[Congressional Record Volume 145, Number 51 (Wednesday, April 14, 1999)]
[Senate]
[Pages S3701-S3705]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DOMENICI (for himself, Mr. Wellstone, Mr. Chafee,

[[Page S3702]]

        Mr. Specter, Mr. Reid, Mr. Sarbanes, and Mr. Kennedy):
  S. 796. A bill to provide for full parity with respect to health 
insurance coverage for certain severe biologically-based mental 
illnesses and to prohibit limits on the number of mental illness-
related hospital days and outpatient visits that are covered for all 
mental illnesses; to the Committee on Health, Education, Labor, and 
Pensions.


             Mental Health Equitable Treatment Act of 1999

  Mr. DOMENICI. Mr. President, today I rise with great pleasure to 
introduce the Mental Health Equitable Treatment Act of 1999. I also 
thank Senator Wellstone, my cosponsor, and the other Senators who have 
already joined me in an effort to make this case. This will say to the 
insurance companies and the businesses of America, unless they have 25 
or fewer employees, their insurance coverage of their employees and 
their employees' families, if there is going to be mental illness or 
mental disease coverage, they will have to, as to severe illnesses, 
have coverage with full parity. As to other mental illnesses, they will 
have to stop trying to get around the parity law by cutting some of the 
copays and the like. This will prohibit that.
  Essentially, we are going to take a piece of America that is 
currently discriminated against in health care because those Americans 
do not have a disease that is a disease of the heart but have a disease 
of the brain. We now can define it sufficiently that there is no reason 
to cover one and not the other, and in the process we will stop 
discriminating against about 10 million American families.
  Mr. President, I rise today with great pleasure and excitement to 
introduce the Mental Health Equitable Treatment Act of 1999. I would 
also like to thank Senator Wellstone for once again joining me to 
cosponsor this important piece of legislation.
  The human brain is the organ of the mind and just like the other 
organs of our body, it is subject to illness. And just as illnesses to 
our other organs require treatment, so too do illnesses of the brain.
  Medical science is in an era where we can accurately diagnose mental 
illnesses and treat those afflicted so they can be productive. I would 
ask then, why with this evidence would we not cover these individuals 
and treat their illnesses like any other disease?
  We should not. So, I would submit there should not be a difference in 
the coverage provided by insurance companies for mental health benefits 
and medical benefits.
  The introduction of this bill marks a historic opportunity for us to 
take the next step toward mental health parity. As my colleagues know, 
this is an issue I have a long involvement with and I would like to 
begin with a few observations.
  I believe that we have made great strides in providing parity for the 
coverage of mental illness. However, mental illness continues to exact 
a heavy toll on many, many lives.
  Even though we know so much more about mental illness, it can still 
bring devastating consequences to those it touches; their families, 
their friends, and their loved ones. These individuals and families not 
only deal with the societal prejudices and suspicions hanging on from 
the past, but they also must contend with unequal insurance coverage.
  I would submit the Mental Health Parity Act of 1996 is a good first 
start, but the act is also not working. While there may be adherence to 
the letter of the law, there are certainly violations of the spirit of 
the law. For instance, ways are being found around the law by placing 
limits on the number of covered hospital days and outpatient visits.
  That is why I believe it is time for a change.
  Some will immediately say we cannot afford it or that inclusion of 
this treatment will cost too much. But, I would first direct them to 
the results of the Mental Health Parity Act of 1996. That law contains 
a provision allowing companies to no longer comply if their costs 
increase by more than 1 percent.
  And do you know how many companies have opted out because their costs 
have increased by more than 1 percent? Only four companies out of all 
the companies throughout the country.
  Mr. President, with that in mind I would like to share a couple of 
facts about mental illness with my colleagues:
  Within the developed world, including the United States, 4 of the 10 
leading causes of disability for individuals over the age of 5 are 
mental disorders.
  In the order of prevalence the disorders are major depression, 
schizophrenia, bipolar disorder, and obsessive compulsive disorder.
  Disability always has a cost and the direct cost to the United States 
per year for respiratory disease is $99 billion, cardiovascular disease 
is $160 billion, and finally $148 billion for mental illness.
  One in every five people--more than 40 million adults--in this Nation 
will be afflicted by some type of mental illness.
  Nearly 7.5 million children and adolescents, or 12 percent, suffer 
from one or more mental disorders.
  Schizophrenia alone is 50 times more common than cystic fibrosis, 60 
times more common than muscular dystrophy and will strike between 2 and 
3 million Americans.
  Let us also look at the efficacy of treatment for individuals 
suffering from certain mental illnesses, especially when compared with 
the success rates of treatments for other physical ailments. For a long 
time, many who are in this field--especially on the insurance side--
have behaved as if you get far better results for angioplasty then you 
do for treatments for bipolar illness.
  Treatment for bipolar disorders--this is, those disorders 
characterized by extreme lows and extreme highs--have an 80-percent 
success rate if you get treatment, both medicine and care. 
Schizophrenia, the most dreaded of mental illnesses, has a 60-percent 
success rate in the United States today if treated properly. Major 
depression has a 65-percent success rate.
  Let's compare those success rates to several important surgical 
procedures that everybody thinks we ought to be doing: Angioplasty has 
a 41-percent success rate; atherectomy has a 52-percent success rate.
  I would now like to take a minute to discuss the Mental Health 
Equitable Treatment Act of 1999. The bill seeks a very simple goal: (1) 
provide full parity for severe biologically based mental illnesses; (2) 
prohibit limits on the number of covered hospital days and outpatient 
visits; and (3) eliminate the Mental Health Parity Act's sunset 
provision.
  The bill would provide full parity for the following mental 
illnesses: schizophrenia, bipolar disorder, major depression, obsessive 
compulsive and severe panic disorders, posttraumatic stress disorder, 
autism, and other severe and disability mental disorders.
  Like the Mental Health Parity Act of 1996, the bill does not require 
a health plan to provide coverage for alcohol and substance abuse 
benefits. Moreover, the bill does not mandate the coverage of mental 
health benefits, rather the bill only applies if the plan already 
provides coverage for mental health benefits.
  In conclusion, the bill expands full parity to those suffering from a 
severe biologically based mental illness and it closes a loophole in 
the Mental Health Parity Act of 1996 by prohibiting limits on the 
number of covered hospital days and outpatient visits and I would urge 
my colleagues to support this important piece of legislation.
  Mr. President, I ask unanimous consent that the text of the bill and 
additional material be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                 S. 796

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Mental Health Equitable 
     Treatment Act of 1999''.

     SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY 
                   ACT OF 1974.

       (a) In General.--Section 712 of the Employee Retirement 
     Income Security Act of 1974 (29 U.S.C. 1185a) is amended--
       (1) in subsection (a), by adding at the end the following:
       ``(3) Hospital day and outpatient visit limits.--In the 
     case of a group health plan (or health insurance coverage 
     offered in connection with such a plan) that provides both

[[Page S3703]]

     medical and surgical benefits and mental health benefits--
       ``(A) No inpatient limits.--If the plan or coverage does 
     not include a limit on the number of days of coverage 
     provided for inpatient hospital stays in connection with 
     covered medical and surgical benefits, the plan or coverage 
     may not impose any limit on inpatient hospital stays for 
     mental health benefits.
       ``(B) Certain inpatient limits.--If the plan or coverage 
     includes a limit on the number of days of coverage provided 
     for inpatient hospital stays in connection with certain 
     covered medical and surgical benefits, the plan or coverage 
     may impose comparable limits on inpatient hospital stays for 
     mental health benefits.
       ``(C) No outpatient limits.--If the plan or coverage does 
     not include a limit on the number of outpatient visits in 
     connection with covered medical and surgical benefits, the 
     plan or coverage may not impose any limit on the number of 
     outpatient visits for mental health benefits.
       ``(D) Certain outpatient limits.--If the plan or coverage 
     includes a limit on the number of outpatient visits in 
     connection with certain covered medical and surgical 
     benefits, the plan or coverage may impose comparable limits 
     on the number of outpatient visits for mental health 
     benefits.
       ``(4) Severe mental illness.--In the case of a group health 
     plan (or health insurance coverage offered in connection with 
     such a plan) that provides medical and surgical benefits and 
     mental health benefits, such plan or coverage shall not 
     impose any limitations on the coverage of benefits for severe 
     biologically-based mental illnesses unless comparable 
     limitations are imposed on medical and surgical benefits.'';
       (2) by striking subsection (b) and inserting the following:
       ``(b) Construction.--
       ``(1) In general.--Nothing in this section shall be 
     construed--
       ``(A) as requiring a group health plan (or health insurance 
     coverage offered in connection with such a plan) to provide 
     any mental health benefits; or
       ``(B) in the case of a group health plan (or health 
     insurance coverage offered in connection with such a plan) 
     that provides mental health benefits, as affecting the terms 
     and conditions (including cost sharing and requirements 
     relating to medical necessity) relating to the amount, 
     duration, or scope of mental health benefits under the plan 
     or coverage, except as specifically provided in subsection 
     (a) (in regard to parity in the imposition of aggregate 
     lifetime limits and annual limits and limits on inpatient 
     stays or outpatient visits for mental health benefits).
       ``(2) Care, treatment, and delivery of services.--Nothing 
     in this subpart shall be construed to prohibit the provision 
     of care or treatment, or delivery of services, relating to 
     mental health services, by qualified health professionals 
     within their scope of practice as licensed or certified by 
     the appropriate State or jurisdiction.'';
       (3) in subsection (c)--
       (A) by striking paragraph (2); and
       (B) in paragraph (1)--
       (i) by striking subparagraphs (A) and (B) and inserting the 
     following:
       ``(A) In general.--This section shall not apply to any 
     group health plan (and group health insurance coverage 
     offered in connection with a group health plan) for any plan 
     year of any employer who employed an average of at least 2 
     but not more than 25 employees on business days during the 
     preceding calendar year.'';
       (ii) by redesignating subparagraphs (A) and (C) as 
     paragraphs (1) and (2), respectively, and realigning the 
     margins accordingly; and
       (iii) in paragraph (2) (as so redesignated), by 
     redesignating clauses (i) through (iii) as subparagraphs (A) 
     through (C), respectively;
       (4) in subsection (e), by adding at the end the following:
       ``(5) Severe biologically-based mental illness.--The term 
     `severe biologically-based mental illness' means an illness 
     that medical science in conjunction with the Diagnostic and 
     Statistical Manual of Mental Disorders (DSM IV) affirms as 
     biologically based and severe, including schizophrenia, 
     bipolar disorder, major depression, obsessive compulsive and 
     panic disorders, posttraumatic stress disorder, autism, and 
     other severe and disabling mental disorders such as anorexia 
     nervosa and attention-deficit/hyper activity disorder.''; and
       (5) by striking subsection (f).
       (b) Effective Date.--The amendments made by this section 
     shall apply with respect to plan years beginning on or after 
     January 1, 2000.

     SEC. 3. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT RELATING 
                   TO THE GROUP MARKET.

       (a) In General.--Section 2705 of the Public Health Service 
     Act (42 U.S.C. 300gg-5) is amended--
       (1) in subsection (a), by adding at the end the following:
       ``(3) Hospital day and outpatient visit limits.--In the 
     case of a group health plan (or health insurance coverage 
     offered in connection with such a plan) that provides both 
     medical and surgical benefits and mental health benefits--
       ``(A) No inpatient limits.--If the plan or coverage does 
     not include a limit on the number of days of coverage 
     provided for inpatient hospital stays in connection with 
     covered medical and surgical benefits, the plan or coverage 
     may not impose any limit on inpatient hospital stays for 
     mental health benefits.
       ``(B) Certain inpatient limits.--If the plan or coverage 
     includes a limit on the number of days of coverage provided 
     for inpatient hospital stays in connection with certain 
     covered medical and surgical benefits, the plan or coverage 
     may impose comparable limits on inpatient hospital stays for 
     mental health benefits.
       ``(C) No outpatient limits.--If the plan or coverage does 
     not include a limit on the number of outpatient visits in 
     connection with covered medical and surgical benefits, the 
     plan or coverage may not impose any limit on the number of 
     outpatient visits for mental health benefits.
       ``(D) Certain outpatient limits.--If the plan or coverage 
     includes a limit on the number of outpatient visits in 
     connection with certain covered medical and surgical 
     benefits, the plan or coverage may impose comparable limits 
     on the number of outpatient visits for mental health 
     benefits.
       ``(4) Severe mental illness.--In the case of a group health 
     plan (or health insurance coverage offered in connection with 
     such a plan) that provides medical and surgical benefits and 
     mental health benefits, such plan or coverage shall not 
     impose any limitations on the coverage of benefits for severe 
     biologically-based mental illnesses unless comparable 
     limitations are imposed on medical and surgical benefits.'';
       (2) by striking subsection (b) and inserting the following:
       ``(b) Construction.--
       ``(1) In general.--Nothing in this section shall be 
     construed--
       ``(A) as requiring a group health plan (or health insurance 
     coverage offered in connection with such a plan) to provide 
     any mental health benefits; or
       ``(B) in the case of a group health plan (or health 
     insurance coverage offered in connection with such a plan) 
     that provides mental health benefits, as affecting the terms 
     and conditions (including cost sharing and requirements 
     relating to medical necessity) relating to the amount, 
     duration, or scope of mental health benefits under the plan 
     or coverage, except as specifically provided in subsection 
     (a) (in regard to parity in the imposition of aggregate 
     lifetime limits and annual limits and limits on inpatient 
     stays or outpatient visits for mental health benefits).
       ``(2) Care, treatment, and delivery of services.--Nothing 
     in this part shall be construed to prohibit the provision of 
     care or treatment, or delivery of services, relating to 
     mental health services, by qualified health professionals 
     within their scope of practice as licensed or certified by 
     the appropriate State or jurisdiction.'';
       (3) by striking subsection (c) and inserting the following:
       ``(c) Exemption.--This section shall not apply to any group 
     health plan (and group health insurance coverage offered in 
     connection with a group health plan) for any plan year of any 
     employer who employed an average of at least 2 but not more 
     than 25 employees on business days during the preceding 
     calendar year.'';
       (4) in subsection (e), by adding at the end the following:
       ``(5) Severe biologically-based mental illness.--The term 
     `severe biologically-based mental illness' means an illness 
     that medical science in conjunction with the Diagnostic and 
     Statistical Manual of Mental Disorders (DSM IV) affirms as 
     biologically based and severe, including schizophrenia, 
     bipolar disorder, major depression, obsessive compulsive and 
     panic disorders, posttraumatic stress disorder, autism, and 
     other severe and disabling mental disorders such as anorexia 
     nervosa and attention-deficit/hyper activity disorder.''; and
       (5) by striking subsection (f).
       (b) Effective Date.--The amendments made by this section 
     shall apply with respect to plan years beginning on or after 
     January 1, 2000.

     SEC. 4. PREEMPTION.

       Nothing in the amendments made by this Act shall be 
     construed to preempt any provision of State law that provides 
     protections to enrollees that are greater than the 
     protections provided under such amendments.
                                  ____


         Mental Health Equitable Treatment Act of 1999--Summary

       The Bill seeks to ensure greater parity in the coverage of 
     mental health benefits by prohibiting limits on the number of 
     covered hospital days and outpatient visits for all mental 
     illnesses and providing full parity for specified severe 
     adult and child mental illnesses.
       The Bill only applies to group health plans already 
     providing mental health benefits.


      prohibition on day and visit limits for all mental illnesses

       Expands the Mental Health Parity Act of 1996 (MHPA) to 
     include parity for the number of covered hospital days and 
     outpatient visits for all mental illnesses.


       full parity for severe biologically-based mental illnesses

       Provides full parity for the following severe biologically-
     based mental illnesses: schizophrenia, bipolar disorder, 
     major depression, obsessive compulsive and severe panic 
     disorders, post traumatic stress disorder, autism, and other 
     severe and disabling mental disorders such as, anorexia 
     nervosa and attention-deficit/hyperactivity disorder.
       The term ``severe biologically-based mental illness'' means 
     the above illnesses as defined by current medical science in 
     conjunction with the Diagnostic and Statistical Manual of 
     Mental Disorders (DSM IV).

[[Page S3704]]

                      requirements and exemptions

       Elimination of the September 30, 2001 sunset provision in 
     the MHPA.
       Like the MHPA the bill does not require plans to provide 
     coverage for benefits relating to alcohol and drug abuse.
       There is a small business exemption for companies with 25 
     or fewer employees.

  Mr. WELLSTONE. Mr. President, today I rise to introduce the Mental 
Health Equitable Treatment Act of 1999, a bit that will ensure that 
private health insurance companies provide the same level of coverage 
for mental illness as they do for other diseases. This bill will be a 
major step toward ending the discrimination against people who suffer 
from mental illness.
  For too long, mental illness has been stigmatized, or viewed as a 
character flaw, rather than as the serious disease that it is. A cloak 
of secrecy has surrounded this disease, and people with mental illness 
are often ashamed and afraid to seek treatment, for fear that they will 
be seen as admitting a weakness in character. We have all seen 
portrayals of mentally ill people as somehow different, as dangerous, 
or as frightening. Such stereotypes only reinforce the biases against 
people with mental illness. Can you imagine this type of portrayal of 
someone who has a cardiac problem, or who happens to carry a gene that 
predisposes them to diabetes?
  Although mental health research has well-established the biological, 
genetic, and behavioral components of many of the forms of serious 
mental illness, the illness is still stigmatized as somehow less 
important or serious than other illnesses. Too often, we try to push 
the problem away, deny coverage, or blame those with the illness for 
having the illness. We forget that someone with mental illness can look 
just like the person we see in the mirror, or the person who is sitting 
next to us on a plane. It can be our mother, or brother, or son, or 
daughter. It can be one of us. We have all known someone with a serious 
mental illness, within our families or our circle of friends, or in 
public life. Many people have courageously come forward to speak about 
their personal experiences with their illness, to help us all 
understand better the effects of this illness on a person's life, and I 
commend them for their courage.
  The statistics concerning mental illness, and the state of health 
care coverage for adults and children with this disease are startling, 
and disturbing.
  One severe mental illness affecting millions of Americans is major 
depression. The National Institute of Mental Health, a NIH research 
institute, within the U.S. Department of Health and Human Services, 
describes serious depression as a critical public health problem. More 
than 18 million people in the United States will suffer from a 
depressive illness this year, and many will be unnecessarily 
incapacitated for weeks or months, because their illness goes 
untreated. The cost to the Nation in 1990 was estimated to be between 
$30-$44 billion. The suffering of depressed people and their families 
is immeasurable.
  Depressive disorders are not the normal ups and downs everyone 
experiences. They are illnesses that affect mood, body, behavior, and 
mind. Depressive disorders interfere with individual and family 
functioning. Without treatment, the person with a depressive disorder 
is often unable to fulfill the responsibilities of spouse or parent, 
worker or employer, friend or neighbor.
  Available medications and psychological treatments, alone or in 
combination, can help 80 percent of those with depression. But without 
adequate treatment, future episodes of depression may continue or 
worsen in severity. Yet, the steady decline in the quality and breadth 
of health care coverage is truly disturbing.
  The results of a major survey of employer-provided health plans was 
published in 1998 by the Hay Group, an independent benefits consulting 
firm. The Hay Report showed a major decline in benefits in the last 
decade:
  Employer-provided mental health benefits decreased 54%--while 
benefits for general health decreased only 7%;
  Even before this erosion occurred, mental health benefits made up 
only 6% of total medical benefits paid by employers. Today--that has 
been cut in half--it is down to 3%;
  The number of plans restricting hospitalization for mental disorders 
increased by 20%;
  Descriptions of benefit limits themselves are misleading. Although 
plans may say that they allow 30 days for hospitalization, this is 
rarely approved. In 1996, the average length of stay was 8\1/2\ days, 
down from 17 in 1991.
  In 1988, most insurance plans allowed 50 therapy sessions per years. 
In 1997, the average number was 20.
  A 1998 study published by Health Affairs found that between 1991 and 
1995, HMO enrollees were twice as likely to encounter limits on 
psychiatric visits, and about three times as likely to have separate, 
and higher, copayments than for general medical health care.
  No one, of course, expects coverage of any illness to cost nothing. 
But what we do know is that fears of spiraling costs for mental health 
treatment are unfounded. Studies from HHS that have examined the 
effects of mental health and substance abuse treatment parity have 
shown that full parity for these benefits would be just slightly higher 
than current premiums. Most reports, like the one requested by Congress 
from the National Advisory Mental Health Counsel, showed that when 
mental health coverage is managed, either moderately or tightly, that 
premium increases can be as low as 1%.
  These costs are so low. And the cost of NOT treating is so high--
especially when one looks at the toll that untreated mental illness 
takes on individuals, families, employers, corporations, social service 
systems, and criminal justice systems. I have seen first hand in the 
juvenile corrections system what happens when mental illness is 
criminalized, when youth with mental illness are incarcerated for 
exhibiting symptoms of their illness. To treat ill people as criminals 
is outrageous is outrageous and immoral. We must make treatment for 
this illness as available and as routine as treatment for any other 
disease. The discrimination must stop.
  Our bill includes parity for hospital day and outpatient visits for 
all mental illnesses. Additionally, for many of the most severe adult 
and child mental illnesses, the bill establishes full parity, i.e., 
parity for copayments, deductibles, hospital day, and outpatient visit 
benefits. The bill also provides protection for non-physician 
providers, and for states with stronger parity bills; it also includes 
a small business exemption, and eliminates the sunset provision and the 
1% exemption from the 1996 Mental Health Parity Act. Covered services 
include inpatient treatment; non-hospital residential treatment; 
outpatient treatment, including screening and assessment, medication 
management, individual, group and family counseling; and prevention 
services, including health education and individual and group 
counseling to encourage the reduction of risk factors for mental 
illness.
  The Mental Health Equitable Treatment Act of 1999 provides for major 
improvements in coverage for mental illness by private health insurers. 
It does not require that mental health benefits be part of a health 
benefits package, but establishes a requirement for parity in coverage 
for those plans that offer mental health benefits. This bill goes a 
long way toward our bipartisan goal: that mental illness be treated 
like any other disease in health care coverage.
  Mr. President, the Mental Health Equitable Treatment Act of 1999 is 
designed to take a large step toward ending the suffering of those with 
mental illness who have been unfairly discriminated against in their 
health coverage. We must end this discrimination.
  Mr. CHAFEE. Mr. President, I am pleased to join my colleagues, 
Senators Domenici and Wellstone, in introducing the Mental Health 
Equitable Treatment Act of 1999, and I applaud them for their 
leadership on this issue. This legislation is an important step towards 
ensuring that people with mental illness have access to the care they 
need.
  For too long, insurance plans have treated patients with mental 
illnesses differently than those with physical illnesses. However, 
research has proven the biological origins of mental illness. It is now 
time to bring coverage of mental illness into the 20th century. There 
is no rational basis for excluding or limiting coverage for such 
conditions; doing so is patently discriminatory. Enactment of the 
Mental Health Parity Act in 1996, which I cosponsored,

[[Page S3705]]

was the first step in correcting this disparity. This legislation 
builds upon the 1996 law by adding some important new protections.
  In my home state of Rhode Island, over 28,000 people are suffering 
from severe mental illnesses such as schizophrenia, bipolar disorder 
and major depression. These disorders can be as threatening to the 
health of the patient as physical illnesses, such as cancer or AIDS. 
Discriminatory coverage restrictions or cost-sharing requirements--such 
as limits on the number of therapy visits or disparate co-payments--
place an undue hardship on these patients at a time when they require 
medical care.
  If left untreated, mental illnesses can result in more serious 
disability or even death. This legislation takes another step in 
helping to prevent such tragedies. I hope we one day will be able to 
end discrimination in the coverage of all mental illnesses. I urge my 
colleagues to support this measure.
                                 ______