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For children with emotional and mental disorders, a new $24 billion federal program for America’s 10 million uninsured children is a start, but just a start, concludes a report commissioned by the APA-led Coalition on Fairness in Mental Illness Coverage.
The results of the report by the HayGroup, titled "Value of Benefits Offered in Benchmark Plans for State Children’s Health Insurance Program (SCHIP)," were released at a press conference in November in Washington, D.C. The report evaluated children’s health insurance coverage in 16 states: Alaska, Arizona, California, Connecticut, Florida, Georgia, Illinois, Kansas, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Pennsylvania, Texas, and Utah.
APA’s Division of Government Relations mailed a copy of the report to every APA district branch president and executive secretary, according to Julie Shroyer, deputy director for congressional affairs. Members can obtain copies of the report from DGR while supplies last.
"Our message for members is that they need to get involved in coalitions at the state and local level to influence the approach that their state takes with respect to implementing the SCHIP," said Shroyer. "It is important that uninsured children in their state have access to the best mental health coverage possible."
The program became effective October 1, with $4.27 billion in matching funds available through the end of Fiscal 1998. The remaining funds will be available through Fiscal 2002. The new program for uninsured children generally applies to families at 200 percent or less of the federal poverty level. SCHIP was created as part of the Balanced Budget Act of 1997.
States applying for funds under SCHIP must offer benefits based on one of three benchmarks or an alternative of equivalent actuarial value. These benchmarks include the Federal Employees Health Benefits Program (FEHBP) available to all federal employees; the health plan generally available to state employees in the state; or the largest commercial, non-Medicaid HMO in the state.
States may expand their Medicaid programs to cover uninsured children, a strategy favored by the coalition. Medicaid provides relatively comprehensive mental health coverage through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Federal law requires EPSDT services be provided to all Medicaid-eligible recipients under age 22 both to identify physical and mental problems and to provide medically necessary treatment for physical and mental illness identified through the screenings.
Although the Clinton Administration should be applauded for its efforts to see that uninsured children have access to mental health services through SCHIP, the inadequacies revealed by the HayGroup’s study show that more must be done, said APA Medical Director Steven Mirin, M.D. The report "dramatizes the urgent need for parity mental illness coverage and shows that our work is not complete," he said.
"Given that 1 in 5 of all children from birth to age 17 suffers from a diagnosable mental, emotional, or behavioral disorder, and nearly 9 percent of all youths ages 9 to 17 have a serious emotional disturbance, our goal is to be sure that policymakers will be able to discern which coverage option is best for their state," said Mirin.
The coalition’s guiding principle is that "every child deserves the same access to mental health care and levels of care that are available for all other medical conditions," he asserted.
If a state designs a plan different from a benchmark, the alternative must provide mental health benefits valued at 75 percent or more of those in the benchmarks. Federal matching funds are contingent on the plan’s approval by the Secretary of Health and Human Services.
On the bright side, the HayGroup study reveals that all 16 states surveyed offer some mental health benefits for children. But the level of coverage varies widely, in some cases discriminating harshly against the most severely mentally ill. Most plans provide inpatient hospitalization, outpatient services, and substance abuse benefits.
"We are pleased that there is a mental health benefit in this law for children," remarked Barbara Huff, executive director of the Federation for Families. Huff, who has a child with a severe mental disorder, said that although the inclusion of any mental health benefit is a victory, she and others worry about the level of benefits provided. "Our concern is that the choice of benefits will not be enough to cover the range of services needed to keep a child with a mental or emotional disturbance in the home and in the community."
The 16 surveyed states represent 63 percent of eligible uninsured children and together will receive more than 65 percent of the federal funds used to finance the SCHIP initiative.
Four of the states in the study, Connecticut, North Carolina, Minnesota, and Texas, already have parity laws prohibiting discrimination in insurance coverage of mental illness. The experience of these four states proves that "providing mental health benefits to children—and parity for those benefits—is affordable and within the means of states that set up children’s health insurance programs," observed Mirin.
The coalition’s goal is true parity, and by that standard SCHIP falls short, said Clarke Ross, D.P.A., executive director of the American Managed Behavioral Healthcare Association. Although all the plans surveyed had some mental health coverage, said Ross, "there was great variability and great inadequacies."
Based on the HayGroup’s Benefits Value Comparison (BVC), the actuarial value of the FEHBP benchmark is $1,460 a year, of which $72 (4.9 percent) goes to children’s mental health.
For state employee plans, the survey finds actuarial values ranging from $1,248 for California to $1,740 for Utah, with greater disparity in mental health values. Mental health values run from $52 a year in Illinois to $115 a year in Texas. As a percentage of total coverage, mental health services range from 3.4 percent in Utah to 7.6 percent in Texas.
Under benchmark HMO’s, total actuarial values range from $986 for Minnesota to $1,285 for Illinois. Mental health values run from $29 for NYLCare in Texas to $45 for the Harvard Community Health Plan in Massachusetts. As a percentage of total coverage, mental health services range from 2.7 percent for Texas NYLCare to 4.4 percent for HealthPartners Select in Minnesota.
Discriminatory design is also reflected in annual and lifetime limits. But under the 1996 Mental Health Parity Act, which took effect January 1, a plan offering any mental health benefit must provide annual and aggregate lifetime limits for mental health services equal to those for other medical services.
The SCHIP law grandfathers existing comprehensive state plans in Florida, Pennsylvania, and New York.
The Coalition for Fairness in Mental Illness Coverage consists of the National Alliance on Mental Illness, the Mental Health America, the American Behavioral Healthcare Association, American Medical Association, APA, American Psychological Association, Federation of American Health Systems, and the National Association of Psychiatric Health Systems.