Mental health parity may finally become a reality

The Wellstone Act could bring better health care to millions of Americans

"There's no consistency in terms of what the law is asking for, and so it's been up to the insurance company," says Nell Hurley, head of the Minnesota Recovery Connection.

As the companies are writing their own rules, they've had little oversight or enforcement.

"Everyone's heard the federal regulator basically saying, 'We know there are some big loopholes, and so don't worry, [health] plans, we're not going to enforce the gray areas,'" explains Carol McDaid, a Washington, D.C., lobbyist who works closely with both Ramstad and Dave Wellstone. "It has had a chilling effect on the implementation and definitely on the enforcement."

Dave Wellstone, Rep. Jim Ramstad, and Kitty Westin of the Emily Program Foundation in Washington, D.C.
Dave Wellstone, Rep. Jim Ramstad, and Kitty Westin of the Emily Program Foundation in Washington, D.C.
Wellstone at an event for the Eating Disorder Coalition, with then-Sen. Hillary Clinton behind him
courtesy of Ellen Gerrity
Wellstone at an event for the Eating Disorder Coalition, with then-Sen. Hillary Clinton behind him

Now, following President Obama's call to finalize regulations, Ramstad is hopeful that the law he sponsored will finally make the changes it was designed to do.

"I've never heard of a major bill taking this long, but we're getting closer," he says. "I've got page seven of the president's plan memorized. We can see the finish line."

Others worry that it's far from a done deal. Two of Obama's other mental health orders have strict deadlines: He directed regulators to decide on final rules for the Affordable Care Act by February. But for the Wellstone Act, Obama hasn't yet ordered a date.

"Sandy Hook has put a new focus on mental health," says Franken. "But I think we've been a little frustrated that they've said, 'Okay, we're committed,' but they haven't set a timeline. It's very important that we get this done."

In 1998, second-term Sen. Paul Wellstone went to an event for the Woodley House in D.C., which offers housing and support for people with mental illness. His older brother, Stephen, had stayed there decades earlier, during a time when he had to be institutionalized for his own mental illness.

Wellstone was scheduled to speak, along with distinguished panelists like then-Vice President Al Gore. Ellen Gerrity, Wellstone's chief staffer for mental health parity reform, was standing nearby when her boss took the stage.

"He was talking about how to get parity done and what it would have meant to his family to have had good care," Gerrity remembers. "I looked back at the audience and these hundreds of people were all looking up at him. It was family members trying to get care; it was providers who had worked so long without enough pay. I could see the inspiration they were receiving from him. Many times when I saw him speaking to audiences, many times that passion carried over."

Much of that passion stemmed from Wellstone's own childhood experiences with mental health services, seeing Stephen after he was diagnosed with a serious illness that was likely schizophrenia and required him to be institutionalized.

"My dad visited that hospital several times," says Dave Wellstone. "He committed to himself then that if he was ever in a position to make a difference he would."

In 1990, when Minnesotans elected Wellstone to the U.S. Senate, he got his chance. He began work on a mental health parity bill and in 1996 got the first part passed, a law that made it harder for insurance companies to put annual or lifetime caps on behavioral treatments.

Jim Ramstad recalls the first time Wellstone called him about parity.

"I remember him saying, 'Will you help me?' and I said, 'Help you what?'" Ramstad says. "He asked, 'Why should people with diseases of the brain be forced to pay higher deductibles and co-payments? Why should they face limited treatment stays arbitrarily imposed by,' — as he put it — 'some green-eyed insurance companies?'"

Ramstad, himself a recovering alcoholic, came on board the cause.

"We teamed up in 1996 on what became a 12-year odyssey to pass the parity bill," Ramstad recalls.

Soon after he signed up, Ramstad says, his phone started ringing off the hook.

"I got boxes of letters telling horror stories of denial," Ramstad says. "In 1996 the average treatment stay was seven days for chemical addiction. Nobody who is an addict or an alcoholic can get primary treatment in seven days. It just doesn't work that way."

But Wellstone was just getting started.

"He was tireless," remembers Gerrity. "In addition to expanded coverage he wanted to include addiction treatment as well. At the time, it seemed extreme, but he was very, very serious about this. There was never a moment when he wasn't thinking about it."

For the next six years, Wellstone and Ramstad fought hard. They tried different strategies, like Wellstone introducing one version of the bill in the Senate and Ramstad introducing another one in the House.

"Paul and I were talking every day," Ramstad remembers. "He would call me at midnight; I don't think the guy ever slept."

In 1998, they got close to a success, but then, as Ramstad tells it, "the insurance companies came out of the weeds," and at the last minute, lobbied hard enough to get key legislators to change their minds.

In 1999, the duo met with President Clinton. In 2000, they criticized the government for spending $1 billion on drug eradication rather than treatment and education. By 2001, Ramstad introduced another bill in the House, and got over 200 co-sponsors. Momentum started to build, but the bill was ultimately defeated.

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I worked for Cigna for five years and saw all of this unfold on a daily basis.  Sometimes it was blatant, and other times it was a bit more confusing.  I completely agree that if a person has benefits and has not used them, then regardless of the level of care, especially if it is being recommended by an M.D., that person should be allowed to receive care for their issues.  If they have no insurance, that's another complicated matter.  

The one hang up, and I think this article pointed it out, is that when a person does not get the care needed, and they end up getting tossed around the system, getting "lower levels" of care, such as outpatient or intensive outpatient to save on cost, when the reality of it is that if they were simply allowed to receive a residential program from the beginning, maybe the years of hassle, other failed treatments, and expense could have been avoided.  Unfortunately, once you've maxed your benefits for the calendar year, forget it, your done!  And there is an abundance of elephant dung sized health care plans to see to it that you exhaust your benefits as fast as possible.  In other words, if your benefits renew calendar year starting in January, and your actively seeking help for you mental health or substance abuse  issues, you could conceivably max out by February, and spend the rest of the year without help or treatment, unless you keep paying out of pocket.  

This issue could easily be a 900 volume tome, and I could ramble on at great length, but I guess from the insurance perspective, they only do what is necessary to keep a human being alive and functioning (feed themselves, dress themselves, bathe)  at the bare minimum of expense, which I think is where the term "medical necessity" stems from.  And why the insurance companies have the power to determine this over the M.D. treating the patient, I will never know.  Mental health and substance abuse are not as easy a fix as mending a broken arm, or stitching up a wounded knee, they're much more long term, and progress can move very slowly.  If I may be allowed to be a bit of a hippie about it, my hope is that if we the human species have any hope of progressing further, and sustaining life on this planet, the cost, no matter what ridiculous financial figures they produce, would ultimately become a true non-issue.

...bit of rant I know, sorry, just wanted to get that out and add it to the discussion.  Thanks. 


There is an important technicality here that needs to be better explained.  Minnesota already has a mental health parity law so Minnesotans who buy health coverage from anything other than large employers were already covered by the parity law.

This new law was only for large employers who are exempt from all state mandates like mental health parity.  And, most important for these large employers, they don't actually buy insurance.  They are self insured so it isn't actually the insurance company issuing the denial, it's a third party administrator (many times an insurer who is running a TPA) that is implementing the coverages laid out by the employer.

So the complaints about the insurers not paying, should be more appropriately leveled at the employers who were not willing to pay.

Finally, there is a very important reason for claims denials.  It's to keep costs low.  While the call for better coverage is certainly worthy and nobody can deny it is very much needed, the problem is that it is extraordinarily expensive and most of these people want the treatment, but they want somebody else to pay for it.   The 'somebody elses' of the world would likely be more willing to pay for the care, if there was a way to make the care less expensive. 


Mental Illness = America's BIGGEST Health Care problem


the lines between illness and health are very blurry, and political.  my own doctor has told me to lose 60 pounds.  I cannot find success-- despite spending thousands of my own money on various plans and groups.  I would like to try total immersion (similar to the article's subject, a residential treatement plan).  However just like the other ways I've tried, insurance won't cover a dime of it. 

My point is this:  I am basically sort of healthy, but my asthma, depression, and blood pressure are getting worse, and I would be more productive and happier if I could lose weight.  But, Big Insurance doesn't see this as a problem, and won't pay to try to get me "healthier". 

It's not the middle-health people like me who get care, it's the extremely low-health people who get care, just like government benefits--  the middle class pay pay pay their taxes, but the low-income receive the majority of benefits.


Great article.  I hope people will start paying more attention to the laws that protect our most vulnerable people.