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May 18, 2000, Thursday


LENGTH: 5601 words


 Mr. Chairman and members of the committee. I am Dean Rosen, senior vice president of policy and general counsel for the Health Insurance Association of America (HIAA). HIAA is the nation's most prominent trade association representing the private health care system. Its 294 members provide health, long-term care, dental, disability, and supplemental coverage to more than 123 million Americans. HIAA also is the nation's premier provider of self-study courses on health insurance and managed care.

Before joining HIAA, I worked for several years as a congressional staff member, including as health counsel for the former chair of this committee, Senator Nancy Landon Kassebaum.

I am honored to have the opportunity to address the committee today on the issue of mental health parity in health coverage. Federal Mental Health Parity Legislation

The Mental Health Parity Act of 1996, which prohibits employers from imposing annual or lifetime dollar limits on mental health coverage that are more restrictive than those imposed on medical and surgical coverage, is scheduled to sunset in September of next year. Some have criticized the act as not going far enough to equalize mental and physical benefits.

Senators Domenici (R-NM) and Wellstone (D-MN).have introduced new legislation, the Mental Health Equitable Treatment Act of 1999 (S. 796). which would go significantly further. It would prohibit employer-sponsored health plans from imposing limits on the number of covered inpatient days or outpatient visits for mental health conditions unless the same limits are imposed on medical and surgical benefits. In addition, no limitations whatsoever would be allowed on "severe biologically-based mental illnesses" unless the same limitations are imposed on medical and surgical benefits (roughly half the states that have enacted parity legislation have coveredonly serious or "biologically-based" mental illnesses/l). Employers with 25 or fewer employees would be exempted from the requirements of the legislation.

The issue of parity for mental health coverage raises a host of complex issues. Some believe coverage for treatment of mental illness should be equal with other areas of coverage. On the other hand, added coverage almost always increases costs. One thing is clear: Mental illness takes a tremendous toll on our society. According to the Surgeon General's recent report on mental health, one out of every five Americans suffers from some form of mental disorder,2 with direct and indirect costs to society totaling nearly $200 billion a year.3

As we seek ways to ensure that the needs of those with mental illness are met, there are a number of difficult public policy issues that must be confronted. One of these is the difficulty that health care payers sometimes have in effectively administering mental health benefits. Related to this is the cost associated with expanded benefit levels. Increases in the cost of health insurance, whatever the source, make coverage less affordable and contribute to the growing number of Americans who lack coverage. In fact, it was in the context of the 1996 legislative debate on mental health parity that the Congressional Budget Office estimated that a 1 percent increase in premiums would increase the number of uninsured Americans by 200,000. Since then, a number of private economists have estimated that at least 300.000 Americans lose their health coverage each time a mandate increases costs by 1 percent.

Vermont Governor Howard Dean underscored the link between coverage mandates, costs, and the number of people who lack health insurance in this year's State of the State address, noting that "state-passed mandates have contributed about 25 percent of this year's increase in insurance premiums. Many of these I have supported. But this year I ask the Legislature not to pass any additional mandates .... We cannot vote on the one hand to expand insurance coverage and increase the cost of liability insurance, and then go out in an election year and point the finger elsewhere for the increase in insurance costs."4

As Governor Dean points out, increases in the cost of insurance matter. Ultimately, increased costs are not borne by health insurers - they fall on employees and individual consumers. There is a balance that must be achieved between benefit mandates and the cost of insurance - where that balance is struck will have an impact on how many Americans have health coverage, and how many do not.

Treatment Options Raise a Host of Complex Issues

Coverage of mental health services presents some unique challenges. As the Surgeon General's report recognizes, "mental health" itself is difficult to define - what it means is subject to different interpretations that are value- and culture-based.5 As a result, our current conceptions of mental illness incorporate a wide variety of conditions of varying significance.6 While some severe mental disorders can be diagnosed as reliably as most medical conditions, for a substantial number of other diagnostic categories there is little research evidence.? That is why it is important to consider not only the level of coverage required by mental health parity mandate legislation, but also which conditions are required to be covered. As we will see, the costs associated with "severe biologically-based mental illnesses" can be better managed than those associated with many other mental disorders or with alcoholism and substance abuse.

Roughly one out of every five children and adolescents suffers from a diagnosable mental illness or addiction each year, but only 11 percent experience a significant functional impairment.8 Overall, one in five Americans has a mental disorder in any given year.9 (Fifteen percent of adults and 21 percent of children between the ages of nine and 17 receive mental health services each year.)10

For most mental illnesses there is a range of different treatment approaches that may be used. including various forms of psychosocial therapy and, in many cases, pharmacological treatment.11 Unfortunately, for a variety of reasons, treatments that work well in clinical trials can be much less effective in real-world settings.12 Moreover, there has been little research comparing the relative merits of the different treatments available for the various mental disorders, and some studies suggest that the characteristics of the therapist may affect outcomes more than the specific treatment used.13 (This is particularly an issue with children.)14

The challenges presented by misdiagnosis are well illustrated by the recent concern that psychotropic medications such as Ritalin may be over-prescribed for many children.15 It now appears that in many cases treatment was, in fact, inappropriate. This is a clear example of how difficult it can be to diagnose certain mental disorders, and to determine both when treatment is appropriate and what treatment is appropriate.

Because different courses of treatment may have significantly different costs, this uncertainty complicates the management of mental health costs. For instance, a recent study identified five major treatment categories for schizophrenia.

Considering just pharmacotherapy, costs vary. significantly, with the' cost of newer drugs being roughly 100 times that of older, generic ones. 16 In one study of acute-phase depression, researchers found that 20 to 26 percent of the spending was on treatments that were unlikely to provide meaningful benefits.17 For all treatments, the average incremental cost per depression-free case was $6,031. But for treatment with selective serotonin reuptake inhibitors (SSRIs) alone, the incremental cost per depression-free case was only $2,351.18

The Costs of Mandated Mental Health Parity

Uncertainty regarding the diagnosis of many mental disorders and the appropriateness and effectiveness of the various treatment options that are available can make the cost of mental health benefits very difficult to manage. There have been many different studies of the cost of mandated mental health parity. While the approaches used by these analyses vary, some common conclusions may be drawn from a survey of these studies.

First. while the studies may disagree over the exact level of cost, it is clear that there is a cost associated with parity. The level of cost varies dramatically based on the type of health coverage a person has. The lowest costs are associated with tightly managed health maintenance organization (HMO) coverage. However. the cost impact of mandated mental health parity coverage is felt much more acutely by consumers with coverage through health plans using point of service (POS) and preferred provider organization (PPO) arrangements, and the highest costs typically are associated with indemnity coverage. For instance, one study estimated that mental health parity would raise the average family premium for HMO coverage by only 0.6 percent, but also found that the impact on POS coverage would be 3.4 percent, and that the impact on PPO and indemnity coverage would be 4.8 percent.19

It is also important to note that those studies that have claimed that mandated parity has no cost, or results in cost savings, have looked at employer-sponsored plans or other health benefit programs that adopted managed care at the same time they incorporated mental health parity in their benefits. In those cases, the savings resulting from the adoption of managed care masked the cost of expanded coverage for mental illness.20 It is also extremely important to note that current discussions about mandated coverage are not taking place in a vacuum. While proponents of mental health parity mandates must rely on the widespread adoption of managed care (in particular, tightly managed HMO coverage) to hold down the cost impact of the mandate, they often ignore the fact that legislation being considered simultaneously would banish the very tools insurers and employers must rely on to effectively manage these costs. (Even more ironic is the fact that some are proponents of both types of legislation.) For instance, the Senate version of the Patients' Bill of Rights legislation would require employers to offer a POS option to all employees. Yet as noted above, the cost of parity is significantly higher with POS coverage than with HMO coverage.

Perhaps the one issue in the "patient protection" debate with the greatest potential adverse impact is that of health plan liability. The negative cost effects of "defensive medicine" are recognized and well documented. For example, in states with weak or no limits on malpractice liability, spending on treatment of heart attacks alone rose 25 percent faster than in states with meaningfullimits--with no appreciable effect on health outcomes.21 Several studies have estimated the costs associated with defensive medicine. One study by the Office of Technology Assessment found that up to 8 percent of diagnostic procedures were undertaken because of liability concerns.22 Another study focusing on Medicare beneficiaries found a 5 to 9 percent reduction in services resulted from reducing provider liability pressures.23 An examination of the combined costs of liability premiums and defensive medicine practices found such costs amounted to 5 percent of total costs for an Indiana hospital.24 Even a limited number of lawsuits over wrongful death or denial of care could lead plan administrators to authorize unnecessary care--despite a lack of objective medical information supporting such care--in order to avoid potential lawsuits? Because of the relative lack of information on the most appropriate and effective treatments for many mental disorders, this area is particularly vulnerable to defensive over- treatment.

It is not only the so-called "patient protection" proposals that have the potential to undermine managed care's ability to control costs. The Quality Health-Care Coalition Act of 1999 (H.R. 1304), expected to be considered by the House of Representatives later this month would, by waiving antitrust restrictions, allow physicians and other health care providers to collude and demand higher reimbursement. It also would reduce or eliminate utilization management crippling the ability of health plans to control costs. By increasing the prices paid for health care and weakening public and private health plans' ability to manage costs, over the long run this legislation alone could increase the cost of private health insurance by 10 to 13 percent.26 It almost certainly would magnify considerably the impact of any mental health parity mandate.

While much of the work on the cost of parity focuses on average cost levels, it is important to consider the impact on specific populations. For instance, managed mental health networks are not widely available, or even practical, in many rural areas.27 Further, the cost impact of mental health parity legislation clearly will be more significant for small employers. But small employers are significantly less likely to offer health benefits than are other firms, and their employees are more likely than other workers to be uninsured.28 Moreover, workers in small firms are less likely to be covered by HMOs? Thus, the costs of parity are likely to fall hardest on those who are most vulnerable to the loss of coverage.

Not surprisingly, parity laws have been shown to result in increased use of managed care and tighter utilization management of mental health care services.30 HMO coverage is a good choice for many consumers. However, both public opinion surveys and market penetration data suggest that most Americans are not willing to embrace HMO coverage as their only option. Consumers are increasingly turning from tightly managed HMOs to PPOs, POS plans, and other delivery system models characterized by increased choice and flexibility. HMO market share has declined from 31 percent in 1996 to 28 percent in 1999, whereas PPO market share has increased from 28 percent to 38 percent and POS market share has increased from 14 percent to 25 percent.31

The Public Sector Has a Difficult Time Managing Mental Health Benefits As Well Managing the cost of mental health coverage is not a concern unique to the private sector. Public sector programs have found this to be challenging as well. There are a number of significant examples of the difficulties the Medicare and Medicaid programs have had in controlling benefits for mental health care. Some cases represent outright fraud. Of course, these instances do not imply that all, or even most, providers of mental health services act improperly. But they do illustrate the difficulty payers have in managing these benefits.

One example is the Medicare program's experience with coverage for partial hospitalization services. Congress in 1990 expanded Medicare's partial hospitalization benefit, which provides for intensive psychiatric treatment to be provided on an outpatient basis by allowing community mental health centers (CMHCs) to provide partial hospitalization services to Medicare beneficiaries. (Prior to that time, Medicare only reimbursed for partial hospitalization services if they were provided in a hospital outpatient department.) The number of centers has grown rapidly since Congress passed the law. Since then, the Health Care Financing Administration (HCFA) and the Inspector General of the Department of Health and Human Services (HHS) have identified significant waste, fraud, and abuse in the partial hospitalization benefit administered by CMHCs:32

o Between 1993 and 1996 payments to these centers rose significantly - total payments by 342 percent, per capita payments by 319 percent, with average payment per beneficiary, exceeding $10,000.

o A review of 18 Florida CMHCs concluded that 17 did not provide necessary core services; 89 percent of beneficiaries were not eligible for services; and 100 percent of the services provided were not covered. Payments were suspended to all 18 centers and 15 centers have since been terminated from the Medicare program.

Numerous other instances of waste and fraud have been documented in the mental health area?

One estimate put the overall price tag for mental health-related fraud (public and private programs) at $42 billion a year? The same source concluded that: "Psychiatrists make up 8% of doctors, but 18 % of those health care practitioners that have been kicked out of the Medicare system for fraud. Last year, ($)411 million was paid to the government in fines and penalties for health care fraud and, 90 percent of that was paid by psychiatrists or psychiatric institutions.


Administration of benefits is not the only challenge public programs face. It is clear that public payers also recognize the importance of balancing cost and coverage is clearly recognized. For instance, new Medicare guidelines have just been announced to more directly recognize the importance of cost when deciding what items and services will be covered by the program.35 In contrast to the long-standing rule that care would qualify for coverage if it was "reasonable and necessary," the new rule requires clinical evidence of effectiveness and "added value" over alternatives that are already covered. This policy change illustrates that public health insurance programs are no more immune to cost pressures than are private programs.

Costs of Mental Health Parity Mandates Would be Borne by Consumers and Employers Health insurers act as financial intermediaries. The costs of the benefits we provide are passed on to our customers in premiums. Ideally. health insurers would like to sell as much coverage as possible. However, the benefits provided by insurers are determined by the demands of the markets we serve and the prices that our customers are willing and able to pay.

Employers have made a significant commitment toward addressing the mental health needs of their employees. Some level of coverage for inpatient and outpatient mental health care is provided to over 90 percent of the employees participating in employer-sponsored health plans? The past 10 years have also seen the introduction of many new pharmaceutical treatments for mental disorders.37 At the same time these innovative new drugs have become available, private prescription drug coverage, which makes no distinction between mental and physical disorders, has grown dramatically? In addition, a growing majority of employer-sponsored plans are addressing workers' mental health needs outside of the traditional health benefit plan, through innovative approaches such as Employee Assistance Programs (EAPs).39 Many. however, do find it necessary to take some action to limit the cost of mental health coverage.

The cost of health coverage is not just a parochial concern of employers, but is perhaps the primary health policy challenge facing the nation. Roughly 44 million Americans lack any health insurance coverage. The primary reason so many are uninsured is the high cost of health care and health care coverage? In fact, research shows that the decline in employer-sponsored health insurance coverage over the period from 1979 to 1995 can be attributed almost entirely to the increase in health care spending relative to personal income.41 One out of five uninsured Americans is offered health coverage by an employer but declines it - when asked why, twothirds of them cite the cost.42

In May of 1998. the HIAA Board of Directors formally adopted a policy (InsureUSA) for dealing with the problem of the millions of Americans who lack health insurance coverage. Since that time. HIAA has aggressively promoted the proposal, because HIAA believes the uninsured are the most significant long-term threat to the American health care system. Two central themes of the InsureUSA proposal are a firm commitment to private health insurance markets and a recognition of the need to help low-income Americans gain access to coverage.

Because uninsured Americans are not all identical, there is no single solution for them all. InsureUSA recognizes that there is a role for both the public and private sectors and for both employer-sponsored and individually purchased health insurance. However, the high cost of coverage is a constantly recurring problem that must be addressed if we are to make meaningful headway in providing health care coverage to more Americans.

As the number of Americans unable to afford health insurance has risen, the number of specific benefit mandates has also skyrocketed, adding significantly to the cost of coverage. The number of state mandates has increased 25-fold during the last two decades, making health insurance disproportionately more expensive for small companies and causing as many as one in four Americans to be uninsured.43 For example, mandates account for 21 percent of health insurance claims in Virginia, 11 to 22 percent of claims in Maryland, and 13 percent of claims costs in Massachusetts.44

At least one in five (and perhaps as many as one out of every four) uninsured Americans lacks coverage as a result of the cost of these mandates? As employers try to keep their health plans affordable, they must carefully consider which benefits are most valuable to their employees and their families. Survey research indicates that while most Americans support coverage for mental disorders, that support decreases when they realize that it will result in higher premiums, and that they generally consider coverage for physical disorders more important than coverage for mental disorders.46 In addition, there is greater public support for the coverage of such severe mental disorders as schizophrenia than there is for coverage of other conditions.47 These priorities are naturally reflected in the decisions they and their employers make when purchasing health insurance. While there is disagreement mound the level of cost associated with parity, it is clear that there is a cost and that this increased cost will put health insurance out of reach for some Americans. Recently, Dr. William Custer of Georgia State University, performed a study for HIAA that looked at the impact that state health insurance laws and regulations have on coverage levels. The one benefit mandate that he included in the study was mandated mental health coverage. This study was unique in that it directly measured the impact on the number of people who have health insurance coverage. Dr. Custer found that in states that mandate coverage for mental illness, the likelihood that a given citizen will be uninsured increases by 6 percent.48 Similarly, estimates of the impact of the number of Americans who would lose health insurance coverage as the result of a full federal parity requirement range from 800,000 to 3.2 million.49 The highend estimate represents more than three times the number of Americans who lose coverage each year due to all other causes, and even the low-end estimate would double the number of Americans who lose coverage.50


There is a perception that private health care plans have unlimited dollars for coverage, and therefore, expansions of benefit plans are an acceptable way to bring more services to insured persons. We must understand that not everyone has the high level of employer contributions that federal employees enjoy, nor do businesses have unlimited dollars for the health benefits programs that they voluntarily offer to their employees. Nor do consumers have unlimited dollars for health care coverage given other competing demands. Each group, no matter how well intended, that advances one level of benefits may fail to see the effects of its advocacy for extended coverage as it relates to the efforts of other groups. While we can argue over the merits of individual mandates, the fact is the cumulative impact can be devastating, particularly for those Americans who are most vulnerable to cost increases.

And let me add one additional note on the issue of mandated benefits. All too often when a mandated benefit is proposed, the benefit mandated can become far more extensive in scope than originally intended. Take the current discussions in both houses of Congress on the issue of emergency room services. The original intent of many legislative proposals was to guarantee insured persons the right to payment for their emergency care services if their condition, or their perception of their condition, warranted a trip to an emergency facility. Now, however, when we talk about mandates on emergency care, we include payments for post-stabilization services as well as maintenance. All too often legislative proposals dictate not only the benefit required but the terms of the service, how it must be provided, whether it can be exempt from any utilization review or plan oversight, and so on. As the scope of the mandate itself expands, so does its costs.

Mr. Chairman, HIAA's members share the concerns of this committee about the impact that mental illnesses have on patients, their families, their employers, and our society. However, we must also recognize that extending full parity in this area will drive up the costs of coverage, and increase the number of uninsured Americans. Instead. we believe that we must work together to expand health coverage to as many consumers as possible.

Again, thank you for the opportunity to testify today. I am happy to answer any questions you may have.

Thank you.


1 Merrile Sing et al., The Costs and Effects of Parity for Mental Health and Substance Abuse Benefits, U.S. Department of Health and Human Services. Public Health Service, March 1998, p. 5.

2 Mental Health.' A Report of the Surgeon General. U.S. Department of Health and Human Services, Substance Abuse and Mental Heath Services Administration.

Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999, p. 46.

3 Mental Health: A Report of the Surgeon General, p. 411, 412.

4 Howard Dean, 2000 State of the State Address, January 4, 2000.

5 Mental Health; A Report of the Surgeon General, p. 5.

6 For a discussion of the how conditions come to be included in the Diagnostic and Statistical Manual of Mental Disorders (D,S.M.) see Joe Sharkey. "It's a Mad, Mad, Mad, Mad World: You're Not Bad, You're Sick. It's in the Book," New York Times. September 28, 1997, Section 4. page 1.

7 Grayson Norquist and Steven E. Hyman. "Advances in Understanding and Treating Mental Illness: Implications for Policy," Health Affairs, September/October 1999, p. 35.

8 Mental Health; A Report of the Surgeon General, p. 124.

9 Mental Health; A Report of the Surgeon General. p. 20.

10 Mental Health; A Report of the Surgeon General, p. 408. 409.

11 Mental Health; A Report of the Surgeon General, p. 65.

12 Mental Health; A Report of the Surgeon General, p. 72.

13 Issues in Mental Health Care Benefits: The Costs of Mental Health Parity. EBRI Issue Brief Number 182, Employee Benefit Research Institute, February 1997, p. 13. John Morgan, "Why Freud Isn't Dead," Scientific American. December 1996.

14 Mental Health: A Report of the Surgeon General, p. 140.

15 Julie Magno Zito et al., "Trends in the Prescribing of Psychotropic Medications to Preschoolers," Journal of the American Medical Association, February 23, 2000, p. 1025. "Psychiatric drugs soaring among toddlers." USA Today. February 22.2000. Al Neuharth, "Drugging unruly kids lazy parents' cop-out," USA Today, December 17, 1999.

16 Anthony F. Lehman, "Quality of Care in Mental Health: The Case of Schizophrenia," Health Affairs, September/October 1999, p. 55.

17 Richard G. Frank et al.. "The Value of Mental Health Care at the System Level: The Case of Treating Depression," Health Affairs, September/October 1999, p. 85.

18 "The Value of Mental Health Care at the System Level: The Case of Treating Depression," p. 82, 85.

19 The Costs and Effects of Parity for Mental Health and Substance Abuse. p. 32.

20 For a graphic illustration of this offset effect, see Parity in Financing Mental Health Services. Managed Care Effects on Cost, Access, and Quality, U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health, May 1998, p. 18.

21 Kessler. D.P. and M. McClellan, "Do Doctors Practice Defensive Medicine?" The Quarterly Journal of Economics, Feb. 1996.

22 U.S. Office of Technology Assessment, Defensive Medicine and Medical Malpractice, July 1994

23 "Do Doctors Practice Defensive Medicine?"

24 Macintosh and Murray, "The High Cost of Medical Liability,." Hudson Institute Briefing Papers, Hudson Institute, April 1994.

25 Gresenz, et al., A Flood of Litigation? RAND. July 1999.

26 Charles River Associates Inc. The National Costs of Physician Antitrust Waivers, HIAA, March 2000.

27 Rural Neglect: Medicare HMOs Ignore Rural Communities, Families USA Publication No. 99-15, Families USA Foundation, September 1999. R.T. Slifkin, "Medicaid Managed Care Programs In Rural Areas: A Fifty-State Overview," Health Affairs, November/December 1998.

28 William S. Custer. Health Insurance Coverage and the Uninsured, Health Insurance Association of America, January 1999.

29 Employer Health Benefits. 1999 Annual Survey. Kaiser Family Foundation and Health Research and Educational Trust, 1999, p 56.

30 The Costs and Effects of Parity for Mental Health and Substance Abuse Benefits, p. 15.

31 Employer Health Benefits; 1999 Annual Survey.

32 "Fact Sheet. Protecting Medicare's Partial Hospitalization Benefit in Community. Mental Health Centers," HCFA, October 5. 1998. In September of 1998 HCFA announced a 10-point program intended to address these problems. This program included: terminating the worst offenders, intensified medical review, and the implementation of a prospective payment system.

33 In February, 1999, Nova Southeastern University agreed to pay the state of Florida $4.2 million to settle claims of improper billing and the provision of questionable mental health care services to Medicare and Medicaid beneficiaries. Shortly before that, Integra, a Pennsylvania-based provider of outpatient mental health services, agreed to pay $3 million to settle charges that it had billed Medicare for unnecessary individual and group therapy provided to nursing home residents. In November of 1998 an Indiana businessman was indicted by a federal grand jury for receiving $900.000 in kickbacks from two Florida psychiatric hospitals in return for patient referrals. A similar but unrelated indictment was brought against two other businessmen, one from Texas and one from Georgia. In February of this year. Charter Behavioral Health agreed to pay $600.000 to settle Medicare and Medicaid fraud charges involving claims for psychiatric services. Just last month, an Illinois psychiatrist and his office manager were indicted on 15 counts including mail fraud, health care fraud, false claims, and conspiracy. They allegedly submitted claims to Medicare. Medicaid. and private health plans for services that were never provided and for services provided by unqualified personnel. Also last month, a psychologist in Birmingham, Michigan, was charged with fraudulently billing Blue Cross and Blue Shield of Michigan.

34 "The Hidden Side of Psychiatry: Part I of a 2-Part Series," Alt Health Watch. Townsend Letter for Doctors and Patients, January 1997.

35 BNA Daily Report for Executives, May 12, 2000, p. A-13.

36 Paul Fronstin, et al., EBR1 Databook on Employee Benefits, 4th edition, Employee Benefit Research Institute, 1997.

37 Mental Health: A Report of the Surgeon General, p. 68.

38 Mental Health: A Report of the Surgeon General, p. 417.

39 Issues in Mental Health Care Benefits. The Costs of Mental Health Parity, EBRI Issue Brief Number 182, Employee Benefit Research Institute, February 1997, p. 7.

40 Health Insurance Coverage and the Uninsured: 1990-1998.

41 Richard Kronick and Todd Gilmer, "Explaining the Decline in Health Insurance Coverage, 1979-1995/' Health Affairs, March/April 1999, p. 30.

42 Kenneth E. Thorpe and Curtis S. Florence. "Why are Workers Uninsured.?" Employer-Sponsored Health Insurance in 1997," Health Affairs, March/April 1999. p. 213. Peter J. Cunningham et al., Who Declines Employer-Sponsored Health Insurance and is Uninsured?, Center for Studying Health System Change. Issue Brief Number 22, October 1999. The Surgeon General's report estimates that 75 percent of the uninsured are in employed families that cannot afford to purchase health insurance. Mental Health Report of the Surgeon General, p. 419.

43 Gail A. Jensen and Michael A. Morrisey, Mandated Benefit Laws and Employer-Sponsored Health Insurance, Health Insurance Association of America. January 1999.

44 Jensen and Morrisey, Mandated Benefit Laws and Employer-Sponsored Health Insurance.

45 Mandated Benefit Laws and Employer-Sponsored Health Insurance.

46 Mental Health. A Report of the Surgeon General. p. 8.

47 Mental Health. A Report of the Surgeon General. p. 8.

48 William S. Custer. Health Insurance Coverage and the Uninsured. Health Insurance Association of America, January, 1999, p. 14.

49 Issues in Mental Health Care Benefits.' The Costs of Mental Health Parity, p. 11.

50 There were 43.l million uninsured non-elderly Americans in 1997. By 1998 this number had grown to 43.9 million, an increase of 800.000. Health Insurance Coverage and the Uninsured, p. 3. Health Insurance Coverage and the Uninsured: 1990-1998. p. 1.


LOAD-DATE: May 19, 2000

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