School of
Medicine.
As you know, we have 5-minute opening statements. We will
put your statements in the record. If you would like to give us
some additional material later, you can do that as well, and
then we will take some questions.
So we will start with Mr. Purcell.
STATEMENT OF JAMES E. PURCELL, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, BLUE CROSS & BLUE SHIELD OF RHODE ISLAND
Mr. Purcell. Thank you very much. It is a pleasure to be
here, Chairman Pallone, Ranking Member Deal and members of the
committee.
Representing the health insurer at hearings like this, we
are usually the skunk at the lawn party. Typically, we are
testifying against mandates for a variety of reasons, most
often because they increase the cost of health insurance; and
many times, they are anecdotally driven and they, quite
frankly, sometimes don't improve the quality of care that is
rendered.
Here, I believe this to be an exceptional case, and that is
why I am here testifying in favor of this legislation.
My comments here today reflect my experience and the
experience of my Blue Cross plan in the State of Rhode Island.
This experience involves both behavioral and physical health.
The two are inextricably inclined. You can't separate one from
the other and think that you are providing good health care,
because you are not.
My statement, I will say, only reflects the position of
Blue Cross and Blue Shield of Rhode Island. It does not reflect
the other positions of other Blue Cross plans nor does it
affect the position of Blue Cross Association.
We are an independent local nonprofit plan closely
regulated by the State of Rhode Island, and our vision is to
improve the lives of our members by improving their health.
That is our bottom line. On our members' behalf and in
recognition of the leadership of our senior Congressman,
Patrick Kennedy, and your invitation, I am here today about a
simple message.
Unlike most mandates, this doesn't cost much, if anything.
Even if you just look at the cost of the claims expense
associated with behavioral health care that we cover, it is 3.6
percent of the total bill, and that doesn't even take into
account the savings on the physical side associated with early
intervention for all of the reasons that we have heard from the
other witnesses.
I am of the passionate view that without full integration
of behavioral and physical health, we cannot fully achieve our
vision of improving our members' lives by improving their
health; and unfortunately, without a meaningful behavioral
health parity bill on a Federal level, I think we demonstrate
to ourselves that it is just not going to happen.
I submit this testimony mindful of the insurers' special
role in all of this.
We have a very difficult balance between maximizing
coverage for our members, improving reimbursement to providers
and trying to keep health insurance premiums at a reasonable
level. Some could argue, it is not at a reasonable level
anymore, but we do everything that we can to try to minimize
the increases associated with this. This is a very delicate,
very difficult balance, and we are in the middle of it. So that
is our job. That is what we do.
Like most insurers, we are not generally supportive of
mandates with regard to coverage. But here I quite frankly
think, given what we have observed in the State of Rhode Island
with our mental health parity law and what we have observed in
our own plan, we can demonstrate to you that this has
dramatically improved the quality of care that our members get,
and it has not significantly increased the cost of that care.
One of the things I would strongly urge the committee is
with regard to the effective date of the bill. Six months is
too little time. If we want to do it and do it right, you have
to give plans time to do the system changes. Some plans are
going to have to create networks, negotiate contracts.
It took a long time to implement the FEP program parity. So
here, please, I would ask you first of all, you might want to
consider extending the effective date to 11/09. I think that
would allow plans to do a good job and, still, you would
implement the parity.
Second, I would be less than candid if I didn't address two
issues that I have some concerns about. And I think these are
details that it looks like you wish to cover. I just want to
make sure it does. And those are the issues with regard to
medical management and out-of-network coverage.
One of the things that we can do to ensure quality-of-care
access and do something about costs, medical management and
network, the network gives us the contractual right to do these
things. And if we have an adequate network so that we have
adequate access, there should be no reason to have complete
open access to added network coverage. I can't guarantee to my
members that they are receiving quality of care if they can go
anywhere that they want to.
So somewhere within this we have to ensure that if there is
adequate access to care within the network, if members choose
to go out of the network, they pay an additional amount for
that so that there is an incentive to say that we can guarantee
their quality.
Since the initial passage of Rhode Island's partial mental
parity in 1994, we have continued to ratchet up our coverage.
We have done many things with regard to coverage as set forth
in my testimony. I will not go through that here, but in
essence, through the combination of State statute and how we
have changed--voluntarily changed our coverage, we have, in
essence, de facto parity in our State.
And in 2006, we increased office visits from a maximum of
30 to a maximum of 50. We voluntarily did that. Why on earth
would we do that? Because those very few people that need in
excess of 30 office visits really, really need it. And when do
they run out of the 30? Right at the----
Mr. Pallone. I have got to tell you are over by a minute so
you are going to have to summarize.
Mr. Purcell. I will summarize it. It doesn't break the
bank. I think it gives better care. I think the experience in
Rhode Island demonstrates that, and I would urge its passage.
The prepared statement of Mr. Purcell follows:]
[GRAPHIC] [TIFF OMITTED] T2868.001
[GRAPHIC] [TIFF OMITTED] T2868.002
[GRAPHIC] [TIFF OMITTED] T2868.003
[GRAPHIC] [TIFF OMITTED] T2868.004
[GRAPHIC] [TIFF OMITTED] T2868.005
Mr. Pallone. Ms. Rogers.
STATEMENT OF EDWINA ROGERS, VICE PRESIDENT, HEALTH POLICY, THE
ERISA INDUSTRY COMMITTEE (ERIC)
Ms. Rogers. Good afternoon, Chairman Pallone and Ranking
Member Deal. Thank you for the opportunity to testify today.
I am going to speak from the plan sponsor perspective
representing companies that pay for health coverage for tens of
millions of Americans. My testimony will focus on concerns
about the Kennedy-Ramstad Mental Health Parity bill, H.R. 1424.
ERISA members are in favor of expanding coverage, but this
bill's approach is fundamentally flawed, we believe. The bill
fails to incent better coverage options. It creates mandates,
micromanaging the distribution of benefits, creating costly
administrative quagmires and failing to keep up with
integrations and demands widely accepted in the market.
Today, major employers offer benefits to the employees on a
voluntary basis to attract and keep employees, improve morale
and productivity, and because they take pride in providing for
the employees' life security.
Congress developed ERISA so that major employers could
create uniform national plans that fit the needs of their
employees regardless of where they live, work or receive their
health care. ERISA was created as a floor upon which States
could create--was not created as a floor. ERISA was meant to be
the ceiling.
As Congress considers a bill that would burden employers by
forcing them to increase coverage and dissolving their plan
flexibility, look to ERISA for guidance. Rather than leaving
plan sponsors at the mercy of various State laws, Congress
could make a parity law that preempts conflicting State laws,
giving employers clear guidance on how to become compliant on a
national level.
Plan sponsors are concerned about the accreditation of
mental health providers and facilities, as well as their
accountability and transparency, and must be able to designate
which facilities and treatments are bona fide and which should
not be covered.
Plan sponsors are moving away from a system of trust, don't
verify in demanding metrics in transparency for all medical
providers, data that lets employers and patients know the cost
of an episode of care and make informed decisions on where to
get quality treatment. A bill to promote mental health and
substance abuse treatment would fail in its mission if it did
not include such provisions for the mental health community.
Proponents of the mental health mandate claim it would
lower health care costs, but the bill includes provisions
anticipating cost increases. New ERISA members stated that
simply implementing this bill, ignoring the costs associated
with actually covering the benefits, would cost millions of
dollars. One member company cited preexisting contracts with
more than 150 plans, all of which would require amendment or
renegotiation.
Other major employers mentioned that a 2 percent increase
would be more than $10 million for them and that every 1
percent of health care costs shifted to employees translates to
about $70 annual costs per employee.
Historically, it was employers who developed consumeristic
strategies, demanded transparency, urged adoption of health IT
and evidence-based medicine, proposed paying for performance,
initiated patient-centered medical homes and began sponsoring
disease management and drug therapy programs, and the list goes
on.
The current health care systematic actively discourages
employers from participation with the regulatory structure so
burdensome that it effectively requires them to operate two
businesses, One to operate their core business and one to
administer benefits. As employers are moving to simplify the
system and leveling the playing field, this bill moves in the
wrong direction complicating coverage and increasing financial
burdens.
The bottom line is that legislation, this legislation will
likely reduce coverage and not improve quality for major
employers. Plan sponsors have to reduce coverage or further
shift costs. In mandating how plan designs and how they offer
their voluntary benefits, this legislation will hurt plan
sponsor flexibility and force one-size-fits-all policies.
The bill will open floodgates of State mandates and
substance abuse mandates which will be extremely costly and
burdensome, if not impossible, to comply with. The scope of
benefits being managed is clearly written in favor of mental
health groups.
Those pushing for legislation are not taking into account
the extremely volatile financial situation of current voluntary
benefit plans. Further, the bill does not even approach the
issue of mental health providers and facilities keeping up with
the necessities and innovations of today's health care
markets--transparency of quality and pricing data, use of
health information technology and performance-based
reimbursement systems.
If Congress wants to increase mental health and substance
abuse coverage, it should address the transparency,
accountability, and affordability and the education issues, not
create new mandates.
Thank you, Mr. Chairman.
[The prepared statement of Ms. Rogers follows:]
Testimony of Edwina Rogers
Good morning, and thank you Chairman Pallone and Ranking
Member Deal for the opportunity to testify at this hearing.
I am Edwina Rogers, vice president for health policy at
The ERISA Industry Committee (ERIC). ERIC is a non-profit trade
association committed to the advancement of employee health,
retirement, and compensation plans of America's largest
employers. We represent exclusively the employee benefits
interests of major employers. ERIC is engaged in policy
affecting our members' ability to deliver benefits, their cost
and their effectiveness, as well as the role of employee
benefits in America's economy.
Today I will speak from a plan-sponsor perspective,
representing companies that pay for health coverage for tens of
millions of Americans. My testimony will focus on issues of
concern in the Kennedy-Ramstad Mental Health Parity bill, H.R.
1424.
ERIC members are broadly in favor of expanding coverage,
but the approach contained within H.R. 1424 is fundamentally
flawed. The bill fails to incentivize better coverage options,
instead injecting government into the world of voluntary
benefits, creating mandates, micromanaging the distribution of
benefits, failing to protect plan sponsors from burdensome and
costly administrative quagmires, and failing to keep up with
innovations and demands already widely accepted in the private
health benefits marketplace.
Voluntary Benefits and ERISA Preemption
Today major employers offer health, pension, and other
benefits to their employees on a voluntary basis. They pay the
exorbitant costs associated with these benefits in order to
attract and keep employees, to improve morale and productivity,
and because major employers take pride in providing for their
employees' life security.
Major employers operate in multiple states--some in all
50--and their employees have common needs that are often not
shared with arbitrarily-drawn regions, states, or localities.
Congress developed the Employee Retirement Income Security Act
of 1974 (ERISA) so that major employers could create uniform
national plans that fit the needs of their employees,
regardless of where the employees lived, worked, or received
healthcare. ERISA was not created as a ``floor'' upon which
states could create differing, conflicting laws; this would
have made voluntarily sponsoring a plan extremely expensive and
burdensome. ERISA is meant to be the ceiling--the Department of
Labor regulates the operations of employer-sponsored benefit
plans in every state, regardless of the laws various states
create.
As Congress considers a bill that would burden those
employers who have chosen voluntarily to offer mental health
and/or substance abuse benefits by forcing them to increase
coverage and dissolving their plan flexibility, they should
look to ERISA for guidance. Rather than leaving plan sponsors
at the mercy of various state laws, Congress could choose to
pass a mental health parity law that preempts conflicting state
laws, giving employers clear guidance on how to be compliant on
a national level. We should all be moving to support a uniform
national system. Instead, by allowing states to craft their own
laws, and not including preemption language, the Kennedy-
Ramstad bill would further disincentivize plan sponsors from
offering any mental health coverage at all. Further, there is
no indication that legislators will not simply continue to
expand on employer healthcare mandates, for mental and medical
care, continuing to drive up costs and push employers closer to
one-size-fits-all plans.
Plan Flexibility and Accountability
Major employers have used logic, experience, and
experimentation to create plans that offer affordable coverage
that works for their employees. Many plans have determined that
certain conditions should be covered, while other conditions
(particularly some that are listed in that mental illness
handbook authored by the mental health lobby, the Diagnostic
and Statistical Manual of Mental Disorders, DSM-IV) are not
valid. Because plan sponsors were able to make these judgments,
engage in medical management, and design plans that covered the
conditions they chose, many plan sponsors currently offer
extremely generous mental health and substance abuse coverage.
The soundness of some conditions endorsed by the mental
health lobby is not the only issue plan sponsors are wary of
when purchasing mental health care--plan sponsors are also
concerned about the accreditation of mental health providers
and facilities, as well as their accountability and
transparency. Must employers pay preposterously high rates to
treat imagined detriments like jet lag, shyness, or other
ailments treated with ``folk'' remedies or possibly unnecessary
medications from unaccredited professionals? Plan sponsors need
the flexibility to define which treatments, focusing on
evidence-based medicine, should be covered. They must be able
to define a network of providers within (and outside) their
preferred network. Plan sponsors must be able to designate
which mental health facilities are bona fide and which should
not be covered under their plan offerings.
If mental health and substance abuse treatment are
mandated to have the same financial and treatment rules as
medical coverage, they should also have the same accountability
standards. Plan sponsors are moving away from a system of
``trust, don't verify,'' and beginning to demand metrics and
transparency from all medical providers--data that lets
employers and patients know the costs of an episode of care,
and helps them make informed decisions on where to get
treatment through reporting on quality measures. A bill to
promote mental health and substance abuse treatment would fail
in its mission if it did not include accountability and
transparency provisions for the mental health community, if not
also including value-based purchasing language and urging these
providers, facilities, and programs to begin using health
information technology. It would be a mistake to impose a host
of new elements into the healthcare coverage equation without
also requiring those elements to comply with the innovations
and advances (in both quality and cost efficiency) already made
standard in the rest of the healthcare community. ERIC members
overwhelmingly reject the one-way street of information from
the mental health community--while the bill demands plan design
details and claims information from ERISA plans, it does not
require any transparency from the mental health and substance
abuse community. A balanced bill must include accountability
provisions that include transparency of price and quality data.
Out of Control Costs
Proponents of the mental health mandate claim that it will
lower healthcare costs, but the bill includes very clear
provisions anticipating cost increases. No doubt the bill's
backers believe that they are making a concession in offering a
one-year exemption if, six months into a compliant program, a
plan sponsor finds that costs are rising at more than an
additional two percent in the initial year or one percent in
subsequent years due to the mandate. This demonstrates a
critical lack of understanding of the financial strains US
employers are currently facing. While trying to stay globally
competitive, employers have been burdened with double-digit
healthcare inflation costs, and are under severe pressure to
curb these costs--or to cut benefits. Employers have gone to
great lengths to lower costs by one or two percent, and any
instant infusion of greater costs could be catastrophic for
workers' coverage. Numerous ERIC members have stated that
simply implementing this change in their plans
administratively, ignoring the costs associated with actually
covering this benefit, would cost millions of dollars,
requiring extensive revision to pre-existing plans. One member
company cited pre-existing contracts with more than 150 plans,
all of which would require amendment or renegotiation. Other
major employers mentioned that a two percent increase would be
more than $10 million, and that every one percent of healthcare
costs shifted to employees translated to about $70 annual cost
per employee.
If the Federal Government steps in, fencing off mental
health benefits and mandating that employers provide them, the
prices of mental health services are sure to rise. Creating an
instant, massive increase in demand will certainly dry up the
supply, making mental health providers and facilities an even
rarer commodity than they already are. It is highly probable
that this legislation will lead to an unnecessary rise of
utilization, which will in turn lead to a lack of mental health
and substance abuse services, denying care to those who need it
most. Creating an artificial demand will disrupt the market,
drive up prices, and lead to shortages.
Employers, not government, started all the major
healthcare quality and efficiency improvement innovations in
the past decade. Employers developed consumerist strategies,
demanded transparency, urged adoption of health IT and
evidence-based medicine, proposed paying for performance,
initiated patient centered medical homes, began sponsoring
disease management and drug therapy programs, and the list goes
on. It took the government ten years just to decide that plan
sponsors who offer more coverage to early retirees than to
those eligible for Medicare are not engaging in age-
discrimination. Now the government, at the urging of a lobby
that has specific financial interests in the outcome, is
purporting to dictate to the business community how to offer
health benefits and save money--something is certainly amiss
here. If in fact proponents of mental health parity can prove
that it lowers plan costs and improves employee health, they do
not need to force this ``reform'' by legislative fiat. Rather,
this would be an issue of education and advocacy, not
government interference and employer mandates.
Just this week the employer community proposed a new
platform for life security that could serve to expand all
manner of health coverage to many more individuals and small
businesses, without harming the current employer-sponsored
system. ERIC's New Benefit Platform for Life Security envisions
competing expert third-party administrators who manage
employers' voluntary contributions, as well as individuals'
contributions, and provide affordable, effective, and
innovative retirement and healthcare security benefits. These
administrators will allow major employers, small businesses,
and individuals all to purchase fully portable coverage at
equal rates. This private market system, coupled with tax
parity, an individual mandate, and subsidies for low-income
individuals, embodies a revolutionary step forward in expanding
access and coverage to all Americans, while improving our
global competitiveness.
The current healthcare system actively discourages
employers from participation with a regulatory structure so
burdensome that it effectively requires an employer to operate
two businesses, in which one operates the employer's core
business and the other provides and administers benefits. As
employers are moving to simplify the system and build a level
playing field, this bill moves in the wrong direction,
complicating providing coverage and increasing financial
burdens on plan sponsors and beneficiaries.
The government specializes in micro-mismanagement and
reducing coverage; between crowd-out by entitlement programs,
ill-conceived healthcare mandates, and other botched attempts,
the government has failed to address with any real success the
more than 40 million uninsured Americans. This is partially
because government has failed to address costs before pushing
for coverage--instead of deregulating and making the individual
and small business healthcare market more affordable, they have
continued to pile on cost-drivers. Instead of enacting tort
reform, allowing small businesses to band together for
purchasing clout, or allowing insurance to be purchased over
state lines, government continues to regulate how voluntary
benefits are provided, further incentivizing plan sponsors to
cut back coverage. If this bill is enacted, some ERIC members
have stated they will reduce coverage, increase employee
contributions, and implement treatment limits on medical care.
What Treatment Is Covered?
In defining the minimum scope of the new mandated
benefits, this legislation works in a very round-about way. The
bill reads that if a plan offers any related benefit, it must
cover all the mental health and substance abuse benefits (with
significant enrollment) covered by the Federal Employees Health
Benefit (FEHB). The FEHB implemented mental health parity in
2001--and according to a 2005 study by HHS, has seen cost
increases due to it. More than 56 percent of FEHB beneficiaries
are enrolled in Blue Cross Blue Shield plans. This, in essence,
means that Blue Cross plans will always be in compliance, while
other plans will be forced to conform to the models adopted by
Blue Cross. This has serious implications for plan competition
and flexibility, and may lead to increased costs (and decreased
participation and coverage).
The legislation does not clearly define how much
enrollment in FEHB is necessary such that a condition or
substance is mandated to be covered. It also does not designate
which conditions or substances might require ``emergency care''
that would surely incur substantially increased costs. These
facets of the legislation leave the door wide open for price-
fixing, as any mental health or substance abuse group that can
convince a particular plan to adopt coverage for a particular
condition or substance can thus force all other plans to adopt
it--and can charge vastly different rates to Blue Cross than to
other plans.
It is doubtful that this was the intention of the
legislation--in the rush to legislate, the bill's backers may
have been attempting to avoid the pitfalls of using the overtly
lobbyist-driven DSM IV. However, the option selected is only
slightly better--perhaps an omen to alert Congress that plan
design is best left to plan sponsors, not outside actors who
have financial incentives to overcharge ERISA plans.
The bottom line is that this legislation will very likely
reduce coverage, not improve quality or increase coverage. Plan
sponsors, already stretched thin, will have no avenue to deal
with their increased costs other than to reduce coverage or to
further shift costs to employees. In mandating how plans design
and offer their voluntary benefits, this legislation will
reduce plan sponsors' flexibility and force one-size-fits all
policies on diverse and varying pools of workers. The bill will
open floodgates of state mental health and substance abuse
mandates, which will be extremely costly and burdensome, if not
impossible, to comply with. The scope of benefits being
mandated is hazy, but clearly written in favor of mental health
interest groups, and leaves room for serious vice. Those
pushing this legislation are not taking into account the
extremely volatile financial situations of current voluntary
benefit plans. Further, the bill does not even approach the
issue of mental health and substance abuse treatment providers
and facilities keeping up with the necessities and innovations
of today's healthcare market--transparency of quality and
pricing data, use of information technology, and performance-
based reimbursement systems. If Congress wants to increase
mental health and substance abuse coverage, it should address
transparency, accountability, and affordability and education
issues, rather than creating a new mandate.
----------
Mr. Pallone. Thank you. Ms. Prunty-Lara.
STATEMENT OF MARLEY PRUNTY-LARA, BOARD MEMBER, MENTAL HEALTH
AMERICA
Ms. Prunty-Lara. Thank you very much for this invitation.
I am here before you for one simple reason: because I am
dedicated to the proposition that mental health matters. It
matters because many lose their dignity and sometimes their
lives in the struggle for mental wellness. It matters to me
because mental illnesses compromised my mental health so
profoundly that it put my life and dreams in jeopardy.
My name is Marley Prunty-Lara, and today I am here to
testify in support of a bill to establish simple fairness in
insurance coverage for people with mental health conditions.
I serve on the National Board of Directors for Mental
Health America, formerly the National Mental Health
Association. I work to improve mental health care policies, not
simply because I have a mental illness, but because I know
treatment works.
I have passionately lived within the prison of mental
illness and have experienced the incalculable emancipation that
accompanies wellness. I am here today because effective
treatment saved my life. I am also here because the opportunity
of health should not be something granted only to the lucky and
privileged few.
When I was diagnosed with bipolar disorder at the age of
15, I never imagined the pain I would endure as a result of my
illness. Before adequate treatment, I intimately knew the
harrowing, sinister suicidal depression no one likes to talk
about. I knew the mania that could obscure the world and
deprive me of sleep for days. It would fill my mind with racing
thoughts and grandiose ideas, most of them unfeasible and left
abandoned, incomplete.
Living with this disease has meant not only enduring the
disabling lows and exhilarating highs, but also fighting for
insurance coverage, educational accommodations and appropriate
health care. I have experienced firsthand the narrow mindedness
insurance companies and some in the business industry show
toward mental illness.
During my teen years, as my mom searched for a psychiatrist
available to treat me in South Dakota, a rural State with
limited mental health resources, we were told we would have to
wait 4 to 5 months before I could get an initial appointment. I
did not have that long to live.
We found help 350 miles away in another State. And I was
hospitalized for 2 months. However, the treatment facility was
not covered by my mother's insurance, forcing my parents to
take a second mortgage out on their home in order for me to
receive the care that I urgently needed.
Had I suffered a spinal cord injury requiring long-term
hospitalization, my insurance company would have paid for my
care, but because my hospitalization involved a disease of the
mind, my insurance company deemed it unworthy of equitable
coverage.
I am one of the lucky ones. My family was able to take out
a mortgage to afford my inpatient care. However, many in this
country currently face a question with no easy answer. What
happens when the insurance benefits run out and you are not
better yet?
My family did everything we were supposed to. My mother, a
CPA, an ardent advocate on behalf of her daughter, had a good
paying job and health insurance. She was adept at handling our
insurance claims, and we exhausted our efforts to receive
treatment within the coverage system.
I did not chose my disease.
I ask those who oppose this legislation what are people to
do when they don't have the options my family had, when parents
must choose between watching their children deteriorate or
giving up custody to obtain insurance benefits? At what point
do we decide collectively to end the suffering of millions?
For children struggling to cope with a mental illnesses,
wellness should not depend on luck, on whether a family's
particular health plan provides ample and equitable mental
health coverage. In my case, it has proven far cheaper to treat
my mental illnesses with medication and proper psychiatric care
than to have me in and out of hospitals and emergency rooms. I
understand the power of successful treatment because I am
living it.
Congress enacted a parity law in 1996, but it requires only
partial parity. Current law still permits discrimination based
on mental health conditions, and it is routine in practice.
Both current law and practice are untenable. Americans agree
that partial fairness is unacceptable. In a survey conducted by
International Communications Research, an independent research
company, and paid for by Mental Health America----
Mr. Pallone. I hate to interrupt you because I am--you are
really telling an important story--because you are over a
minute.
Ms. Prunty-Lara. Let me just conclude.
I implore this committee to act soon to adopt H.R. 1424. I
urge you further to reject amendments that would weaken it. Kay
Jamison once said this gap between what we know and what we do
is lethal.
The time is right and the time is now to enact
comprehensive Federal parity. I leave with you that charge and
hope today. Please remember my name, my face, and my story as
you work and decide to pass this vital legislation.
America is waiting. Thank you.
Mr. Pallone. Thank you, and I wanted you all to know that
we do put your entire statement in the record even if I ask you
to summarize at the end.
Thank you.
[The prepared statement of Ms. Prunty-Lara follows:]
Testimony of Marley Prunty-Lara
Good morning. I am here before you for one simple reason--
because I am dedicated to the proposition that mental health
matters. It matters because many lose their dignity, and
sometimes their lives, in the struggle for mental wellness; it
matters to me because illness compromised my mental health so
profoundly that it put my life and dreams in jeopardy.
My name is Marley Prunty-Lara and today I am here to
testify in support of a bill to establish simple fairness in
insurance coverage for people with mental health conditions. I
serve on the national Board of Directors for Mental Health
America, formerly the National Mental Health Association. I
work to improve mental health care policies, not simply because
I have a mental illness, but because I know that treatment
works. I have passionately lived within the prison of mental
illness and have experienced the incalculable emancipation that
accompanies wellness. I am here today because effective
treatment saved my life. I am here today because the
opportunity of health should not be something granted only to
the lucky and privileged few.
When I was diagnosed with bipolar disorder at the age of
15, I never imagined the pain I would endure as a result of my
illness. Before adequate treatment, I intimately knew the
harrowing, sinister, suicidal depression no one talks about. I
knew the mania that would obscure the world and deprive me of
sleep for days. It would fill my mind with racing thoughts and
grandiose ideas; most of them unfeasible and left abandoned
incomplete. Living with this disease has meant not only
enduring the disabling lows and exhilarating highs but also
fighting for insurance coverage, educational accommodations,
and appropriate health care.
I have experienced first hand the narrow-mindedness
insurance companies and some in the business community show
toward mental illness. During my teen years, as my mom searched
for a psychiatrist available to treat me in South Dakota, a
rural state with limited mental health resources, we were told
we would have to wait four to five months before I could get an
initial appointment. I did not have that long to live. We found
help, 350 miles away, in another state, and I was hospitalized
for two months. However, the treatment facility was not covered
by my mother's insurance; forcing my parents to take a second
mortgage out on their home in order for me to receive the care
that I urgently needed. Had I suffered a spinal cord injury
requiring long-term hospitalization, my insurance company would
have paid for my care; but because my hospitalization involved
a disease of the mind, my insurance company deemed it unworthy
of equitable coverage.
I am one of the lucky ones; my family was able to take out
a mortgage to afford my in-patient care. However, many in this
country currently face a question with no easy answer: What
happens when the insurance benefits run out and you're not
better yet? My family did everything we were supposed to; my
mother, a C.P.A., had a good-paying job and health insurance.
She was adept at handling our insurance claims and we exhausted
our efforts to receive treatment within the coverage system. I
did not choose my disease. I ask those who oppose this
legislation: what are people to do when they don't have the
options my family had; when parents must choose between
watching their children deteriorate and giving up custody to
obtain insurance benefits? At what point to we decide
collectively to end the suffering of millions?
For children struggling to cope with a mental illness,
wellness should not depend on luck, on whether a family's
particular health plan provides ample and equitable mental
health coverage. In my case, it has proven far cheaper to treat
my mental illness with medication and proper psychiatric care,
than to have me in and out of hospitals and emergency rooms. I
understand the power of successful treatment because I am
living it.
We live in a time where discrimination ought not be
tolerated, in any form, against any people. Having a mental
illness should neither determine one's fate nor limit one's
potential. As our country faces the challenges of war, of
returning veterans changed forever by the trauma of combat,
Congress must reaffirm its commitment to the principles of
justice and the pursuit of happiness by enacting comprehensive
mental health parity legislation. It is not enough to simply
continue to say, ``We must change,'' veterans, active-duty
military personnel, and their families; employers; teachers;
doctors; and those that are struggling--are all counting on
Congress to be the difference, to make prevention, treatment,
and recovery believable realities.
The costs of mental health and substance use conditions are
unavoidable. Our only decision is how we pay for them. Society
can either invest in treating mental health and substance use
conditions or pay a greater price through homelessness, lost
productivity, suicide, and an increased reliance on the
criminal justice system. Enacting a comprehensive mental health
parity law sends a strong message to people across this country
that mental health is fundamental to overall good health. It
sends a message to those living with a mental illness that
their disease is just as real as cancer and diabetes. Enacting
mental health parity sends a message to the business community
that we value the health of their employees and their bottom
line. I believe that treatment access follows dollars; by
eliminating a barrier to treatment, we provide an incentive for
providers to enter the mental health field.
Congress enacted a parity law in 1996. However, that law
required only partial parity. Current law still permits
discrimination based on mental health conditions, and it is
routine in practice. Both current law and practice are
untenable. Federal law must demand fairness in health coverage
on behalf of people with or at risk of mental health
conditions. Americans agree that ``partial'' fairness is
unacceptable. In a survey conducted by International
Communications Research, an independent research company, and
paid for by Mental Health America, 89 percent of Americans
asserted that insurance plans should cover mental health
treatments at the same level as treatments for general health
problems. 74 percent believe that insurance plans should cover
substance abuse treatments at the same levels as treatments for
general health issues and 89 percent of employees and employers
want health insurance coverage for mental health treatments to
be equitable to general health treatments. \1\
---------------------------------------------------------------------------
1 Interviews were conducted via telephone and the Internet from
October 10 to November 1, 2006 among a nationally representative sample
of 3,040 respondents age 18 and older.
---------------------------------------------------------------------------
I implore this committee to act soon and adopt H.R. 1424. I
urge you further to reject amendments that would weaken it. I
ask you to consider my testimony not solely as one person's
story, but as a microcosm of millions of Americans. We are
people whose treatment has been cut short by arbitrary
treatment limits, not only annual, day, and visit limits, but
even lifetime caps on outpatient visits. Consider your son or
daughter, with health insurance, being told that their
treatment for cancer would not be covered because their
diagnosis required more chemotherapy treatments than their plan
allowed. Imagine finding out that your broken leg, which could
be healed with appropriate care, would have to fester un-cast
because your insurance provider denied your claim on the basis
that a broken leg could be managed on its own. Many with mental
health conditions face these realities every day. The Paul
Wellstone Mental Health and Addiction Equity Act seeks to
remedy the incorrigible and nonsensical practices of the
insurance industry. The industry has failed to act alone. The
time has come for accountability and justice.
It is imperative that help be available to those that seek
it. Sanctioned discrimination toward those with mental illness
must end. H.R. 1424 provides fundamental protections against
the range of discrimination experienced by people like me.
Please do not dilute it. Please adopt it with utmost
expediency. Insurance must not stand in the way of goals and
dreams and normalcy; rather it should be the means by which one
achieves health. Kay Jamison once said, ``The gap between what
we know and what we do is lethal.'' The time is right and the
time is now to enact comprehensive Federal parity. I leave with
you that charge today. Remember my name; remember my face;
remember my story. America is waiting. Thank you.
----------
Mr. Pallone. Mr. Klein.
STATEMENT OF JAMES A. KLEIN, PRESIDENT, AMERICAN BENEFITS
COUNCIL
Mr. Klein. Thank you very much, Mr. Chairman.
I am testifying today on behalf of the American Benefits
Council. Our member companies are primarily very large national
employers, as well as health plans and other organizations that
design and administer health coverage of all sizes, 100 million
Americans overall, in health and retirement plans.
Today, I would like to pose and then answer four questions.
The first question is: why are mental health benefits so
important? The second is: can employers, insurers, mental
health providers and patient advocates reach consensus on
mental health parity? Third, does H.R. 1424, the Kennedy-
Ramstad bill which is the topic of today's hearing, meet the
criteria needed for consensus? And fourth, if parity is so
vital, why doesn't the proposed legislation apply to numerous
federally sponsored health plans?
The answer to the first question, why are mental health
benefits so important, is quite obvious. There probably is not
a single person in this hearing room who has not been affected
by mental illness either personally, or as we heard from the
compelling witnesses today, Ms. Prunty-Lara, Congressman
Kennedy and Congressman Ramstad, or through a family member or
a friend.
For me personally, just a few months ago, a young woman who
was a friend of my teenage daughter took her own life after
struggling with mental illness. Ms. Prunty-Lara is one of the
happy cases. My daughter's friend was not. This issue touches
us all.
U.S. employers believe in the value of mental health
coverage and spend vast sums to provide it to their workers and
family members. Employer opposition over the past decade to
expanding current parity law does not reflect lack of support
for mental health benefits for all of the reasons noted earlier
that providing mental health benefits can save employers money.
Rather, the concern and opposition is based on concern over
a highly prescriptive legislation that dictates the details of
health plans that denies employers the opportunity to manage
plans in ways that are permitted for medical and surgical
benefits, and that it allows States to impose varying
standards.
Mr. Chairman and members of the subcommittee, that is not
parity. That is a proposed set of rules that treats mental
health benefits vastly differently than health coverage for
other conditions.
This raises the second question: Can employers and
insurers, mental health providers and patient advocates reach
consensus on parity? The answer is an emphatic ``yes,'' and it
has already been done.
Over the past several months, Senators Kennedy, Enzi and
Domenici brought together the major stakeholders on this issue
on a process that addressed all parties' primary concerns. The
American Benefits Council was privileged to work on behalf of
employers during this effort. The resulting bill, which passed
the Senate Health Committee by a strong, bipartisan 18 to 3
vote, may not be anyone's ideal, but it resolves the mental
health debate in a way that patients, providers, employers and
insurers can all be proud and satisfied.
The Senate bill retains private employers' flexibility to
design the plans they pay for, just like the Federal Government
does for the plan it sponsors. It protects medical management
and ensures uniformity between Federal and State parity
requirements. Even more important than what the collaborative
process means for achieving mental health parity legislation is
that it can serve as a model to be emulated as Congress seeks
consensus on much broader health care reform challenges.
With that in mind, let me pose the third question: Does
H.R. 1424 meet the criteria for consensus? Regrettably, my
answer must be ``no.'' My written statement describes more
fully the deficiencies of the House bill, but the essence of
our concern is that it approaches for employers--employer and
health plan priorities in exactly the opposite way that the
Senate bill resolves this.
First, H.R. 1424 requires that if a health plan covers any
mental health or substance-related disorder benefits, that it
must cover all conditions described in this DSM-IV volume that
identifies such disorders. My point here is not to make a value
judgment as to whether some health conditions are more worthy
of coverage than others. My point is to say that Congress
should not do so either. Wisely, Federal law does not impose
such prescriptive rules on coverage for other physical
conditions, and it is not justified for mental health benefits
either.
Second, unlike the Senate bill, the House bill does not
protect medical management practices to ensure that patients
are receiving appropriate care. Health care providers, consumer
groups and purchasers are actively promoting evidence-based
measures of quality care. The House bill would stymie these
efforts as it relates to mental health conditions.
I will quickly sum up.
Third, the House bill mandates coverage for mental health
disorders by out-of-network providers if the plan covers out-
of-network coverage for certain categories of medical and
surgical services. This goes even disposing beyond the rules
governing the Federal employers' benefit plans.
Fourth, the House bill authorizes States to expand
enforcement and remedy schemes, either creating special rules
applicable only to mental health benefits, which seems patently
unfair, or arguably creating a whole new set of State-by-State
enforcement-of-remedy standards for all types of health
benefits, which is clearly beyond the scope of the mental
health parity bill.
ERISA's uniform framework should not be dismantled and
certainly not as an afterthought on the mental health parity
bill.
And finally, the American Benefits Council asks why, if
parity is so vital, does the proposed legislation treat people
different depending on the plan from which they receive
coverage. More specifically, why impose parity requirements on
health plans sponsored by private employers and State and local
governments when full parity is not required in Medicare,
Medicaid, veterans health care and TRICARE for active and
retired military personnel.
I cannot answer that question. Only Congress can explain
why there is already parity in FEHBP, which covers Federal
employees, including Members of Congress and their staff, but
the proposed legislation completely ignores these other vital
health programs. Surely the elderly, the poor, and those who
have bravely put their lives at risk for this Nation should not
be overlooked.
Basic fairness, not to mention leadership by example,
dictates that Congress should not impose requirements on
private employers and State and local governments when it has
not yet extended the same requirements to all health plans that
the Federal Government itself designs and pays for.
Thank you very much for the opportunity to testify.
[The prepared statement of Mr. Klein follows:]
Testimony of James A. Klein
Mr. Chairman and members of the Health Subcommittee, thank
you for the opportunity to share our views with you today on
the Paul Wellstone Mental Health and Addiction Equity Act of
2007. My name is James Klein and I am president of the American
Benefits Council.
The American Benefits Council's members are primarily major
employers and other organizations that collectively sponsor or
administer health and retirement benefits covering more than
100 million Americans. Most of the Council's members are very
large companies that have employees in most or all 50 states
and provide extensive health coverage to active employees and
retirees. Our membership also includes organizations that
provide benefits services to employers of all sizes, including
small employers who often face the greatest challenges in
providing health coverage for their workers.
Employers Recognize the Importance of Behavioral Health Care
The American Benefits Council's members highly value and
have long recognized the importance of effective health
coverage for the treatment of both physical and behavioral
disorders. Indeed, because of the importance our members place
on these services, we have repeatedly urged Congress that the
current Federal parity requirements not be expanded in a way
that would add to plan costs or increase the complexity of plan
administration. Doing so could unintentionally risk a reduction
in coverage for these or other benefits provided to employees
and their families.
We also recognize that much has changed in the behavior
health care field over the past decade since the enactment of
the current Federal mental health parity requirements in 1996.
Better medical evidence on behavioral health conditions has
become available and better treatment options have advanced
during this period. In a great many cases, the way in which
behavioral health conditions are covered by health plans has
also changed, particularly with the emergence of health plan
administrators that specialize in the management of behavioral
health care services in a wide range of outpatient and
inpatient settings.
As the field of behavioral health care has changed during
this time, it has become increasingly clear that the ability of
employers to provide access to affordable and appropriate
health care services, including for behavioral health
conditions, depends on the ability of health plans to do an
effective job in the medical management of health benefits.
This involves often challenging tasks to try to ensure that
plan participants get the right care and effective care under
the terms of their plans and for the health conditions they
have. Employers have a strong interest and an enormous stake in
seeing that these tasks are performed well, not only because
employers are the primary payers for the health care coverage
for millions of American workers, but also because of the
importance they place in maintaining a healthy and productive
workforce.
Senate Parity Legislation Developed through Inclusive Process
Before I address the concerns we have with the House mental
health parity bill, H.R. 1424, let me see if I can dispel the
myth that employers are simply irrevocably opposed to any
legislation in this area or that employers somehow do not
understand or appreciate how vitally important effective
behavioral health care is for millions of Americans.
Over the past several months, the three Senate sponsors of
mental health parity legislation--Senate HELP Committee
Chairman Edward Kennedy, HELP Committee ranking member Senator
Mike Enzi and Senator Pete Domenici, who is a longtime champion
of mental health parity and an author of the original
legislation enacted a decade ago--have taken a fresh approach
to trying to resolve the difficult and important issue of
changing the current law Federal parity requirements. Under
their joint leadership, a new bill was developed, S. 558,
through a balanced, candid and extensive process that has given
all the major stakeholders on this issue--employers, health
plans, behavioral health care providers and patient advocates--
the opportunity to have their priority concerns addressed.
The American Benefits Council has been privileged to have
participated in this process with the three Senate sponsors as
a representative of employer interests. While these discussions
have been demanding and have required much give and take on all
sides, we also think that it has unquestionably resulted in a
bill that is a bipartisan in the best sense of the term. In
fact, we believe it could serve as a model for how Congress
might be able to tackle other similarly challenging health
policy issues, ones which members of this subcommittee must
frequently work to resolve, too.
The Senate parity measure is not perfect. No true
compromise proposal ever is. But the Senate parity measure is
the only one of its kind which includes among its supporters a
leading coalition of mental health parity proponents as well as
a broad range of organizations representing employers and
insurers. We hope this good faith effort sends an important
message that employers will support legislation where their
priority concerns are addressed in a thoughtful manner and with
a careful attention to details, even when our preferred outcome
would be no new legislation or an even better bill.
Unlike previous parity measures considered by the Senate or
the parity bill which has been introduced here in the House of
Representatives, the Senate proposal does not mandate that
plans cover specific mental health benefits. It leaves those
decisions up to employers and, in the case of fully insured
health plans, the Senate bill permits States to continue to
determine whether to require any particular benefits. In
addition, the Senate bill includes a provision making clear
that medical management of these important benefits may not be
prohibited and preserves flexibility for employers and health
plans in the formation of networks of health care providers who
deliver these services. These provisions are vitally important
because they allow employers to appropriately design and manage
the health coverage they offer to meet their employees' needs.
Finally, and most importantly, several of the key
provisions of the Senate parity bill are subject to a rule
which is intended to ensure uniformity between the Federal
parity requirements and those established by the States, while
maintaining the traditional role of the States to regulate the
business of insurance in all other respects. Major, multi-state
employers, in particular, rely upon the uniform Federal
framework established by the Employee Retirement Income
Security Act (ERISA). It is crucial to these employers, who
provide health coverage to over 70 million Americans, that this
framework not be eroded.
Employer Concerns with the House Mental Health Parity Bill
Unfortunately, we do not see the same balanced approach in
the House parity bill to the issues of key concern to employers
and we would urge that several changes be made to the
legislation as it is considered further by this subcommittee
and the other committees of jurisdiction in the House of
Representatives. The primary issues which we believe need to be
addressed are the following:
Flexibility Needed in Covered Benefits
Under the House parity bill, if a health plan provides
``any'' mental health or substance-related disorder benefits,
then the plan must cover all of the same mental health and
substance disorder benefits as are provided to Federal
employees under the Blue Cross and Blue Shield standard option
health plan (the most heavily enrolled health plan offering
under the Federal Employee Health Benefits Program). Plans
offered to Federal employees are required to cover all
conditions listed in the so-called DSM-IV manual, the
diagnostic manual used by mental health care professionals to
identify and categorize all disorders in this area. So, while
the benefit mandate is stated somewhat differently than it has
been in previous mental health parity bills, the basic
requirement in the House bill is to cover all mental health and
substance-related disorders if a plan covers any services at
all in this area. Of course, the vast majority of plans do
provide such services.
Employers have several concerns about this sort of
requirement. First, it is not necessary to achieve the purposes
of the legislation, which is to provide parity in any financial
requirements and treatment limits which a plan applies to the
benefits it covers. Requiring a plan to provide coverage for
all of the conditions which are identified in the diagnostic
manual used by health care providers is not ``parity'', it is
simply a benefits mandate. It also requires much more
specificity of coverage than is required for any non-behavioral
health conditions. Such a requirement would send an immediate
message to employers that they no longer have any discretion
over decisions about what benefits they cover for their
employees in this area of their plan, except the decision to
provide no coverage for these conditions at all, which is an
unacceptable alternative.
In addition, state laws currently govern which benefits are
required to be covered for fully insured health coverage, so
this is a matter that can be, and often is, decided by the
states for the health plans which they regulate. In terms of
self-insured health plans which are regulated under Federal
law, there are no similar requirements applied to any other
broad category of health conditions or services which are
typically covered by employer-sponsored health plans, in
recognition that this is an important area of discretion for
employers when they voluntarily choose to provide health
coverage to their employees.
Protection Required for Medical Management Practices
Another major concern with the House bill is that, unlike
previous mental health parity bills considered by Congress or
the current Senate measure, there is no specific protection for
plan medical management practices. It is very important to
protect the ability of plans to appropriately manage coverage
for mental health conditions and substance-related disorders as
part of any Federal parity legislation. Proposed treatments for
these conditions should, whenever possible, be consistent with
standards for evidence-based care. Ultimately, to quote the
conclusion of an April 11, 2007 op-ed column in the New York
Times by Maia Szalavitz, ``we need parity in evidence-based
treatment, not just in coverage--for mental health conditions.
One of the most important developments now occurring in the
health care field is in the preparation of measures by numerous
clinical specialty groups to help define appropriate care and
expected outcomes for patients for a wide range of conditions.
Purchasers, health care providers, consumer groups and many
others are actively working in several different forums to
reach consensus on evidence-based measures of quality health
care. While much more needs to be done to achieve a fully
transparent and more accountable health care system, there can
be little doubt that the movement to achieve consistent
measures of quality care is a major step in the right direction
and can help drive overall health system reform.
We need to be careful to ensure that neither State nor
Federal laws undercut or diminish efforts by plans to try to
ensure that the health care services received by plan
participants are medically necessary and appropriate for their
conditions. Some health plans contract with managed behavioral
health care organizations for this purpose while others perform
medical management services as part of their core plan
operations. Either way, it is essential to safeguard these
important activities so that plans are able to both protect
themselves and their participants from unnecessary costs as
well as to try to ensure that coverage is provided for quality
health care services. Indeed, an August 2006 report by the
Congressional Research Service on the impact of health parity
laws cited evidence that there was little adverse impact in the
Federal Employee Health Benefits Program in terms of access,
quality or cost of care because the parity requirements for
mental health benefits covered under that program were coupled
with the management of care by plans offered to Federal
employees.
Discretion Needed for Out-of-Network Coverage
A third significant concern that employers have with the
House bill is that it mandates coverage for mental health and
substance-related disorders by out-of-network providers if a
plan provides coverage for substantially all medical or
surgical services on an out-of-network basis in any of three
different categories (emergency services, inpatient services or
outpatient services). Again, this requirement limits important
plan discretion and exceeds what is required under the Federal
Employee Health Benefits Program where parity is required only
for services provided on an in-network basis.
We would recommend that the House bill be modified to
conform to either the FEHBP requirement or the comparable
provision in the Senate parity bill which includes a Federal
standard that calls for parity in plan financial requirements
and treatment limitations for any out-of-network mental health
coverage provided by a plan, but the Senate provision does not
require plans to offer out-of-network coverage. The Senate bill
also preserves the traditional role of the States to regulate
fully insured health plans in this area, so it does not
interfere with State laws which may require insurers to offer
out-of-network health coverage.
Changes Needed to Provisions Related to State Laws
Finally, we have significant concerns with the provisions
in the House parity bill which would authorize States to
provide ``greater consumer protections, benefits, methods of
access to benefits, rights or remedies--than those in the
legislation. This is extraordinarily broad language and
arguably gives States the ability to develop parity laws, at
least for fully insured health plans, that could differ
significantly from the Federal standards provided and that are
determined to be even ``greater'' than those in the House bill.
More troubling, however, is that the House bill provision
on the relationship to State laws would give States broad
authority to enact greater ``consumer protections...methods of
access to benefits, rights and remedies than any applicable
Federal standards. This provision appears to go far beyond a
mental health parity requirement in that it opens the door for
the States to develop separate enforcement and remedy schemes,
a matter of frequent review by the United States Supreme Court
which has ruled unanimously that the Federal remedy scheme
included in ERISA is exclusive for all health benefits covered
by employer-sponsored benefit plans.
Moreover, if the bill is intended to only change
enforcement and remedy schemes for mental health coverage, then
there is no justification for a separate set of rules for just
one category of benefits. If, in fact, this provision is
intended to permit states to create a new enforcement and
remedy scheme for all benefits, then such a fundamental change
in the law should not be an adjunct to a bill whose purpose is
to address mental health parity.
The uniformity ERISA establishes for employer-sponsored
coverage, including its enforcement and remedy scheme, is based
on sound public policy and is something employers consider
crucial to their voluntary decision to offer health coverage to
their employees. Federal preemption is not unlimited, but where
it does apply it fosters uniform administration of covered
benefits and reduces costly burdens of complying with differing
State laws which would occur in the absence of ERISA's
uniformity provisions.
If Congress believes that changes are needed in this area,
is should be fully debated on its own merits rather than
included as one of many provisions of a mental health parity
bill.
House and Senate Parity Bills Fail to Apply to Medicare or Medicaid
One of the most glaring omissions of both the House and
Senate parity bills is that they fail to apply the same
requirements to the mental health benefits provided to millions
of elderly and low-income Americans who are covered under
Medicare and Medicaid. While we are aware that separate
legislation sponsored by Rep. Pete Stark, H.R. 1663, would
partially address this situation by requiring parity for
benefits covered by Medicare, nearly all of the debate and
focus concerning mental health parity over the past decade in
Congress has been around employer-sponsored health coverage.
We believe it is simply indefensible for Congress to impose
parity requirements on employer-sponsored health coverage while
ignoring the same issues in the programs where it has direct
responsibility. Failing to do so would mean that if either the
House or Senate bills were to be enacted, mental health parity
would be the law for employer-sponsored coverage and, through
previous action by Executive Order, for coverage offered to
Federal employees (including members of Congress), but not for
those covered under Medicare or Medicaid.
This committee has jurisdiction over Medicare outpatient
services covered under Part B and the Medicaid program. We
would be in a very different place in this debate if the
fundamental policy decision had been made long ago that mental
health parity was not simply something that Congress was
seeking to apply solely to employer-sponsored health coverage,
but was being done as part of a more omnibus effort to achieve
the same standards in all Federal health programs as well. Such
an approach would send a substantially different message to
employers that sponsor health benefits for their employees and
it is an approach that we strongly urge be done before you
compel private sector employers to make changes to their plans.
Again, I appreciate the opportunity to testify today and
share our views with you on these important issues. The
American Benefits Council has played a constructive and highly
engaged role in the multi-stakeholder negotiations that helped
shape the Senate mental health parity bill. We and our allies
on this issue are prepared to do the same with the House bill
if a similar approach is taken to making what we believe are
important and needed changes to ensure a more balanced
proposal.
Employers understand the importance of quality mental
health coverage for their employees and to maintaining a
productive, healthy workforce. We also fully understand the
strong sentiment in Congress to change current Federal mental
health parity requirements. We believe the candid discussions
among all the major stakeholders which were used to develop the
Senate bill have demonstrated that employers and insurers are
prepared to engage seriously in resolving this longstanding
issue, provided that the process is respectful of the priority
needs of all the parties involved. As this legislation moves
forward, we urge that you consider the merits of this approach
so that a consensus measure can ultimately be considered by the
House of Representatives.
----------
Mr. Pallone. Dr. Goldman.
STATEMENT OF HOWARD H. GOLDMAN, M.D., PROFESSOR OF PSYCHIATRY,
UNIVERSITY OF MARYLAND, SCHOOL OF MEDICINE
Dr. Goldman. Thank you very much for the invitation to
speak here today.
I am Howard Goldman. I am a professor of psychiatry at the
University of Maryland School of Medicine. I served as the
senior scientific editor of the Surgeon General's report, and I
was the principal investigator of the evaluation of behavioral
health parity for Federal employees.
My testimony today focuses principally on that evaluation.
The comments are derived from papers that were published in the
New England Journal of Medicine and the Journal of Pediatrics,
and they are also based on an editorial written by two health
economists that accompany our paper in the New England Journal
of Medicine.
The parity policy in the Federal Employees Health Benefits
Program began on January 1, 2001, and it offered comprehensive
insurance coverage for all mental disorders, including
substance abuse, all of the conditions in the international
classification of diseases.
The terms were the same for behavioral disorders as they
were for general medical conditions when the treatment was
provided by in-network providers under the managed care
arrangements.
Our study compared seven Federal plans with a matched set
of plans that did not change benefits or management and did not
have parity. We compared use and spending by enrollees in these
plans for the 2 years before parity, 1999 and 2000, with the 2
years afterwards in 2001 and 2002.
We observed the proportion of Federal employees, retirees
and their dependents who use behavioral health services. We
looked at how much they spent and how much of this spending was
out of their own pockets.
The study found, one, that the policy was implemented very
smoothy and without any of the Federal plans dropping out of
the Federal Employees Health Benefit Program, which is
something that has been feared by some in their testimony
today.
Two, there was a significant decline in out-of-pocket
spending in the Federal plans compared to the nonparity plans,
which indicates that parity coverage resulted in improved
insurance protection against financial risks. After all, that
is the principal objective of health insurance, and we have
heard about this tremendous financial burden that a mental
disorder can impose.
Three, the savings to Federal plan members was not
associated with significant increases in use and spending
attributable to parity. In fact, for the most part, increases
that we did observe in use and total spending in the Federal
plans were no greater than use and spending increases in the
comparison plans. This was true for adults just as it was for
children and adolescents.
In our published paper, we concluded that these findings
suggest that parity of coverage of mental health and substance
abuse services, when coupled with management of care, is
feasible and can accomplish its objective of greater fairness
and improved insurance protection without adverse consequences
for health care costs.
In their editorial, the two health economists note that the
purpose of the parity policy was to provide better financial
protection to everyone who has health insurance. The coverage
is not only for people who have currently a mental disorder,
but any one of us who might have a mental disorder in the
course of the year.
The economists state that the article by Goldman, et al,
provides the first controlled study of parity in two decades.
The compelling evidence presented suggests that in today's
environment, parity and health insurance coverage is both
economically feasible and socially desirable.
The policy performed just as insurance should. It reduced
the cost of out-of-pocket payments with a small increase in
plan payments. This could result in very small increases in
insurance premiums without leading to an increase in use of
services. The CBO estimates a premium impact for group plans of
0.4 percentage points, and that is the same increase in
premium, very small, that we observed for Federal employees.
Furthermore, there is a concern raised about mandated
benefits. We conclude that by reducing financial risk, parity
improves the well-being of insured people without distorting
the market for mental health services. Legislation is the way
to accomplish that social good because parity coverage offered
by only one or two plans would result in those plans attracting
a disproportionate group of people with persistent mental
illness. This is referred to as adverse selection, and it is
only through a parity policy such as that which is offered that
we can avoid the financial risks associated with adverse
selection.
For decades, advocates for parity relied only on an
argument of fairness to gain support for their cause. Now they
can argue that parity promotes social well-being and economic
efficiency in the form of better insurance benefits for all of
us.
Thank you, Mr. Chairman, Ranking Member and Members of
Congress.
[The prepared statement of Dr. Goldman follows:]
Testimony of Howard H. Goldman, M.D.
Thank you for the invitation to address you today. I am
Howard H. Goldman, MD, PhD, professor of psychiatry at
University of Maryland School of Medicine in Baltimore. I
served as the senior scientific editor of the Surgeon General's
Report on Mental Health and was the principal investigator of
the evaluation of behavioral health insurance parity for
Federal employees.
My testimony today focuses on that evaluation and its
findings and conclusions. My comments are derived from our
report posted on a Department of Health and Human Services Web
site as well as from published papers. I have appended papers
by our research team published in the New England Journal of
Medicine (1) and pediatrics (2). I will also refer to an
editorial published with our paper in the New England Journal
of Medicine, written by two health economists (3) and also
appended to the testimony as well.
The parity policy in the Federal Employees Health Benefits
[FEHB] program began on January 1, 2001 and offered
comprehensive insurance coverage for mental disorders,
including substance use disorders, on terms that were identical
to the coverage of general medical conditions, when the
treatment was provided by in-network providers.
Our study compared 7 FEHB plans with a matched set of plans
that did not change benefits or management and did not have
parity. We compared use and spending by enrollees in these
plans for the 2 years before parity [1999 and 2000] and for the
2 years after parity began [2001 and 2002]. We observed (i) the
proportion of Federal employees, retirees and their dependents
who used behavioral health services, (ii) how much they spent
for behavioral health services, and (iii) how much of the
spending was out of their own pockets.
The study found that:
1. The policy was implemented smoothly and without plans
dropping out of the FEHB program.
2. There was a significant decline in out-of-pocket
spending in the FEHB plans compared to the non-parity plans.
This indicates that parity coverage resulted in improved
insurance protection against financial risks--the principal
objective of health insurance.
3. This savings to FEHB plan members was not associated
with significant increases in use and spending attributable to
parity. In fact, for the most part increases in use and total
spending in the FEHB plans were no greater than use and total
spending increases in the comparison plans. This was true for
adults as well as for children and adolescents. (2)
In our published paper we concluded that ``these findings
suggest that parity of coverage of mental health and substance
abuse services, when coupled with management of care, is
feasible and can accomplish its objectives of greater fairness
and improved insurance protection without adverse consequences
for health care costs.'' (1; p. 1386)
In their editorial, ``Better Behavioral Health Care
Coverage for Everyone,'' in the New England Journal of
Medicine, two health economists (Glied and Cuellar) note that
the purpose of the parity policy was to provide better
financial protection to everyone who has health insurance. The
coverage is not only for individuals who already have a mental
disorder but it is for all of us. (3)
The economists state that ``the article by Goldman et al.--
provides the first controlled study of parity--in two decades.
The compelling evidence presented suggests that in today's
environment, parity in health insurance coverage is both
economically feasible and socially desirable.'' (3; p. 1415)
The parity policy performed just as insurance should, it
reduced costs from out-of-pocket payments with a small increase
in plan payments. This could result in very small increases in
insurance premiums, without leading to an increase in the use
of services. CBO estimates a premium impact for group plans of
a 0.4 percentage point increase (4), a figure which is
identical to our estimate based on the FEHB experience.
Furthermore, in response to concerns raised about a
mandated benefit, we conclude that by reducing financial risk
parity improves the well-being of insured people, without
distorting the market for mental health services.
Legislation is the way to achieve this social good, because
parity coverage offered by only one or two plans would result
in those plans probably attracting a disproportionate share of
people with persistent mental illness. This is what is referred
to as ``adverse selection.''
In fact, parity provides the best protection for insurers
and self-insured companies from experiencing adverse selection.
When they offer parity benefits at the same time, they can
avoid a shift of high-cost individuals into their plans.
For decades advocates for parity relied only on an argument
of fairness to gain support for their cause. Now they can argue
that parity promotes social well-being and economic
efficiency--in the form of better insurance benefits for all of
us.
References
HH Goldman et al. ``Behavioral Health Insurance Parity for
Federal Employees,'' New England Journal of Medicine
354(13):1378-1386, March 30, 2006.
Stazrin et al. ``Impact of Full Mental Health and
Substance Abuse Parity for Children in the Federal Employees
Health Benefits Program,'' pediatrics 119:452-459, 2007.
Glied and a Cuellar. ``Better Behavioral Health Care
Coverage for Everyone,'' New England Journal of Medicine
354(13):1415-1416, March 30, 2006.
Congressional Budget Office cost estimate, S. 558, Mental
Health Parity Act of 2007, March 20, 2007. CBO.gov/ftpdocs/
78xx/doc7894/s558.pdf.
Some additional comments and potentialquestions/answers:
Quality. We also looked at indirect measures of quality of
behavioral health care in the FEHB plans during this same
period. Parity was accomplished without increases in
hospitalization of patients and without a decline in the
measures of quality of care that we studied, such as likelihood
of receiving follow-up care for depression or being referred
for substance abuse treatment.
What is included in the term ``behavioral health
services''?This term refers to all use of health care services
for any of the disorders (including substance use disorders) in
the diagnostic and statistical manual or the mental disorders
chapter in the International Classification of Disease (ICD).
It includes specialty mental health services such as
psychotherapy as well as visits to a general medical provider,
when a mental disorder diagnosis is recorded. It also includes
the use of all medications for which behavioral health
conditions are an indication. When medications might be used
for a mental disorder or a general medical condition, use and
spending were included only if accompanied by a mental disorder
diagnosis in the record. This is the broadest definition of use
and spending, designed to capture the impact of parity.
There was no use or spending for (oft-parodied) trivial
behavioral conditions under managed care plans.
It is probably worth noting that the ICD contains a wide
range of general medical conditions, such as scrapes and
bruises, rashes, sprains, and the common cold, just as it
includes sleep disorders, mild phobias and mild learning
problems. Managed care arrangements and ``medical necessity''
criteria control un-necessary use and spending for trivial
cases of general medical conditions and mental disorders alike.
Can you say anything about the impact of parity on spending
for general medical care?
Unfortunately our study did not include such analyses.
Adverse selection. Adverse selection occurs when plans
offer different benefits and individuals select plans with
coverage they expect to use. These plans are said to experience
``adverse selection'' resulting in higher costs on average than
other plans that do not offer special benefits. Without a
parity mandate plans that wish to offer better benefits attract
to them a group of users with high costs, resulting in adverse
economic consequences for the plan and its other members. If
all plans offer the same benefits (such as under a mandate)
they can avoid adverse selection. Left to the incentives of
market pressures, plans either offer the same extremely limited
set of benefits or a few plans offer better benefits and risk
selection, while the other plans have a selective advantage and
lower costs. For everyone to enjoy the benefits of parity and
the cost-neutral experience of parity in the FEHB program,
there must be a mandate for parity coverage, and the benefits
should be standardized. This is why the two health economists
who commented in the New England Journal of Medicine (Glied and
Cuellar) concluded that a legislative mandate was required to
achieve the economic efficiency demonstrated by the FEHB
experience with behavioral health insurance parity. In this
instance a mandate promotes market efficiency--or at least
avoids the market failure associated with adverse selection.
Ironically, a mandate may help insure employers and plans
against financial risks when they try to offer better benefits
to their employees.
Summary of the key points from the subcommittee hearing testimony
Focusing on Behavioral Health Insurance Parity in the Federal Employees
Health Benefits Program
The parity policy in the Federal employees health benefits
(FEHB) program began on January 1, 2001 and offered
comprehensive insurance coverage for mental disorders,
including substance use disorders, on terms that were identical
to the coverage of general medical conditions, when the
treatment was provided by in-network providers.
The most important positive finding in the evaluation was a
significant decline in out-of-pocket spending in the FEHB plans
compared to the non-parity plans. This indicates that parity
coverage resulted in improved insurance protection against
financial risks
Furthermore, this savings to FEHB plan members was not
associated with significant increases in use and spending
attributable to parity. In fact, for the most part increases in
use and total spending in the FEHB plans were no greater than
use and total spending increases in the comparison plans.
Goldman et al. concluded: ``These findings suggest that
parity of coverage of mental health and substance abuse
services, when coupled with management of care, is feasible and
can accomplish its objectives of greater fairness and improved
insurance protection without adverse consequences for health
care costs.'' (1; p. 1386) these findings were true for
children as well as adults. (2)
Glied and Cuellar, two health economists state: ``the
article by Goldman et al.--provides the first controlled study
of parity--in two decades. The compelling evidence presented
suggests that in today's environment, parity in health
insurance coverage is both economically feasible and socially
desirable.'' (3; p. 1415)
The parity policy performed just as insurance should, it
reduced costs from out-of-pocket payments with a small increase
in plan payments. This could result in very small increases in
insurance premiums, without leading to an increase in the use
of services. CBO estimates a premium impact for group plans of
a 0.4 percentage point increase (4), a figure which is
identical to our estimate based on the FEHB experience.
Legislation is the way to achieve the benefits of parity,
because it helps to avoid ``adverse selection.''
References: (1). HH Goldman et al. ``Behavioral Health
Insurance Parity for Federal Employees,'' New England Journal
of Medicine 354(13):1378-1386, march 30, 2006. (2). Stazrin et
al. ``Impact of Full Mental Health and Substance Abuse Parity
for Children in the FEHB Program,'' Pediatrics 119:452-459,
2007. (3) Glied and Cuellar. ``Better Behavioral Health Care
Coverage for Everyone,'' New England Journal of Medicine
354(13):1415-1416, march 30, 2006. (4) Congressional Budget
Office cost estimate, S. 558, Mental Health Parity Act of 2007,
March 20, 2007. CBO.gov/ftpdocs/78xx/doc7894/s558.pdf.
----------
Mr. Pallone. Thank you very much.
We will have questions from the members, and I should point
out that if you can't answer the question or you want to get
back to us in writing, that is certainly permissible, but we
would like you to try to answer today obviously.
I am going to start with myself for 5 minutes, and I wanted
to ask of Ms. Prunty-Lara and possibly Mr. Purcell, as well; it
deals with the preemption.
Let me start with Ms. Prunty-Lara.
Over the last few years, several States have enacted very
strong parity laws, Rhode Island, Mr. Purcell's State, along
with some others such as Washington, Oregon--I won't go through
the list--have strong mental health parity laws.
Do you have concerns about legislation that would preempt
States' stronger mental health parity laws and what would that
mean for patients?
Ms. Prunty-Lara. I believe, for the 130 million people
covered by health insurance plans, that they have the right and
the honor and they deserve the dignity of being provided with
equitable mental health coverage at the same level that a lot
of people who have fully funded insurance plans at the State
level are also offered.
To disregard what States have already achieved and throw
that by the wayside, I think is irrefutably wrong, frankly. I
think that we need to institute a baseline of sorts so that we
have equitable coverage for as many people as possible in terms
of mental health care.
For me personally, in the State of Minnesota we have a
stronger parity law, and so we need to let that stand as it is
so that we don't adversely affect those people who are
currently influenced by the parity laws already in existence.
Mr. Pallone. Let me ask, Mr. Purcell, what are your
thoughts on passing a Federal law that would preempt Rhode
Island's more protective mental health parity law?
Mr. Purcell. I would be against it. I am here only because
Rhode Island was innovative enough and perhaps courageous
enough to pass a law, and we were able to operate under it and
see the results; and hopefully, those results help you have a
context in terms of understanding what may happen if you pass
your law. So this is the old federalism argument, and I think
it makes abundant sense to have the preemption issue handled
the way the House bill does throughout the Senate bill.
Mr. Pallone. OK.
One of the major differences between the House and the
Senate bills is that while the Senate legislation allows
insurers to define what they cover in terms of mental health
treatment, the House bill sets the standard for coverage. In
the House bill, mental health conditions must be covered to the
same extent they are covered for the Federal employees and
Members of Congress.
Critics of the House bill charge that this would open
insurers up to paying for every problem under the sun, but the
simple fact of the matter is that insurers still have many
tools by which to manage the coverage and care provided to the
enrollees. With medical benefits, clients don't have to provide
every covered benefit to anyone who wants it; they only do so
if it is medically necessary. And that would continue to apply
here.
So I wanted to ask again the two of you, Mr. Purcell and
Ms. Prunty-Lara, do you believe that, the way the Senate bill
works, I understand, we would--we might not achieve parity
because we permit insurers to cover only depression, but not
autism, or cover alcoholism, but not bipolar as part of the
parity law.
Is there a reason any of these illnesses is less deserving
of coverage than, say, heart disease or diabetes? This is what
we are trying to get to with the House version.
I will start with you.
Ms. Prunty-Lara. I think the problem, with not explicitly
stating that we need to cover what is considered diagnosable,
is that you end up with a system in which there is
discrimination by diagnosis. And that is inherently wrong. My
disease is no less deserving of coverage than that of a heart
condition or that of a broken leg or that of autism or cerebral
palsy or MS. And it is just as real and just as painful, even
if you can't see it.
So my hope is that you not allow the discrimination to
continue on the basis of diagnosis and on the basis that post-
traumatic stress disorder or an eating disorder would not be
considered medically necessary. Because I assure you, the pain
is real.
Mr. Pallone. Mr. Purcell.
Mr. Purcell. Of course, the devil is in the details with
regard to the Senate definition. It depends upon when the
exception is going to be so big it can eat up the rule. I
assume it would not be that big. Nonetheless, it does seem to
me that using the FEP definition gives you much more context.
If you are going to mandate parity, at least you have to
mandate what coverages have parity.
And you have the example in FEP where you have seen, based
on Dr. Goldman's study, it does not appear to have
significantly increased costs, if at all. So while we can have
some red herrings about some of the more fringe, V-type DSM
types of diagnoses, such as jet lag or gray hair, that is
beside the point.
We have got to bring it back to the middle and even though
you can describe a completely unrealistic or facetious
coverage, the true idea here is to get people coverage. This is
all about the people, so I think you have got an example that
works.
So I would be in favor of the House version on that.
Mr. Pallone. Thank you.
Mr. Deal.
Mr. Deal. Thank you, Mr. Chairman.
Mr. Klein, you held up the book, and I assume that is the
diagnostic and statistical manual; is that correct?
Mr. Klein. That is right.
Mr. Deal. Who compiled that?
Mr. Klein. My understanding is, that is a compilation from
various health care provider groups that identified the panoply
of mental health and behavioral disorders.
Mr. Deal. I have been given some information that indicates
that it does include a wide variety of things, and you can
always find some things that sound ridiculous on their face.
One of them that sounded a little ridiculous to me is a
mathematical disorder. It may or may not be a significant
mental disorder.
My concern is the breadth of coverage, if we require
coverage of all of those potential manifestations.
Dr. Goldman, did you find anything, as it related to such a
broad, expansive coverage, perhaps even to contrast it outside
of the study you did, that you referred to, with States that
have more narrowly limited their parity to biologically based
or serious mental illnesses as State statutes would sometimes
define it.
Could you tell us whether that is a problem or not?
Mr. Goldman. In our experience, studying Federal employees
parity policy, we didn't see utilization of these so-called and
often parity-trivial disorders. Utilization was not governed by
diagnostic criteria, but was governed by management decisions
that were made about the necessity of service.
It is considered now an old-fashioned way to make the
determination of who should get what care, to do it on the
basis of diagnosis or diagnosis alone, that we have the tools
of management that allow us to make much more precise decisions
about allocating the sources based on medical necessity.
Mr. Deal. And that is in the context of a managed care
environment?
Mr. Goldman. Yes. The managed care environment was the
environment in which the parity policy was implemented in the
Federal employees plan. And that was true of most of the State
parity policies as well.
I should note that if you look within the international
classification of diseases, of which the DSM has simply one
chapter on mental disorders, you will see in the other chapters
a wide range of conditions. Everything from scrapes and sprains
and skin tags and colds to more serious conditions. And in the
current health care environment, we use management of care in
order to make appropriate allocation decisions.
Parity would extend that mechanism for cost containment to
mental disorders without having to refer to specific
conditions.
Mr. Deal. I think the concern is that we also allow health
insurance policies to further refine and define the benefits
and the conditions for which those benefits attach.
Mr. Klein, in that regard, and also in regard to any,
perhaps, State studies or variations among the States, do you
have any comment you would like to make on that?
Mr. Klein. No. I read Dr. Goldman's excellent study and
encourage it to everyone.
It is so crucial to keep in mind that perhaps the major
reason--I will let him speak to it--that the cost increases
didn't occur under the Federal Employees Health Plan was
because there was this medical management that I was referring
to earlier; and Mr. Purcell also spoke about how important that
is. Because the issue really isn't, as I said before, making a
value judgment of which of these conditions is worthy or not of
being covered.
The fact of the matter is, not all treatment regimens are
equally successful. And there are countless studies in the
journals that show people with the same diagnosis in two
different parts of the country may get radically different
kinds of treatment; and in order to ensure high-quality
outcomes for patients, it is absolutely essential to have these
medical management tools. And that is something that is
protected under the House--the Senate bill, but not under the
House bill.
Mr. Deal. Would you care to comment on that?
Ms. Rogers. I agree with what Mr. Klein just said about
best practices are extremely important, and the major employers
are really forcing their providers to use best practices. And
they focus on the cost drivers and are able to manage them, and
that is actually the future, it is the direction we should be
doing in.
We should also be going in the direction of making health
benefits more portable, and I think this is a step in the other
direction where you still have all of these different State
mandates. And in order to get to a system where health plans
are portable, because the workers are much more mobile these
days than they used to be, since we are in a global economy,
you need to move closer in the direction of one system--and
this moves, in the other direction. And we also need to move in
the direction of simplicity, and this does not move in that
direction.
Mr. Deal. Thank you all for being here.
My time is out. I am over my time. But thank you all for
being here.
Mr. Pallone. Thank you.
Mrs. Capps.
Mrs. Capps. Thank you.
I want to thank you, Ms. Prunty-Lara, for very powerful
testimony. It is the most eloquent statement I have ever heard
by a consumer of mental health care and someone who has lived
and does live with bipolar disorder. My brother does as well.
And the pain and suffering that you described is also shared,
as you said, by all the family members.
I am glad you are on the board of the Mental--I still call
it the Mental Health Association--the national board; and there
is a very active local chapter in Santa Barbara, and I am going
to tell them what a good spokesperson you are for various
issues as well.
You talked about the lack of equity for physical versus
mental health as being a form of discrimination. And I want you
to describe that connection.
It is like a revictimization, in a way, that the family
really does get in on, a pain and suffering caused by the
denial of treatment, sometimes over and over again. And I think
for our part here, that this stigma of bias becomes systemic
when it is promoted; and the status quo, we here in the
Government are kind of perpetuating as well. That is why I
think it is so timely that we have this legislation before us.
Talk a little bit more, if you would.
But I also want to turn to Mr. Purcell, you were cut off,
and I think you had some more things to say, and I will give
you a minute or so to complete that.
Ms. Prunty-Lara. First of all, I want to comment that there
is nothing in the Kennedy-Ramstad version of this bill that
precludes medical management. So I want to make that perfectly
clear. That is in this legislation. There is nothing to
preclude it.
I also want to submit some comments from James T. Hackett,
who testified before this committee in 2002. And he talked
about the Federal law that currently allows health insurance
discrimination against people with mental illness,
discrimination in duration of needed treatment, discrimination
in cost-sharing burdens and discrimination by diagnosis, as I
said.
There is also a discrimination in ideals, a discrimination
that says that your illness isn't good enough, that we somehow
stigmatize the treatment of mental health conditions and we say
that it is not equitable, that it is not real enough as a
broken leg. And as some Members of Congress have commented,
there is a disparity, there is a difference in how we are going
to treat them. And I am sorry, there is not. It hurts the same,
it feels the same, it deserves the same principal of equality
and justice and accountability to your employees and their
beneficiaries.
Mrs. Capps. Thank you very much.
Mr. Purcell, I really--I am going to remember it the way
you distinguished between mental and physical health. You call
it behavioral and physical health. That is very clear, health
covering both of them, or disease, a lack of health, as
evidenced in different ways.
I also was struck by your description, and I want you to
expand on this in whatever time I have, but the relationship
between mental health problems and their spillover, the
correlation between mental and physical health, because I think
that is one way that we can help to document the cost of not
treating mental health.
Mr. Purcell. I have an example in my written testimony
about how gray the line is between an obese diabetic who has
depression and an eating disorder. Where does the physical
health component end and the behavioral component begins? And
of course nobody knows.
What we are trying in Rhode Island, we have a pilot program
to achieve integration of behavioral and physical health by
collocating and integrating behavioral and physical health. The
whole idea here is to get people in early for office visits.
Office visits don't cost anything in the greater scheme of
things. When we increase from 30 visits to 50 visits a year, it
costs almost nothing. But as I was going to say, the few people
that run out of 30 really need the care. And when do they run
out? Right around the holidays. And where do they go? They go
to the emergency room. Is that cost-effective? Never.
We have more trouble getting people to go to office visits
than having them abuse it. And the key here is if you can get
them to office visits, you keep them from becoming chronically
ill for the most part. And it is tremendously cost-effective
both on the behavioral and physical side.
I hope that answers your question.
Mrs. Capps. If I had more time, I would get into how do you
get them in earlier, because that means someone has to refer;
or there used to be an acknowledgment--I used to work in the
school district, and I know that is a good place for young
people to get started.
Mr. Purcell. Collocation for primary care doctors. That is
the way to do it.
Mrs. Capps. Collocation for primary care?
Mr. Purcell. That is right.
Mrs. Capps. Excellent. Thank you.
Mr. Pallone. Mrs. Myrick.
Mrs. Myrick. Thank you, Mr. Chairman, and thank all of you
for being here.
Ms. Rogers, I wanted to ask you a question. You said that
one of your objections to the House bill is that the nature of
psychiatric medical care requires flexibility in benefit
design. Do you see what you call trust, don't verify, that
culture of psychiatric care, changing as it becomes more
obvious that these are biological-treated illnesses? And then
how do you see the status changing in the future--and aren't
there professional societies like APA that have treatment and
quality standards that could, A, benefit design plans for
companies so that they end up paying for quality care?
Ms. Rogers. Thank you for the question. In our opinion, it
appears that on the physical side that they are much further
down the road with regard to having best practices that have
been pushed out to the primary care physicians and also the
specialists. And they are starting to get used to the idea of
reporting on quality measures. I know that Medicare is pushing
it with the hospitals and also with the physicians.
Mrs. Myrick. Right.
Ms. Rogers. And also with transparency of their costs,
efficiency measures. And we just think that that is key for the
future, coupled with health information technology. And we see
the mental health community much further behind on that side.
So it just seems like they need a push or a nudge, and that
they need to be included in the fold with regard to those
advancements.
Mrs. Myrick. Don't you think that would actually come if
working together with the companies and the different groups to
incorporate that type of thing? Because they haven't had the
same length of experience in doing this that you have with the
other physical illnesses. Am I making sense?
Ms. Rogers. Yes, you are making sense. Well, remember, the
majority of our members have stigma-free mental health. They
don't have ``parity'' according to this bill, but they have
very generous benefits. But they do feel like that there are
quite a few providers, more so on the mental health side than
they see on the physical side, that are less willing to provide
the information that they would like to see.
Mrs. Myrick. So it is less willing.
Ms. Rogers. Yes.
Mrs. Myrick. That is why there needs to be more
cooperation.
Ms. Rogers. And we just look at this as an education issue.
We don't see this as a big legislative, regulatory issue.
Mrs. Myrick. I see.
Ms. Rogers. But more of an education issue that the private
sector has been pushing for for quite a while. And especially
our members on both sides, on the mental health side and also
on the physical health side. It just seems like on the mental
health side they are further behind, and they are not as well
organized and represented.
Mrs. Myrick. OK. Thank you.
Marley?
Ms. Prunty-Lara. If I may just respond, as an organization,
Mental Health America is working to further evidence-based
practices, but it is very hard to do when you don't have
parity, because you don't have the same number of providers,
and you don't have the same access to treatment to formulate
those evidence-based practices.
I would also like to respond about Government interference
into parity regulation. It is not a question of education,
because the private sector has failed. They have not
implemented parity. And it has been 11 years since Paul
Wellstone stood on the floor of the Senate with Pete Domenici
and called for the enactment of the 1996 partial parity law.
These discriminatory practices are, for the best interests of
the American people, to be eliminated. Federal law subsidizes
employers through the Federal Tax Code for providing health
insurance to employees, allowing the cost of insurance as an
ordinary business expense. It is wholly appropriate for
Congress to condition entitlement to such benefits on employers
providing health benefits in a nondiscriminatory manner. This
Congress has the right to demand that mental health be covered
equally.
Mrs. Myrick. Yes. Go ahead. Pardon me, I am almost out of
time, but quickly go ahead.
Mr. Klein. No, I was just going to say that I don't believe
that--I think we are beyond the issue of parity. I mean, the
Senate bill has already embraced it. The point is you don't
need such tightly prescriptive type of parity that is called
for in the House bill in order to encourage the type of quality
improvement outcomes that we are looking for.
Mrs. Myrick. Very good. I appreciate that. Thank you all.
Mr. Pallone. Thank you.
Ms. Baldwin.
Ms. Baldwin. Thank you, Mr. Chairman.
There has already been some discussion, considerable
discussion, about differences between the House bill and the
Senate bill and use of the DSM-IV definitions in the House
bill. But I want to probe for some additional clarity on that.
So at the risk of being redundant, I do want to pursue that
subject a little bit more.
Dr. Goldman, I want to discuss how mental illness should be
defined in a model mental health parity law. And as I hinted, I
have serious concerns about the Senate bill, which allows
insurers basically to pick and choose which illnesses they want
to cover, and I don't think that is right. In the House bill,
mental illness is defined based on DSM-IV. And it is my
understanding that this is the diagnostic manual used by mental
health and addiction professionals, and that it is widely
accepted. Is this correct?
Mr. Goldman. That is correct.
Ms. Baldwin. Do you think that there is any medical basis
for allowing insurers to decide what is a mental health illness
and what is not?
Mr. Goldman. I think, as I said before, we have other
mechanisms to make sure that we allocate resources efficiently
and effectively according to need, and that we don't use
diagnosis as a way of excluding care on the general medical
side. And the spirit of parity is to do the same for the
behavioral disorders. So it is really a matter of not needing
to focus on diagnosis for purposes of exclusion, but allowing
management to deal with the cost concerns.
Ms. Baldwin. So I am concerned that allowing insurers the
type of discretion that I described earlier would lead to
discrimination based on diagnosis. For example, an insurer
might decide that one mental illness or another is simply too
costly, too therapy-intensive or too complex, and they won't
cover it. We know that insurers use nonmedical criteria to make
their coverage determinations now, and so what is to stop them
from doing the same thing if we were to pass a very weak mental
health parity law? Do you think that this would pose a
potential threat to patient health?
Mr. Goldman. If I base my remarks entirely on the
experience that we had with the Federal Employees Health
Benefit Program, we showed that all of the upside benefits that
you want in terms of the social good, avoiding discrimination,
and doing so by improving insurance protection can be done
without reference to restrictions on the basis of disorders, I
would have to substantially agree with your point.
Ms. Baldwin. Thanks.
Mr. Purcell, I thank you for testifying today and sharing
the experiences of Blue Cross/Blue Shield of Rhode Island in
providing mental health parity. It is also useful to have the
data about how things work, and we appreciate you sharing that
with us.
Under Rhode Island's mental health parity law, are insurers
required to provide parity for conditions which are not
medically necessary?
Mr. Purcell. No.
Ms. Baldwin. I have certainly heard arguments from those
opposed to this bill that insurers would be forced to provide
parity for a whole host of conditions which are not necessarily
medically necessary. And it is my understanding that H.R. 1424
also includes language that says that there will be parity only
for medically necessary treatment. Is that your understanding
of the bill as well?
Mr. Purcell. That is what I have been told, and that is the
tie-in with medical management.
Ms. Baldwin. Yes.
Mr. Purcell. Just because there is coverage for a condition
does not necessarily mean it is medically necessary, because
there has to be a linkage here. And you can come up--again,
labels don't help here. If somebody comes in because they are
excessively shy, that may not necessarily in and of itself be a
behavioral disorder, but there may be an underlying function,
there may be an underlying depression that causes that. And an
office visit that is covered will allow a practitioner, using
medical necessity means, to determine if that is so or not. And
if there is, it deserves treatment, because down the road that
patient is going to be healthier, their life is going to be
better. And that is what this is all about.
So I think as long as we are able to use traditional
medical management tools for utilization review for medical
necessity, we can take care of that problem using a little
common sense. I don't have a problem with it.
Ms. Baldwin. Thank you.
Mr. Chairman, I yield back my remaining 16 seconds.
Mr. Pallone. Mr. Sullivan.
Mr. Sullivan. Thank you, Mr. Chairman. And I guess my
questions will be towards Ms. Rogers and Mr. Klein. And we had
a hearing in Tulsa, we had a company--Williams Company has
4,000 employees, and they said that they felt that having
parity in their plans reduced costs, and it was good for their
business.
I have three questions for you. Do you--for both of you.
Do you know any companies that have dropped mental health
benefits in response to State requirements that they equalize
benefits? If so, what percentage of covered lives in that State
lost their benefits as a result?
Mr. Klein. Congressman, I am not aware of specific
companies. I am sure logic would seem to indicate that there
would be some, but I don't know of any. And certainly among my
member companies, which are primarily large ones, that hasn't
happened. But, of course, it is possible any time costs go up
in one area, other changes may be made to the health plan.
I also think, and I am so glad that you posed the question
the way you did, about that there is actually cost savings
relative to parity, because I think that it is inconsistent for
people to argue, as several have done today, that insurers and
employers will save money by providing mental health benefits,
which is correct, if done properly, but then argue that
employers and insurers are excluding certain coverages in order
to save money. I mean, employers and insurers have every
financial incentive to make sure that people are getting the
appropriate coverages. So those two comments that have been
made seem to me at complete odds with one another.
Ms. Rogers. Thank you for the question.
I have talked to members of our trade association that did
drop coverage, and the way they explained it to me was that
they are mainly self-insured plans, but even though they are
large self-insured, they have large pockets of employees in
various States, and so they might have some insured plans,
especially HMOs. And I have been told by numerous companies
that when they are subject to State mandates that they feel
that are too burdensome, like, for example, they also mentioned
the issue of raising the mandatory age where you have to keep a
dependent child on in some States, like New Jersey to 26, and I
think maybe Colorado might be close to 30, that they did get
out of their more managed care plans in those States that
subject them to the State mandates, and they just fell back on
their ERISA preemption.
Mr. Sullivan. Thank you.
I have another question for both of you. Members of
Congress and Federal employees have full equity for mental
health and addiction treatment in our health insurance plans.
As we heard from Dr. Goldman, a thorough study found that
equalizing benefits did not increase costs. Why then would you
suggest that covering the same diseases would be a big cost
increase for your members?
Mr. Klein. Well, I will take that one. First of all, the
Federal Employees Health Benefit Plan only provides parity for
in-network services, and it doesn't require it for out-of-
network services.
The second part of that, again, gets back to this issue of
medical management. And I think we can actually resolve
something here today, because there is a little disagreement
between Ms. Prunty-Lara and me on this question of whether or
not the House bill interferes with that medical management. The
Senate bill explicitly prohibits interference with medical
management. The House bill is simply silent on the issue. So if
the intention--and I am getting the sense that the intention
is, amongst the supporters of the House bill, that it should
not interfere with medical management, which everyone has
indicated is so crucial--then I think a wonderful amendment,
when this bill comes to be marked up here, would be to make
that very clear, as the Senate bill does. That would go a long
way toward encouraging, giving greater confidence that this
very important practice that ensures quality outcomes will be
protected.
Mr. Sullivan. And then a final question, I guess, Ms.
Rogers, I guess. Why do you think that passing this bill will
somehow result in major cost increases, even though parity did
not increase costs to the Federal employee program, or in
several States, including mine, Oklahoma, Vermont, Maine, New
Hampshire, Maryland, Texas, Minnesota, Connecticut or Rhode
Island or any other State studied?
Ms. Rogers. I think that because we surveyed our member
companies, and their responses were--some of them were quite
specific. Some of them said that their estimates are close to
$2 million just to implement all the changes that they need to
do to comply with the House bill. And then others said even
though they have very generous mental health benefits, they are
not identical to what would be mandated, and they feel like
that they can't----
Mr. Sullivan. Have you ever surveyed them about lost
productivity in the workforce or anything like that? We lost
$100 billion last year in America. That is pretty significant.
Ms. Rogers. Yes. No, that is usually an issue in our
surveys, but, remember, I keep saying that our members have
very generous mental health benefits. They all do. And they
call them stigma-free mental health benefits. But they are not
financial parity on the medical side. There is not the same
system. And they do have the ability to medically manage them,
and they want to be able to keep that ability.
Mr. Sullivan. I guess we all have to have someone to fight.
Mr. Purcell, I really appreciated your comments. And you
are very thoughtful. And you, as a CEO of Blue Cross and Blue
Shield, I learned something from what you said, and I
appreciate it. Thank you.
Mr. Purcell. Hopefully it is not inconsistent with a CEO to
be thoughtful.
Mr. Sullivan. No, I think it is well thought out. Thank
you. I yield back.
Mr. Purcell. Thank you.
Mr. Matheson.
Mr. Matheson. Thank you, Mr. Chairman, and thanks to the
panel.
It has been an interesting discussion. To follow up on the
line of questioning Mr. Sullivan led with, Dr. Goldman, you
talk about your study with how the cost was affected in the
Federal Employee Health Benefit Plan when mental health parity
was implemented. We have also heard about the HHS study that
found increased costs. Can you talk about the differences in
the findings and give us some insight into that?
Mr. Goldman. I am not sure I know about the HHS study that
is different from our study. Ours was the HHS-sponsored study,
and what they did find was that there was a small premium
increase of less than one-half of 1 percentage point of total
premium impact, and that resulted not from an increase of
utilization, but a shift of costs onto the plan and away from
the out-of-pocket costs of people who used services. So it was
just due to an improved insurance coverage, the financial
protection associated with the parity benefit. That is a very
small increase in premium.
And I believe that that is what you will find on the HHS
Web site, and it is very similar to the CBO estimate for the
Senate bill, and it is similar to our estimate for the Federal
Employees Health Benefit Program.
Mr. Matheson. Can you also provide insight into that
discussion on the past set of questions on how I think Mr.
Klein indicated the Federal Employee Benefit Plan, that the
savings were not necessarily as realistic for the rest of the
marketplace because of the way the plan is structured?
Mr. Goldman. If I understand, and of course Mr. Klein can
answer for himself, but I think the point was that for Federal
employees parity applied to in-network benefits only where care
was managed. Now, we saw people move from out-of-network
providers to in-network providers in order to follow their
financial incentive. People do behave rationally with respect
to their insurance coverage. And so where they had the option,
they moved. Many of them chose to move to get the parity
coverage by going in network and having managed care, but they
did have the choice. You all still have the choice, as Federal
employees under this plan, to go out of network. Usually out-
of-network benefits are unmanaged, but the coverage is usually
inferior; that is, the cost-sharing arrangements are much
higher.
Mr. Matheson. Right.
Mr. Goldman. And the issue is whether if you mandate parity
on out of network, whether the cost controls will be
sufficient, and that is one of the hardest things. Our study
can only speak to a situation in which in-network benefits are
on a par.
Mr. Matheson. OK. That is helpful.
Mr. Goldman. Is that also with you?
Mr. Klein. Yes.
Mr. Matheson. Mr. Purcell, I was going to ask you, I am
from a State where we have partial parity at this point, and
since you have been involved in the transition that took place
in your State, do you have advice you could give to insurers in
other States who have not yet made that transition about how to
most effectively have a smooth transition toward full parity?
Mr. Purcell. Well, I think most often the characterization
is that insurers are standing in the way of this. Quite
frankly, the more business we get, the better it is for us. So
in some respects, this is good business. But what you have to
do is you have to get out to the business community and bring
the word, with some backup, because they expect some proof,
that this is not going to dramatically increase your costs.
And why is it good business for you? And it is good
business for you, exactly what Mr. Sullivan said. You can
really track the increase in productivity, the lowering of
absenteeism, and the biggest monster in the corner, which is
presenteeism in which you have people who are depressed or
suffering from other behavioral disorders coming to work, and
maybe they are being there a quarter of the time. And there are
ways you can measure this. And if you can bring that measure to
the employer, the business community, and say this will
actually help, I think that is your key, because once you have
got them convinced, they won't have to pay any more premium,
but they also won't viscerally react, oh, no, another mandate,
this is enough, I have had enough. Because Ranking Member Deal
had a great point. How many ornaments do you hang on the tree
before you weigh the tree down? And that is always the issue
with mandates. Each mandate is just a little bit, but you die
by a thousand cuts. Here this one, I think, is substantively
different. So that is why I think if you do that, I think you
stand your best chance of getting it done.
Mr. Matheson. Thanks.
Mr. Chairman, I yield back.
Mr. Pallone. Thank you.
Mr. Burgess.
Mr. Burgess. Thank you, Mr. Chairman.
Mr. Purcell, let me ask you a little bit about the medical
management issue, and I guess you also referred to utilization
review. Now, you made the comment that that was not in the
House bill that is before us, but that language is in the
Senate bill.
Mr. Purcell. What I understand----
Mr. Burgess. You had three things that would improve the
bill before us. One was date of implementation, second was
medical management, and the third was the out of network.
Mr. Purcell. My understanding is that the House bill is
silent on the issue. Whether it does provide the medically
necessary, and therefore by implication that allows medical
management, I suppose I could make that argument as a good
lawyer. I would much prefer that it affirmatively say that you
can employ appropriate medical management techniques in order
to assure medical necessity.
Mr. Burgess. Do you think this is important for the overall
performance of the program?
Mr. Purcell. I very much do.
Mr. Burgess. Dr. Goldman, let me ask you, in your paper
from the New England Journal, in the abstract under the
conclusion line, it says, when coupled with management of care,
implementation of parity in insurance benefits for behavioral
health care can improve insurance protection without increasing
costs. Is that phrase, ``when coupled with the management of
care,'' is that the same thing that Mr. Purcell is referring to
as far as the medical management that he would like to see
incorporated in the legislation?
Mr. Goldman. It is.
Mr. Burgess. And so would you agree with that statement,
that perhaps the bill could be improved by incorporating either
language like the Senate or an amendment that would incorporate
the concept of medical management utilization review?
Mr. Goldman. You are the experts on draft language, but our
study indicates that you want to have the care managed if you
want to have the same experience.
Mr. Burgess. You want to have the care management as part
of the total program?
Mr. Goldman. If you wish to have the same financial impact.
Mr. Burgess. And I would assume that--and, Dr. Goldman, I
guess in full disclosure, I am a simple country doctor, so I
have done this only for the past couple of years.
Mr. Goldman. I am a complicated urban man.
Mr. Burgess. Let me ask you this, because this is something
that has bothered me for some time. When managed care really
burst upon the scene in the mid-1990's, my perception as a
practicing OB-GYN in suburban Dallas, TX, was it didn't do a
thing for the practice of psychiatry, at least in my world. And
Ranking Member Deal also kind of implied that the health
insurance policies sometimes kind of defined the conditions of
the world in which we live. Do you see a potential for some
problems here?
Mr. Goldman. For many professionals managed care is a mixed
blessing. There are down sides in terms of having your work
observed by other people. Some people don't like to have their
professional judgments second-guessed by other professionals.
But when it comes to this issue of whether the allocation
decisions should be made on the basis of arbitrary diagnostic
criteria versus individualized management, I think we have
learned that we can improve people's insurance protection if we
rely on managed care rather than on arbitrary diagnostic
criteria and our nominal benefits. So there are problems.
Mr. Burgess. Right.
Mr. Goldman. But they are the same problems that occur in
general medicine. I don't know very many providers of general
medical care that don't have their problems as well with
managed care.
Mr. Burgess. And we could talk about that at length, but we
don't have time.
Mr. Goldman. Yes, we could. We want it to be just as
unpleasant perhaps --for some on both sides of this issue.
Mr. Burgess. Perhaps.
Let me ask you this, and I appreciate your position as
well, but, as you kind of look at the evolution of insurance
and insurance benefits, at least over the time I was in
clinical practice, I mean, we had the time when all of
obstetric benefits weren't covered, and then slowly those were
incorporated in. There have been other things that have been
slowly incorporated into the insurance world. Would you see
this as just part of the--perhaps the normal evolution of
insurance benefits that we just might otherwise expect to see
happen?
Ms. Rogers. Yes, I do agree with that. As people learn
more, and there is more information out about mental health
issues, I think that you will see more and more issues being
covered.
Now, I never said that we were against mental health
parity. Our issues lie with having one Federal system for major
multinational employers who are trying to compete globally.
That is our main concern. And so that gives us a lot of
heartache, this particular bill does, because of that.
Mr. Burgess. Let me just interrupt you. Does the Senate
bill give you less heartache?
Ms. Rogers. Far less; yes, it does.
Mr. Burgess. Let me move to one last thing, because I just
have to get this out. Mr. Klein, you said it is just an issue
of fundamental fairness that Medicare and Medicaid, I presume
SCHIP, veterans benefits, should provide the same parity that
we are talking about imposing upon the private sector. Did I
grasp that concept correctly?
Mr. Klein. That is correct.
Mr. Burgess. And, Dr. Goldman, your contention would be
should we take that step, we would, in fact, save money for
Medicare, Medicaid, SCHIP, veterans health care. Is that
correct?
Mr. Goldman. I think what I would say is we could improve
insurance coverage and not have a big cost impact.
Mr. Burgess. Has anyone--we have to live and die by the CBO
here, and the Congressional Budget Office refuses to allow us
to dynamically score things. We always used to have to score
things on what the direct cost is. Have any of you looked at
that to any degree?
Mr. Klein. Congressman, I have not looked at it lately, but
memory seems to serve me that back in 1996, when the initial
parity law was enacted, that there was, I think, some CBO
calculation around that issue. I would be happy to check into
that. And it obviously would need to be updated, but I think
there might have been some sometime back.
Mr. Pallone. Mr. Burgess, you are over.
Mr. Murphy.
Mr. Murphy. Thank you, Mr. Chairman.
Ms. Rogers, let us say you are the CEO of a company, or
maybe even vice president of a division, and one of your
employees who has been around for a while has just been
promoted himself to maybe high-level executive of sales. And
you notice, you hear reports that what is happening is his
performance is beginning to deteriorate pretty significantly,
restless, perhaps falling asleep in meetings, absent-minded,
distractable, moody, irritable, perhaps even leading to loss of
sales and productivity. Would you want to have him evaluated?
Ms. Rogers. Well, I don't know if I would require that this
person be evaluated.
Mr. Murphy. You spent a lot of money over the years
training this person.
Ms. Rogers. I think that I would--most of our members have
counselors on staff, and it would be more appropriate for that
type of person to talk to this senior salesperson.
Mr. Murphy. Like an employee assistance person or
something?
Ms. Rogers. Yes.
Mr. Murphy. Let us say they recommended this person have
some medical evaluation, and there is a lot of things that
could relate to that. It could be a tumor, it could be
narcolepsy, could be a diabetic, could be depressed.
Ms. Rogers. That is true.
Mr. Murphy. It could be jet lag. What do you do if there is
a diagnosis of jet lag? You specifically referred to that in
your----
Ms. Rogers. Yes, I do.
Mr. Murphy. Do you know what the treatment is for jet lag?
Ms. Rogers. I would assume that it would be make sure that
you are hydrated, because flying dehydrates----
Mr. Murphy. You adjust your flight schedule. It is not a
psychiatric treatment. But the DSM-IV--I am trying to help you
understand, because it comes up so much among some people
trying to be a little psychiatric diagnosis. They use that one,
or shyness, et cetera. Just because it is in the DSM-IV doesn't
mean it is a psychiatric treatment. You have to label
everything. If a person shows up and they say, well, the good
news is we don't have to spend hundreds of thousands on other
things for you, it is jet lag, instead of talking to a
psychiatrist, you talk to the person who books their flights.
Here is another thing, too, I want you to know, because
this is so important when it comes to providing things for
mental health services, and that has to do with a lot of times
people are not providing mental health services, but they will
have like--they are screened by a general practitioner or
someone. And a good example of where this can break down is I
think in the use of Paxil, psychiatric medication for
depression. Tragically, it is associated with a higher risk of
suicide and other complications. But I know when I have talked
to students in medical school and other things, the highest
risk for suicide comes when the patient starts to get better.
They lose their social supports, they start to get better, they
feel energized. And what happens so often is that 75 percent of
psychiatric drugs are prescribed by nonpsychiatrists. When you
have heart disease, you double the chance of depression. If you
don't treat the depression, you double the cost of the
treatment, the illness. And many times cardiologists say, all
right, looks like you have a terrible heart disease, I am going
to describe Prozac for you, too. But that person never goes on
to get the treatment they need where you can really reduce
costs.
And the point being made by Mr. Purcell, et cetera, is when
this is done--I wouldn't say managed care, I would say care
management, because I hate that word ``managed care.'' it
really is helping to manage a person. It is making sure the
right things get done. And I would hope that as you look at
some of the studies that you refer to, it is so important to
look at who is doing the treatment and how it is done. It could
be a big cost if it is done wrong. But when we look at these
things, shyness and other things like that caffeine withdrawal,
those are simply labels to say if you have caffeine withdrawal,
the treatment is stop drinking so much coffee; jet lag, talk to
the person who books your flights.
But when you are dealing with depression and bipolar
illness and other things, you got to keep this in mind. I think
that, and I hope the business community pays attention, too,
and that is that these are real employees they invest thousands
of dollars in training and all these other things for, and if
we look at this in the big picture, what is the proper
treatment and the proper diagnosis, it is as important as
saying if someone else had some other medical problems, you
want to get the proper treatment.
I would go back to this. If that great sales manager did
have a tumor, and you only sent him to the employee assistance
program that says, Joe's just kind of moody, he has been a bad
employee, get rid of him, I don't think we would want that. If
he did have narcolepsy or diabetes or something, we would want
that treatment.
And so I see us looking at mental health parity as
something where you are really bringing the experts in to make
decision. You manage that case so they just aren't going off
somewhere and making sure, for example, they don't get some
folk treatment. Someday I would like to find out what you mean
by that, too. But I think the idea is you get the experts
together to get more effective and cost-effective treatment.
And that is part of that, so----
Ms. Rogers. Yes. And I think we agree more so than
disagree. And personally, I am a big advocate of mental health
benefits, and I spend a lot of money on them myself. My dad has
psychosis. I have two children that are premature. And none of
the experts I have been to even take insurance. So you might
want to look at that issue.
Mr. Murphy. Probably not covered.
Ms. Rogers. Well, I do have mental health benefits through
Blue Cross, but they don't take my insurance, so I just have to
pay for it personally. So, that is an issue, too.
But, remember, I mentioned that our members have very
generous mental health benefits. In all of our surveys we
couldn't find complaints from employees that felt like they
were not covered for everything that they needed to be covered.
These are America's largest employers, 25,000 employees and up.
Mr. Murphy. Well, then there is a lot of those employers
who really say they have a cost savings, and not a loss.
Thank you, Mr. Chairman.
Mr. Pallone. Thank you. And let me thank all of you. I know
this is such an important issue, and we do really want to deal
with it effectively, and your testimony was very helpful to us
as we proceed.
I would also mention that the members have the option of
submitting additional questions to you within the next 10 days
or so, and the clerk would notify you of that. So just keep
that in mind and respond in writing if you get those requests.
And without further ado, again I want to thank you. And I
hope that we can move in an expedited fashion on the
legislation. This hearing is adjourned.
[Whereupon, at 2:34 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
[GRAPHIC] [TIFF OMITTED] T2868.006
[GRAPHIC] [TIFF OMITTED] T2868.007
[GRAPHIC] [TIFF OMITTED] T2868.008
[GRAPHIC] [TIFF OMITTED] T2868.009
[GRAPHIC] [TIFF OMITTED] T2868.010
[GRAPHIC] [TIFF OMITTED] T2868.011
[GRAPHIC] [TIFF OMITTED] T2868.012
[GRAPHIC] [TIFF OMITTED] T2868.013
[GRAPHIC] [TIFF OMITTED] T2868.014
[GRAPHIC] [TIFF OMITTED] T2868.015
[GRAPHIC] [TIFF OMITTED] T2868.016
[GRAPHIC] [TIFF OMITTED] T2868.017
[GRAPHIC] [TIFF OMITTED] T2868.018
[GRAPHIC] [TIFF OMITTED] T2868.019
[GRAPHIC] [TIFF OMITTED] T2868.020
[GRAPHIC] [TIFF OMITTED] T2868.021
[GRAPHIC] [TIFF OMITTED] T2868.022
[GRAPHIC] [TIFF OMITTED] T2868.023
[GRAPHIC] [TIFF OMITTED] T2868.024
[GRAPHIC] [TIFF OMITTED] T2868.025
[GRAPHIC] [TIFF OMITTED] T2868.026
[GRAPHIC] [TIFF OMITTED] T2868.027
[GRAPHIC] [TIFF OMITTED] T2868.028
[GRAPHIC] [TIFF OMITTED] T2868.029
[GRAPHIC] [TIFF OMITTED] T2868.030
[GRAPHIC] [TIFF OMITTED] T2868.031
[GRAPHIC] [TIFF OMITTED] T2868.032
[GRAPHIC] [TIFF OMITTED] T2868.033
[GRAPHIC] [TIFF OMITTED] T2868.034
[GRAPHIC] [TIFF OMITTED] T2868.035
[GRAPHIC] [TIFF OMITTED] T2868.036
[GRAPHIC] [TIFF OMITTED] T2868.037
[GRAPHIC] [TIFF OMITTED] T2868.038
[GRAPHIC] [TIFF OMITTED] T2868.039
[GRAPHIC] [TIFF OMITTED] T2868.040