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Mental Health: Disparities and Legislation The Presidential Scholars Program brings students from each of MUSC’s six colleges together each year to study broad issues impacting health care. The overall theme this year is the relationship between health care disparities and legislation. Students worked in interdisciplinary teams on specific areas of this theme. This piece is the fourth of a series of articles highlighting the results of their work.   In the United States alone, an estimated 26.2 percent of Americans, or about one in four adults, suffer from a diagnosable mental disorder in a given year. Applied to the 2004 U.S. Census residential population estimate for ages 18 and older, this figure translates to 57.7 million people.    In addition, data from the Global Burden of Disease (GBD) study conducted by the World Health Organization, the World Bank, and Harvard University revealed that mental illness, including suicide, accounts for more than 15 percent of the burden of disease. The GBD was defined in terms of death and disability in established market economies, such as the United States.   Major depression ranked second only to ischemic heart disease in magnitude of disease burden, and schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder also contributed significantly to the total burden of illness attributable to mental disorders. This is more than the disease burden caused by all cancers. However, despite the shocking prevalence and debilitation resulting from mental illness, even those Americans who have health insurance of some form receive inadequate and unequal coverage for mental health care as compared to the coverage allotted for their physical health care. In response to these inequalities, mental health parity laws were written and enacted to ensure equal coverage for both physical and mental health care.    The Mental Health Parity Act (MHPA) of 1996 (P.L. 104-204) amended the Public Health Service Act (PHSA) and the Employee Retirement Income Security Act of 1974 (ERISA) “to provide for parity in applying dollar limits on certain mental health benefits when limits are placed on medical and surgical benefits” (NIMH, n.d., a, p. 1).   However, the MHPA had several shortcomings: the act covered mental illness, but not substance abuse or chemical dependence; businesses with five employees or less were exempt from the law;  no regulations for service charges, co-payments, deductibles, limits, and out-of-pocket expenses were provided; no collaboration for coverage with Medicare or Medicaid was established leaving the millions enrolled in these programs without equal coverage; and employers who had not provided mental health service coverage prior to this act of legislation were not required to provide such coverage after the act was instituted. Thus, the MHPA only applied to employers who already offered mental health benefits. The act expired on Aug. 30, 2001, and no further legislation was passed since then to aid in equalizing physical and mental health insurance coverage.   The MHPA was a federal law, yet it did not affect or influence state parity laws or their execution. As a result, only 23 states had existing mental health parity laws as of 2000. South Carolina is one of those states and was one of the first seven to enact Mental Health Parity Legislation. The state's law S0049, which was passed in May 2005, established an amendment to the Code of Laws of South Carolina by adding a section so as to require health insurance plans to provide coverage for treatment of mental illness. In addition, House Bill 3642 was proposed to add an amendment that requires health insurance plans to provide coverage for treatment of mental illness or alcohol or substance abuse. This bill is under review in the legislative sessions of the state house.    In recognition of the active role the state of South Carolina has taken to make mental health parity legislation a priority, a recent Post and Courier article featuring a report made by the National Alliance for the Mentally Ill, a Washington, D.C.-based advocacy group, gave the South Carolina mental health systems a ranking of B-. The highest ranking given was a B, which was achieved by Colorado and New York.  This B- ranking notes the existence of an infrastructure of good mental health coverage.   However, in the individual area of health care services, South Carolina received a D ranking due to the too few inpatient mental health beds that exist in the state, a result of years of budget reform. Thus there is still room for our state to make even greater strides in providing quality mental health care. This need for continued improvement is made even clearer by the 2004 South Carolina Mental Health Disparities Report Card from the Henry J. Kaiser Foundation, which concluded that 34.5 percent of South Carolinians suffer from poor mental health as compared to 33.2 percent nationally. The majority of those suffering are members of minority groups, many who also lack any form of health insurance.    Just implementing mental health parity laws does not ensure adequate mental health coverage on all fronts or for all citizens. However, the legislation is definitely a step in the right direction. According to Mental Health Parity: State of the States published by the Center for Policy Alternatives in 2000, South Carolina’s Mental Health Coverage: provides comprehensive parity for mental health and substance abuse illnesses; businesses with 50 employees or less are exempt; and only state employee health plans are affected by the law. Out of South Carolina’s total population, a little more then 80 percent have some form of health insurance, leaving 19.4 percent of the state’s population uninsured and not likely to benefit from the state’s parity law. Of those who are uninsured, 74 percent list affordability as the reason they have not purchased health coverage.   Seventy-eight percent of businesses in South Carolina, excluding self-employed and government workers, have fewer than 10 employees, and 53 percent of small employers with one to 10 employees do not offer group-sponsored health insurance to their employees, nor are they required to since the law allows this exemption. Furthermore, those who do provide some form of medical insurance may not be required to offer mental health coverage with the medical insurance. The two issues of better coverage for mental health for the insured and better health care of the uninsured are critical issues that still need to be addressed by our state legislature.   As concerned citizens of our respective communities, health care providers, and researchers, we have much to contribute to the goal of establishing equal mental health care for all. First and foremost, we need to educate ourselves and continue to raise awareness at MUSC, in our communities and in our state about the need for better mental health care and better mental health care parity. We should also encourage the elimination of the stigma that is associated with mental health disorders and that often prevents those with a mental illness from seeking the care they need even when access to treatment and coverage exist.   Next, we can encourage local and state legislators to support current pending legislation to further mental health parity in South Carolina by advocating for mental health legislation that is currently being debated in the state house.  In addition, we can support the introduction of legislation for better regulation, oversight, and enforcement of current and future mental health parity legislation and legislation pertaining to improved mental health care in general.    Many mental illnesses are treatable, and the opportunities to positively influence mental health care legislation, education, practice, and research abound. With the need for adequate and equal mental health care gaining increased national and personal attention, now is the time to improve the lives of many by possibly decreasing the prevalence and debilitation of mental illness.   Friday, April 21, 2006 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island papers at 849-1778, ext. 201.