The Legislative History of the Nasty Fight to Get Insurance Companies to Pay for Mental Health and Addiction Treatment

There is an interesting bill before Congress right now that attempts to address a number of issues regarding addiction and recovery that I believe make a great deal of sense. It is both forward thinking and comprehensive, but it does not address what I view to be the biggest issue facing addiction treatment and recovery support in this country – the reluctance of insurance companies to pay for addiction treatment. This is not the fault of the lawmakers and policy wonks who wrote this bill, but rather the failure to implement and enforce the Mental Health Parity Act of 1996, the Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act of 2010. Each act attempted to address the fact that insurance companies either  (a) do not pay for mental health and/or addiction treatment or  (b) pay for treatment but to a much lesser extent than other illnesses.

Since I chaired the Task Force on Heroin and Other Opiates in 2012, I have heard from at least one parent a week of a young person who died – all of the stories are heart wrenching and a number of the deaths were because the patient was either discharged from treatment too early when insurance ran out or they never could get treatment paid for by their insurance companies in the first place. I spent the last four years working on a Masters in Public Policy in my spare time, and all my work for one class was devoted to the history and implementation of the aforementioned bills.

Both papers are well over 20 pages long. If you are interested in this kind of minutia, you can find both the history and the implementation paper on the policy section of my site (click here). For those of you that want an executive summary, read on.


Third-party payers (including insurance companies) began to pay for mental health treatment after World War II . At that time, people either (a) were treated at in-patient mental health hospitals that were run for and paid for by the state or (b) rarely got treatment. The late 1950’s through the mid-1970’s brought a period of deinstitutionalization, which involved the closing of in-patient mental health hospitals and sending patients to community mental health centers. Deinstitutionalization caused a rise in third-party payments for treatment and a resultant restriction on services. In 1961, President John F. Kennedy forced the Federal Employees Health Benefits Program (FEHBP) to cover mental health treatment with the same level that physical medical care was covered. Federal employees enjoyed this unique benefit until 1975, when it was severely cut back.
The first major national law that set aside funds for addiction treatment was the Comprehensive Drug Abuse Prevention and Control Act of 1970. It was championed by Senator Harold Hughes, passed by the 91st Congress and signed into law by President Richard M. Nixon. Senator Hughes was an Army veteran and a trucker who had a drinking problem and almost committed suicide in 1952. He joined Alcoholics Anonymous and eventually went into politics. He created a treatment program for people with alcohol dependence while he has Governor of Iowa during the 1960’s. His willingness to talk about his own experiences and his work helping others moved other members of Congress and President Nixon into passing the CDAPCA . This would be the last major national legislation that addressed substance abuse treatment for a few decades.

During the 1970’s and 1980’s and early 1990’s, a number of state legislatures made attempts to address parity by creating minimum benefits for mental health (17 states), drug treatment (24 states) and alcoholism (37 states). In 1992, Senator John Danforth (R-MO) and Senator Domenici introduced the first bill that proposed mental health parity. It did not go anywhere, but their ideas were co-opted by President William J. Clinton into his health care plan in 1993-94 . President Clinton’s health care policy would eventually fail to pass as well. In 1995 Senator Domenici partnered with Senator Paul Wellstone (D-MIN) to craft a wide-ranging parity bill and attach it to the Health Insurance Portability and Accountability Act (HIPAA). The Congressional Budget Office reported that the bill would add costs of 4% to private health plans. The bill died.

The Mental Health Parity Act (MPA) of 1996 was introduced and championed by Senators Domenici and Wellstone. It was both a political and a personal issue for them, as Senator Domenici’s daughter lived with schizophrenia and Senator Wellstone’s brother had been hospitalized for depression for two years in college. After much debate and negotiation, a very limited bill was passed that did not mandate mental health coverage (and did not address substance abuse coverage at all). A disappointed but resolute Senator Wellstone acknowledged that it was just a “first step” toward full parity.

Over the next twelve years, the battle for parity was taken up by grass roots organizations such as the National Alliance of the Mentally Ill (NAMI), governmental research organizations like the National Institute of Mental Health (NIMH), professional organizations including the National Association of Social Workers (NASW), the American Psychological Association (APA) and the American Society of Addiction Medicine (ASAM) , as well as a new generation of politicians including Representatives Patrick Kennedy (D-RI) and Jim Ramstad (R-MN), both of whom were public about being recovering alcoholics .

A common refrain argued by those that opposed parity was that it would drive up costs. Those opponents included insurance companies and employer groups, and they were able to defeat a couple of lesser attempts at expanding parity with the rejection of the Mental Health Equitable Treatment Act (MHETA) of 2001 and again in 2002. Undaunted, parity advocates pushed for more and better research and eventually the Congressional Budget Office (CBO) published a report that took into account the effects of managed care and showed that parity did not lead to an increase in health care costs.

This (and other) research combined with the public testimony of the personal experiences of Senator Domenici, Senator Ted Kennedy (D-MA), Representatives Kennedy and Ramstad, and a collapsing economy in the fall of 2008 were able to get the Mental Health and Addiction Parity Act (MHPAEA) passed by the 110th Congress and signed into law by President George W. Bush as a rider on the Emergency Economic Stabilization Act of 2008. “The MHPAEA prohibited differences in treatment limits, cost sharing, and in- and out- of network coverage. It also applied to the treatment of substance disorders, which the MHPA did not address.”

It was hailed as a major victory by parity advocates. And then it got bogged down in the rule-making process. Despite leaving public office at the end of 2010, Patrick Kennedy has continued to advocate for parity. In October of 2013, he announced a new collaboration of stakeholders, political figures and experts called the Kennedy Forum. In a speech before the Senate on November 7, 2013, he lamented the delays of the previous five years:

Five years ago, when my father and I sponsored the Mental Health Parity and Addiction Equity Act (MHPAEA) and shepherded it through the House and Senate, we thought its signing by President Bush was the end of a process. In fact, it was barely the beginning… Just to recap, MHPAEA was passed and signed into law on October 3, 2008, and its provisions became effective exactly one year later. Many insurance plans follow the calendar year; the effective date for them was January 1, 2010. The Interim Final Rule for MHPAEA was issued on February 2, 2010, effective April 5, 2010, and applicable to plans beginning on or after July 1, 2010. We have been waiting for the Final Rule ever since then – over three years.

It has been 6 ½ years since the MHPAEA was signed into law by President Bush, 5 ½ years since it became an active law, 5 years since the Interim Final Rules were released and 1 ½ since the Final Rules were published. The lag between the signing of the law and the release of the final rules led to a prolonged period of murkiness. Additionally, the passage of the Affordable Care Act in 2010, the antipathy of the post-2010-election Republican dominated House of Representatives towards the ACA, and the two year wait until the Supreme Court issued its decision upholding the ACA added to the confusion regarding parity. Employer groups and insurance companies sometimes used these lags, legislative turmoil and legal battles to delay implementation of parity. That said, some of them have offered assistance to the public. In order to help providers and consumers understand this complex law and its constant updates, insurance companies like Aetna and advocacy organizations such as NAMI have posted instructions and frequently asked question pages.

The future of parity can probably be best summed up by an exchange that took place at a panel discussion at the 2014 annual conference of the New Jersey Association of Mental Health and Addiction Agencies (NJAMHAA). The panel was on the Governor’s Task Force on Heroin and Opiate’s report, but a number of questions were asked about parity. The following conversation took place between an Executive Director of a hospital based in-patient mental health program and Dr. Louis Baxter, the past-president of the American Society of Addiction Medicine (ASAM – he is also my friend):
ED: Will the Affordable Care Act actually ensure that insurance companies pay for the treatment of my patients?
Dr. Baxter: Yes.
ED: Multiple insurance companies are continuing to deny coverage, despite the fact that I have a number of well-regarded licensed professionals that have fully documented why our patients need treatment.
Dr. Baxter: I know. It is unfortunate. The delays and lack of instruction from the feds encouraged the insurance companies to drag their feet. But the law is there and they must obey.
ED: They are not…
Dr. Baxter: (interrupting) I know. I know what you are going to say. They are still not paying. They are denying claims. They are clearly violating the Parity Act and the Affordable Care Act. The answer is a combination of litigation and enforcement. A number of consumers and providers will have to sue insurance companies in order to get them to follow the laws.
ED: (interrupting) That could take years.
Dr. Baxter: Yes, probably five or so. But the insurance companies will lose and the government will do a better job of enforcing it. It’s a process. A long one. I know that this is discouraging folks, but parity will happen. It will just require the great American tradition of litigation.

As in the cases of other rule making, implementation will depend upon litigation (that happens to be the case with most rule-making; it’s true of stream pollution and other environmental and ecological violations, although in many of those cases the suit is brought by state and federal agencies). In the matter of health care it’s the individual who has been slighted that is going to have to sue. That places an unfair burden on the individual, but that has been the case before, during and after the parity law movement.

What is Synthetic Weed? What is Synthetic Marijuana? What is K2? What is Spice?

Synthetic marijuana is in the news again, as the Center for Disease Control (CDC) released a report that calls to US poison control centers regarding negative reactions to the drug increased by 229% from the first half of 2014 to the first half of 2015. Newsweek also reported that 15 people have died in 2015 as a direct result of using synthetic marijuana, which is triple the number from the previous year.

Since 2007, I have been asked “what is synthetic marijuana?” and “what is K2?” and “what is spice?” They are different names for the same chemical group, which acts like marijuana but is sprayed on flora to make this new drug. Just like marijuana, it is smoked. It has some similar effects, including the much desired psycho-tropic euphoria. According to the CDC, the most commonly reported negative side effects are: agitation, tachycardia (rapid heartbeats, which people sometimes freak out over and then they go clog up the emergency room), drowsiness or lethargy, vomiting, and confusion.  I began training people on this in 2009, and in addition to the aforementioned names, I have discovered that it also goes by: Pep Spice, Spice Gold, Spice Silver, Sence, Yucatan Fire, Skunk, Orange Dragon Smoke, Black Mamba, RedX Dawn, Zohai, Mr. Nice Guy, Bayou Blaster, Euphoria, Home Spice, Ultra Cloud Ten, and Genie.

The original chemical formula was created by John W. Huffman, a chemist from Clemson University. He was doing research on marijuana that was funded by NIDA and when he created the new compound, he named it after himself: JWH-018. It was introduced in America in the early 2000’s, and was sold in bodegas, gas stations and head shops. It became particularly popular with people who were regularly drug tested (people on probation, some athletes), as it took a few years before a urine screen was developed to detect it. For several years, it was sold in packages as incense with a message on it that read “not for human consumption.” This allowed the burgeoning industry to evade FDA detection for a little bit and shrug their shoulders and say they were shocked when people were ingesting it (no company has openly manufactured it, so I think the “shocked” clip works well when juxtaposed with “not for human consumption,” because it is absolutely made for human consumption).

Because it was legal and easily accessible, use in the late 2000’s and early 2010’s skyrocketed. The FDA acted swiftly and put a temporary ban in place on the 5 most common synthetic marijuana compounds on March 1, 2011. One year later, a full federal ban was enacted and it was made a schedule I drug (highly addictive, no medical value, completely illegal) in July of 2012.

Early on, a number of other countries banned it, including (but not limited to) the United Kingdom, Ireland, Germany, Chile, New Zealand, Japan, and Romania. Surprisingly, synthetic marijuana has not been outlawed in Canada. It has been pushed out of the head shops, but it can easily be found on the internet. A harrowing tale of a professional couple’s addiction to the drug made headlines this past March in Edmonton.

A 2012 Federal Survey reported that 1 in 9 high school seniors had tried it, making it the fourth most familiar substance in high school after tobacco, alcohol, and marijuana. Use went down significantly after the federal ban, but over the last two years it has been making a comeback. It was very much in the news in NJ in March of 2013, as a car with 16 pounds of synthetic marijuana was pulled over in Hunterdon County, a 17 year-old from New Providence was hospitalized after using it, and Governor Christie signed a bill into law that gave harsh penalties to those that manufacture or sell it.

A major problem with it is that instant urine screen tests do not detect it. One must send a test to a lab, which often costs more than many treatment programs (and most probation offices) can afford. This lack of testing encourages people on probation and in drug programs to use synthetic marijuana. Another problem is that drugs that are labeled as K2, Spice, Space, Synthetic Marijuana or other variations are not always of the JWH-018 (or other varieties); rather, they are just flora mixed with bath salts or MDMA or PCP or something else. I expect we will continue to see more and more overdoses and people being rushed to the emergency rooms with dazed and psychotic features.

Yale University Fixes a 53-Year Old Mistake and Returns to Alcohol Research & Policy

Yale Medical School issued a press release yesterday about the opening of a new addiction research and policy center:

The National Center on Addiction and Substance Abuse at Columbia University (CASAColumbia), a leading national organization whose mission is to educate the public and improve the prevention and treatment of addiction, has partnered with Yale School of Medicine and Yale School of Public Health to form a new addiction research and policy center based in New Haven. The Yale–CASA center-of-excellence will expand critically important work to shape public policy, disseminate evidence-based practices, and educate families, providers, and policymakers.

It’s good news, and it was very smart of them to partner with Columbia, which has been one of the universities at the forefront on these issues. The ironic aspect of this is that they once had the premier alcohol research center in the country. This history is provided from the Rutgers Center of Alcohol Studies history page:

The Center of Alcohol Studies is the first interdisciplinary research center devoted to alcohol use and alcohol-related problems and treatment. Evolving in the late 1930s and 1940s at the Yale University Laboratory of Applied Physiology and Biodynamics, which was directed by Yale physician Howard W. Haggard, the Section on Alcohol Studies, headed by E.M. Jellinek, pursued studies of the effects of alcohol on the body, which broadened into a wide perspective of alcohol-related problems. The increasing demand for information about alcoholism led the Center to found the Summer School of Alcohol Studies in 1943. In 1944, the Center also began the Yale Plan Clinics, the first ever outpatient facilities for the treatment of alcoholism. The Yale Plan for Business and Industry, forerunner of current-day employee assistance programs, also began in the mid-1940s, in response to requests from business and industry having to cope with employment shortages during World War II. Another of Dr. Haggard’s contributions to the field was the founding of the Quarterly Journal of Studies on Alcohol in 1940. Today the Journal of Studies on Alcohol and Drugs remains a foremost journal in the field and is one of the top ten most cited substance-abuse journals.

The Center of Alcohol Studies was the leader of the movement to recognize alcoholism as a major public health problem and to have the American Medical Association accept alcoholism as a treatable illness, a policy it formally adopted in the 1950s.

And then in 1962 the Center of Alcohol Studies left Yale and moved to Rutgers. Over the last 17 years, multiple sources have told me that by the early 1960’s Yale had decided that it was beneath them to be in Alcohol Studies. Fortunately, my alma mater was willing to adopt it (full disclosure: I took courses at the Summer School of Alcohol Studies from 1998 through 2007 and I began working there as an instructor in 2008. This summer, I will teach two courses there).

I am glad that Yale made such an egregious error all of those years ago, because the Center of Alcohol Studies (CAS) helped shape the course of my career. Back in 1998, Gail Milgrim (who was in the middle of a 30-year run as the Director of the Education and Training Program), gave me a scholarship to attend the summer school and said, “I think you’d be good in this field.” It hasn’t only helped me though – thousands upon thousands of professionals have been trained by their faculty and CAS is the acknowledged leader in the alcohol research field.

Yale has finally seen the error of their ways. Kudos.

Alcoholics Anonymous Turns 80…But Not Today

AOL (they still exist…I have an email account to prove it) congratulated AA for turning 80 today. In fact, the day that is celebrated as Founder’s Day (June 10) each year by grateful alcoholics is not actually the day AA was created. Bill Wilson (a New York stockbroker) and Dr. Bob Smith (an Akron doctor) met on May 12, 1935 and they discussed their drinking problems with each other. Both left that meeting feeling connected to someone else and hopeful that they could remain abstinent from booze. I view that as the first AA meeting and that date as the founding of Alcoholics Anonymous.

Most people, including Alcohol Anonymous World Services, go with June 10, 1935, which is the last day that Dr. Bob drank. From their website:

Dr. Bob lapses into drinking again but quickly recovers. The day widely known as the date of Dr. Bob’s last drink, June 10, 1935, is celebrated as the founding date of Alcoholics Anonymous. Dr. Bob and Bill spend hours working out the best approach to alcoholics, a group known to be averse to taking directions. Realizing that thinking of sobriety for a day at a time makes it seem more achievable than facing a lifetime of struggle, they hit on the twenty-four hour concept.

But it turns out that his last drink wasn’t June 10 but rather one week later on June 17. After his initial meeting with Bill Wilson, Dr. Bob was able to put a few weeks of continuous sobriety together. He felt so good that he decided to attend the AMA (American Medical Association) Conference in Atlantic City that June. His wife was concerned, but he assured her he would be fine (early recovery people are so similar). This site provides the rest of the story:

That is, until he boarded the train to Atlantic City. Once on the train Dr. Bob began to drink in earnest. He drank all the way to Atlantic City, purchased more bottles prior to checking in to the hotel. That was on a Sunday evening. Dr. Bob stayed sober on Monday until after dinner. He then resumed his drinking. Upon awakening Tuesday morning his drinking continued until noon. He then realized that he was about to disgrace himself by showing up at the convention drunk. He decided to check out of the hotel and return home. He purchased more alcohol on the way to the train depot. He waited for the train for a long time and continued to drink. That was all he remembered until waking up in the home of his office nurse and her husband back in Ohio.

Dr. Bob’s blackout lasted over 24 hours. There was a five-day period from when Dr. Bob left for the convention to when the nurse called Anne and Bill. They took Dr. Bob home and put him to bed. The detoxification process began once again. That process usually lasted three days according to Bill. They tapered Dr. Bob off of alcohol and fed him a diet of sauerkraut, tomato juice and Karo Syrup.

Bill had remembered that in three days, Dr. Bob was scheduled to perform surgery. On the day of the surgery, Dr. Bob had recovered sufficiently to go to work. In order to insure the steadiness of Dr. Bob’s hands during the operation Bill gave him a bottle of beer. That was to be Dr. Bob’s last drink and the “official” Founding date of Alcoholics Anonymous. The operation was a success and Dr. Bob did not return home right after it. Both Bill and Anne were concerned to say the least. They later found out, after Dr. Bob had returned, that he was out making amends. Not drunk as they may have surmised, but happy and sober. That date according to the AA literature was June 10, 1935.

The Archives of the American Medical Association reportedly show that their convention in Atlantic City, in the year 1935 did not start until June 10th. How could Dr. Bob have gone to the convention, by train – check into a hotel – attend the convention on Monday – check out on Tuesday – be in a blackout for 24 hours – go through a three -day detoxification – perform surgery on the day of his last drink – June 10, 1935? Five days had passed since Dr. Bob left for the convention and returned to Akron. There was the three-day detoxification process and then there was the day of the surgery. Approximately nine days had passed from when he left and the date of his last drink. If the records of the American Medical Association are in error as to the date of their convention it is possible that June 10, 1935 was the date of Dr. Bob’s last drink. If the records are in error, the 1935 convention would have been the only one in the history of the American Medical Association that was listed with the wrong date.

I quit the debating society over a decade ago, but I am a history buff and I think it is important that facts be correct. From my viewpoint, AA started on May 12, 1935. If you and yours think that AA started on Dr. Bob’s last drink, then it is June 17, 1935. Regardless of your belief, it is not June 10, 1935.

Female Leads in Comic Books Might Help to Change Our Culture

I’ve been reading comics since the early 1980’s (and I haven’t stopped, except for a brief pause during some lost years in the 1990’s). Growing up, the female characters in comics were all pretty sexy with wonderful come-hither looks (you really should click on this). Even Batman’s female villains were all pretty buxom (enjoy). The few girls in my school that were interested in superheroes all worshiped Wonder Woman, who pretty much just looks like a stripper in Captain America panties (I prefer Woman Woman to be heavily armored and quite violent). I know, she’s iconic. I’m not looking to get into a flame war.

Clearly, art has reflected our culture.

Research reports teachers (despite being overwhelmingly female) tend to call on and interact with boys more than girls. By the time they are teenagers, girls (either consciously or unconsciously) begin to play down their intelligence. This leads to the unfortunate belief by many people that girls are not as smart as boys. In college, despite making up a majority of the student body, women make up less than 40% of student government. Don’t even get me started on Halloween costumes.

In the internet era, the vitriol directed at women who assert themselves can be vicious and disgusting. Women who work full-time earn 70, or 77, or 85 cents for every dollar that men who work full-time make (there is a fight over those statistics, but people generally agree that there is a gender pay gap). Only 24 women head a Fortune 500 company (4.8%). All of these statistics are worse for women of color. The secondization of women is also reflected in our films. In the top 100 grossing movies of 2014, only 12% of the protagonists were females (it was 15% in 2013).

But while these statistics are disheartening, no one can deny that circumstances are better for women now than they’ve ever been before in human history. We are seeing an upward trajectory. This has also been reflected in comics since 2000. We are living in a golden age of strong female protagonists. These are characters that are so well-rounded and interesting that they not only appeal to women, but they appeal to men (they’re still pretty good looking, but at least they have a lot more to offer now).

In 2000, Maryjane Satrapi’s Persepolis was released. Written and illustrated by Ms. Satrapi, it is an absolute literary classic that details the author’s childhood in Tehran and her education in France. Her family were well educated, semi-secular Muslims living under a fairly oppressive regime in Iran. It’s a coming of age story that is easily one of my 10 favorite comics.

Also in 2000, Brian Michael Bendis introduced us to Deena Pilgrim, a smart, young detective who investigates super-powered related crimes (she has a dirty mouth…not sexually dirty, just nasty). While Ms. Pilgrim is not really a role model, she doesn’t have to be. But she’s interesting, and that was a welcome change. Other characters followed. In 2002, Bill Willingham began a multi-award winning series called Fables. One of the main characters is Snow White. She is smart, hardworking and fierce and I will miss her character when the series ends this summer.

In 2007, Alison Bechdel’s Fun Home was released (it was made into a Broadway play this year). It’s an autobiographical story about Ms. Bechdel’s childhood, education, family and especially her relationship with her father, a closeted gay English teacher from central Pennsylvania. It was a finalist for the National Circle Book Critics Award and in 2010 the LA Times named it as one of the 20 classics of gay literature.

Marvel made headlines over two years ago with the introduction of Ms. Marvel, a teenage girl of Pakistani decent who lives in Jersey City. It is written by G Willow Wilson, and while it is not a book that I read (I read the first story arc), I am very happy that it exists. It is in the news again because of a controversy, but that should help add a few readers and drive sales for a bit.

The last few years has seen an introduction of a number of glorious characters. They include Velvet, Lazarus, Brian Azzarello’s Wonder Woman, Scott Snyder’s Pearl Jones, and Saga’s Alana. These aren’t forced attempts at being PC or grabbing new market shares, but instead quality characters in good stories.

This is progress. It is a signal that our culture has changed and is changing. I believe these characters will influence men and women to look at females more progressively, and that our culture will reflect our art.

Alana from Saga, illustrated by Fiona Staples

Gov. Christie Does Some Good

I’ve been introduced in a few articles over the last 18 months as a “frequent critic of Governor Christie” and I have not pulled any punches when he over-trumps a tiny success or refuses to fund programs that he claims to support.

Today his administration did something really good though.

“Gov. Chris Christie announced a deal on Thursday for law enforcement and other public agencies to get nearly 20 percent off the price of naloxone from California-based Amphastar Pharmaceuticals, Inc.”

Naloxone is an anti-overdose drug. Last fall, Amphastar doubled the price of it just as it was starting to be used on a widespread basis. Public health advocates were outraged and claimed it was a blatant money grab. NJ is the third state to negotiate a reduced rate for it. The Governor did not lead the way here, but he did do a good thing. Good work, Mr. Christie.

The full story can be read in this Associated Press report.