The following is a guest post by Emma Frankham.
News coverage about the Graham-Cassidy bill has been inescapable in recent weeks. This news coverage has primarily focused on comparing the Graham-Cassidy bill with the Patient Protection and Affordable Care Act (ACA) in terms of essential benefits and caps on coverage. However, there has been some confusion over how this bill will affect coverage for mental health and substance use disorder treatment. Furthermore, there has been little consideration of the potentially broader effects of this bill, particularly regarding crime.
This blog post aims to: a.) Demystify mental health parity laws and explain the relationship between mental health parity laws and essential benefits coverage in the Graham-Cassidy bill; and b.) Encourage a discussion regarding a potential relationship between mental health and substance use parity laws, treatment for substance use and mental health disorders, and crime. If enacted, how might the Graham-Cassidy bill affect crime? Research on the relationship between treatment for substance use disorders and mental illness and crime would arguably suggest that eliminating full parity of mental health coverage would increase crime.
Mental health and substance use parity laws
Mental health parity laws require insurers to cover treatment for mental illness and substance use disorders similarly to how they cover other medical or surgical costs. Understanding mental health parity laws is fundamental to understanding how coverage works regarding treatment for mental illness and substance use disorders. News reports about the Graham-Cassidy bill have been largely absent of discussion about mental health parity laws. Perhaps this is because knowledge of mental health parity laws is so low among the public (approximately 4% of Americans are aware of these laws).
The following is an explanation of what mental health parity laws are by Health Affairs:
In 1996 Congress passed the Mental Health Parity Act (MHPA)… This law applied to large-employer-sponsored group health plans (those with fifty or more employees) and prohibited them from imposing higher annual or lifetime dollar limits on mental health benefits than those applicable to medical or surgical benefits. The law applied to both fully insured group health plans… and self-insured group health plans
Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008. Like the MHPA, the MHPAEA applied to large-group health plans, both fully insured and self-insured. The MHPAEA went beyond the MHPA and included Medicare Advantage plans offered through group health plans, state and local government plans, Medicaid managed care plans, and state Children’s Health Insurance Program (CHIP) plans… The MHPAEA prohibited differences in treatment limits, cost sharing, and in- and out-of-network coverage… the MHPAEA also applied to the treatment of substance use disorders, which the MHPA did not address… It is important to note that the MHPAEA did not mandate mental health or substance use treatment, but if treatment for these conditions is included as a benefit, plans have to provide it under the same terms and conditions as other medical treatment.
The Affordable Care Act (ACA) applied the MHPAEA to issuers in the individual market and qualified health plans offered through a Marketplace… Importantly, the ACA specified coverage of mental health and substance use treatment as one of its ten essential health benefits.
In other words, the MHPA and MHPAEA created a parity-if-offered system where insurers were not required to offer insurance coverage for mental illness and substance use disorder treatment, but they were required to offer it at parity with medical and surgical benefits if they did. The ACA increased this standard to full parity – insurers were required to offer coverage for mental illness and substance use disorder treatment and this coverage had to be comparable to coverage for other medical and surgical coverage.
So… does the Graham-Cassidy bill cover mental health services?
The Graham-Cassidy bill is essentially a parity-if-offered bill. In other words, if states choose to include mental health care services treatment and/or substance use treatment services as an essential benefit, there has to be parity in coverage compared to other medical and surgical coverage. The bill therefore reverts to pre-ACA legislation and it will require insurers to cover mental health and substance use services similarly to the MHPAEA.
What does this have to do with crime?
There is a large body of research that has examined the relationship between substance use and crime, mental illness and crime, and substance use as a mediator of mental illness and crime. However, what if different types of health insurance parity mediate relationships between substance use and/or mental illness and crime?
Research has indicated that full parity of coverage is associated with higher levels of treatment for substance use disorders than parity-if-offered, or no parity at all coverage. Mental health treatment likely follows this same trend, although to my knowledge there has been no research on this topic to date.
Transitioning from full parity coverage to parity-if-offered coverage will leave more individuals unable to access mental health and substance use services. In turn, this may influence crime rates. For example, crime may be committed by individuals for financial reasons so that they can maintain substance use habits in lieu of treatment and support. Individuals with mental illness who are unable to access treatment may self-medicate, which may also lead to crime. Furthermore, lack of coverage may influence not only whether individuals commit crime, but also whether individuals become victims of crime. For example, individuals may become vulnerable to victimization because of mental illness. Research has indicated that individuals with severe mental illness are 11 times more likely to be a victim of violent crime than those without serious mental illness.
Journalists and non-profits have paid attention to the use of healthcare as a “crime-fighting tool,” both in reducing arrest rates of individuals with mental illness and/or substance use disorders, and in reducing recidivism. However, there appears to be very little research (if any) that examines the relationship between mental health and substance use parity laws and crime. Particularly in the context of the opioid crisis and attacks on healthcare coverage, researchers should explore relationships between healthcare parity, mental illness and/or substance use, and crime.
Emma Frankham is a Ph.D student in Sociology at the University of Wisconsin-Madison.