Mental health parity may finally become a reality

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

Then, in October 2002, Wellstone was traveling to a funeral in Eveleth, Minnesota, when his plane crashed in a forest. The 58-year-old senior senator died, along with his wife, his daughter, and five others.

While his friends and surviving family grieved, they also resolved to take action in his memory. Sen. Edward Kennedy and his son, Rep. Patrick Kennedy, came to Ramstad's office not long after.

"They said, 'We want to get this mental health parity bill done for Paul Wellstone,'" Ramstad remembers.

Dave Wellstone leads a parity action strategy meeting with University of Minnesota student leaders
Mark N. Kartarik
Dave Wellstone leads a parity action strategy meeting with University of Minnesota student leaders

With new motivation, they kept working, and Dave Wellstone joined the cause.

For the next five years they continued to push for a satisfactory bill. In 2007, Ramstad and Patrick Kennedy toured the country, hosting field hearings to drum up support. By 2008, "it got very dramatic," Ramstad remembers. "The House and the Senate were bickering, and Patrick's dad would call in every day from his sick bed."

But before the bill could come to a vote, Congress adjourned.

"I was very dispirited," Ramstad remembers. "But there was this recession and we had to pass a bank bill, and I told my staff, 'We can't quit now. They're going to call us back.'"

Sure enough, a few days later, everyone was called back for a special session. The press box at the Senate was packed, Ramstad remembers, with people waiting to see what would happen on the $700 billion financial bailout.

"Then they shocked everyone and called up our bill for action first," Ramstad says. The Senate Majority Leader "added the bank bailout bill as an amendment to the mental health parity bill, and the whole package passed."

Gerrity was there too, along with Dave Wellstone.

"It was a magic moment," she remembers. "When the vote passed all these members were looking up at Dave and smiling and giving the thumbs up."

The House passed the bill two days after, and one day later, President Bush signed it into law. It was six years to the month after Paul Wellstone's death.

The bill was supposed to change everything. Except it didn't.

"Initially, it seemed pretty normal that there would be interim regulations and public commentaries and of course the insurance opposition," says Gerrity. "Then Obama got elected and we thought, 'This is good. We'll get these done.'"

Everyone has a different theory on why regulations for the bill got derailed. One problem is that three federal agencies have their hands on the bill, which makes the process three times as complicated.

Another issue is the Affordable Care Act, a.k.a. Obamacare. The same regulators tasked with implementing and enforcing the Wellstone Act are the ones overseeing the ACA roll-out.

"They've got a ton on their plate, and it's a legacy issue for the president," says Carol McDaid, the D.C. lobbyist. "So parity has fallen to the side."

The ACA itself has a parity provision, and will go a step further than the Wellstone Act in one regard: Mental health is one of the 10 "essential health benefits," which means insurers will have to cover it.

But elsewhere in the ACA is a parity provision that just cross-references the Wellstone Act and its regulations. As McDaid explains it, if regulators don't figure out a final rule on the one, the other won't have sharp enough teeth either.

Regulators ran into a third roadblock when it dawned on them just how complicated these issues are. A U.S. Department of Labor report from January 2012 notes that after the interim rules went out, regulators "realized the complexity of the law and regulations gives rise to many highly technical issues and questions," and that there has been "considerable confusion" about the details.

"It's pretty easy for us to figure out, 'Okay, if you're allowed six physical therapy visits then you get six therapist visits," says Sue Abderholden, the executive director of NAMI-Minnesota. "But one of the biggest issues has been the non-quantifiable limits. If you're allowing nursing home care to recover from knee surgery, would you allow an intensive residential treatment plan?"

The hypotheticals like that are endless. And a fourth major delay came from the insurance companies themselves. United Health provides coverage to more than 70 million people; UBH provides behavorial coverage for one in six insured Americans. But the company has expressed concern over the Wellstone Act.

In written comments submitted on the interim rules in 2010, United Health argued that the regulations are stricter than the law intended, and "will have unintended, negative consequences that will disrupt access to appropriate behavioral health care." The company cites the possibility of higher premiums, increased out-of-pocket costs that serve as a deterrent to care, "and, in some cases, loss of behavioral health coverage altogether."

United Health recommended a longer transition time to comply with the law, no parity for "non-quantitative" treatment (like Bird's residential care), and deductibles for mental health benefits separate from the medical/surgical deductible.

To Wrobel, the lawyer who has represented Bird and more than 20 other clients with similar cases, the company's complaints are "pretty clear," she says. "I think it's perceived as expensive."

Kim, like Katie Bird, bears the scars of her insurance battles in paper. Hers are organized in a thick, white binder. She sighs as she drops the pile on a coffee shop table.

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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. 


You cannot get something for nothing. Insurance companies probably do not cover these mental maladies because they are difficult to define, diagnose, and successfully treat. Forcing insurance companies to do so at the point of a government gun is evil and will probably result in less coverage for the mentally ill and higher insurance costs for us all.

DonkeyHotay topcommenter

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.  



you replied to me "stop putting so much food in your mouth. Hope that helps."

Unfortunately, it doesn't help.  I have been faithfully on various low-calorie, low-carb, low-fat, etc diets, and none of them had any long-term success. 

What I need to be healthy will take more than "stop putting so much food in your mouth". 

Everything I've done with my own efforts has failed---that's why I need professional help. 

If a stomach-staple surgery would help lose the weight, reduce my asthma, blood pressure and depression/anxiety, then shouldn't I qualify for that?  But I don't weigh ENOUGH yet, so I don't qualify. 

It is really crazy how they restrict medical care only to the very sickest, or the very youngest, or the very poorest.  Those of us with jobs, sort of sick but not deathly sick, who are paying into Medicare & Medicaid, need medical care too, so we can keep paying for all the 47 percent who pay nothing.