By Jeffrey Geller, M.D., M.P.H.

As almost all psychiatrists must know by now, President Clinton signed the 1997 V.A./HUD spending bill that contained the Domenici-Wellstone mental illness parity amendment on September 26. Since that event, APA has joined many individuals and groups in jubilantly congratulating patients, families, and advocates for this success.

But are ebullient proclamations of success in the fight for parity warranted? Or are they premature?

Before I attempt to answer those questions, a comment on terminology. I will use the term "true parity" to refer to nondiscriminatory coverage of mental illnesses-that is, no arbitrary limits, no discriminatory copayments, and no specially designed prior-approval processes. I will use the term "parity" to refer to all advances in the direction of nondiscriminatory practices but that fall short of the goal of true parity.

When the parity provision takes effect, it will prohibit the imposition of annual and lifetime payment limits for mental illness coverage that are different from those for medical illness; it applies to private, group insurance and to self-insurance plans. Some would call this a limited gain. The law does not apply to individual policies, group policies of businesses with 50 or fewer employees, Medicaid, Medicare, or substance abuse treatment. The law does not require equal copayments, deductibles, utilization procedures, or even visit limits for mental illness care.

Some enthusiasts for the new law would point out that the parity provision's application to self-insurance plans is a big crack in the usually inviolable bastions of self-insurance plans, which are heavily protected by ERISA preemptions. And it's surely worth noting that this is the first time Congress passed and the President signed into law some recognition that the historical disparity between insurance coverage for mental and physical disorders needs to be addressed.

A major problem with the new law, however, is that this gain can be easily destroyed. The insurance industry, at the behest of business interests, can use draconian actuarial techniques to wipe out almost all progress from this small step toward true parity. Through the imposition of sliding copayments and progressive deductibles-all pegged toward utilization limits-most users of psychiatric services could be worse off financially than they were before the law. In addition, the law only applies to insurance plans that offer some mental illness coverage. If an insurer elects to drop all such coverage, which is legally permissible under federal law, then none of the new provisions will apply.

Can we minimize the likelihood of this regressive outcome? You bet. Should we then begin the celebration? Remember, in the national health reform effort of 1994 we went for everything and got nothing. In the parity quest of 1996 we went for a little (as much as the Senate proponents of true parity thought we could get at this time) and got a little. So, one jump for joy, perhaps, but I don't think we should start the party. The real celebration depends entirely upon what we all do now and during the next Congress!

Here are some suggestions for continuing progress on the parity front: