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This paper examines mental health giving by foundations and points to a continuing downward trend in philanthropic giving to mental health, relative to overall and health giving. The authors reviewed data and interviewed staff from foundations that accounted for the majority of mental health funding in 2006. Using this quantitative and qualitative information, the authors identify important unanswered questions about foundation funding for mental health and suggest that the lack of precision in how mental health funding is defined and measured is symptomatic of the mental health field in general and may contribute to grantmakers' low level of attention to it.

Minorities have, in general, equal or better mental health than white Americans, yet they suffer from disparities in mental health care. This paper reviews the evidence for mental health and mental health care disparities, comparing them to patterns in health. Strategies for addressing disparities in health care, such as improving access to and quality of care, should also work to eliminate mental health care disparities. In addition, a diverse mental health workforce, as well as provider and patient education, are important to eliminating mental health care disparities.

Between 1997 and 2003, the share of workers subject to mental health parity laws greatly increased. But because of exemptions for self-insured firms and small firms, coverage is much lower than a simple tally of state mandates would suggest. Limits on the types of conditions covered further weaken these laws. This paper summarizes the extent and scope of state parity legislation in terms of the number of insured private-sector employees covered. It explicitly accounts for the Employee Retirement Income Security Act (ERISA) exemption for self-insured plans, exemptions for small employers, and the range of conditions covered by the law.

This paper analyzes the history of the modern consumer/survivor movement and its impact on the policy-making climate in the mental health field. The growing attentiveness to consumers' perspectives is presented largely as a consequence, not a cause, of radical restructurings of the mental health system. Consumers' perspectives have entered policy discourse in the wake of policy failures and have flourished in a climate of perpetual crisis and tight budgets. Precisely because it has been such a contested arena for so long, the mental health field has produced some innovative responses to demands for patient empowerment.

This paper describes gaps in services for low-income people with serious mental illnesses as reported by mental health professionals and other observers in twelve U.S. communities. According to respondents, service gaps have grown in recent years--especially for uninsured people--as a result of state budget pressures and Medicaid cost containment policies. Growing service gaps contribute to the high prevalence of serious mental illness among the homeless and incarcerated populations, as well as crowding of emergency departments. Some states and communities are aggressively addressing these gaps, although funding for new programs remains scarce.

Mental health policy is shaped fundamentally by the definition of mental illness associated with the policy. Changing policies reflect changing definitions. At various times, the definition may be narrow or broad with respect to the scope of conditions covered by a specific policy. The priority accorded to impairment severity is the most crucial and enduring policy issue related to the definition of mental illness and the scope of that definition. This paper explores the role of definitions in framing mental health policy, using examples from the history of policy making over the past half-century.

This paper presents an update on the availability of tobacco-dependence treatments in Medicaid benefit packages from 1998 to 2003 and discusses variation in states' approaches for addressing tobacco cessation. In 2003 thirty-seven states had coverage for at least one evidence-based treatment. Since 1998, thirteen Medicaid programs have added coverage for at least one, while five programs have expanded coverage of these treatments. Overall, the coverage increases indicate a growing awareness of the treatments' importance for the health of Medicaid recipients, although further expansions are still needed.

Evidence-based practice (EBP) is the subject of vigorous controversy in the field of mental health. In this paper I discuss three distinct but interrelated controversies: how inclusive the mental health evidence base should be; whether mental health practice is a variety of applied science; and when and how the effectiveness goal in mental health is defined. I provide examples of evidence-based policy in mental health. These controversies pertain as well to general medicine. To the extent that they remain unresolved, evidence-based policy making may lead to ineffective and limited care.

This paper examines recent trends in the design and organization of coverage for mental health care using data from a Henry J. Kaiser Family Foundation and Health Research and Educational Trust (KFF/HRET) national employer survey. Legislation and changes in the delivery of mental health services have altered how mental health insurance is bought and sold. However, our findings reveal that mental health coverage is still typically not offered at a level equivalent to coverage for other medical conditions. We attempt to synthesize these data with prior research as a foundation for informed debates.

With the creation of the Oregon Health Plan (OHP) in 1994, Oregon placed its Medicaid program under a managed care system. This paper examines the managed care practices of seven health plans serving OHP enrollees between 1996 and 1998. Results indicated that the original vision of integrating substance abuse treatment services with physical care for OHP enrollees evolved into a multilayered, carved-out approach. Factors working against integration included changes in the administration and management of the chemical dependency benefit, financial losses by health plans, and lack of training and incentives for physicians to refer clients to substance abuse treatment.

The 1996 Mental Health Parity Act (MHPA), which became effective in January 1998, is scheduled to expire in September 2001. This paper examines what the MHPA accomplished and steps toward more comprehensive parity. We explain the strategic and self-reinforcing link of parity with managed behavioral health care and conclude that the current path will be difficult to reverse. The paper ends with a discussion of what might be behind the claims that full parity in mental health benefits is insufficient to achieve true equity and whether additional steps beyond full parity appear realistic or even desirable.

The 1996 Mental Health Parity Act requiring equal annual and lifetime dollar limits for mental health benefits is to sunset 30 September 2001. This paper reviews the impact and limitations of both this law and existing state provisions and describes recent research on the actual and projected costs associated with such laws. We contend that full parity provided within the context of managed care not only is possible, but represents a "sequential" rather than a final step toward the broader goal of achieving equity in the treatment of persons with mental and addictive disorders.

Mental illnesses have a significant impact on public health and contribute to a substantial part of the disability of the general population. Recent research on understanding and treating such illnesses has produced data that can inform policymakers about how to improve the condition of persons who suffer from these illnesses. This paper discusses how this research can be used to inform policy decisions regarding the allocation of community treatment resources and what research is still needed.

The Canadian health care system has been frequently discussed but firmly rejected as a model for guiding the transformation of American medicine. In mental health care, however, one can find a growing convergence between the two systems. This convergence is largely coming about as a result of Canadian borrowing from American programs and strategies. In this paper we provide examples of planning service, and policy elements in U.S. mental health care that Canadians have drawn upon. We analyze this phenomenon in terms of cross-national policy learning, identifying the factors and forces that facilitate this trend for Canada while impeding it for the United States.

The enactment of the Domenici-Wellstone amendment in September 1996, which calls for the elimination of certain limits on coverage for mental health care under private insurance, is being hailed as a major step forward in the quest for "parity" in mental health coverage. Parity legislation is being introduced in a number of state legislatures and is finding new enthusiasm in Congress. In this paper we consider the efficiency rationale for these laws and examine their likely impact in the era of managed care. We conclude that although such successes represent important political events, they may offer only small gains in the efficiency and fairness of insurance markets.

The cost of expanding mental health and substance abuse treatment coverage is a major impediment to reforming insurance coverage for these types of conditions. The recent experience with national health care reform offers a case study in cost estimation for mental health and substance abuse coverage. The impact of managed care and the cost of expanding coverage to currently uninsured persons introduced uncertainty into predictions. This paper critically reviews that experience and draws lessons for estimating future costs of policy initiatives.

The U.S. health care system is quickly changing, but is it moving in the right direction? Focusing on care for clinical depression as a test case, this paper summarizes our previously published findings on the effects of various payment strategies, managed care, and primary care gatekeepers on the outcomes and costs for the treatment of mental health conditions. We then synthesize the policy implications of these findings for achieving value of care, lower costs, and good health outcomes.

Praise and blame of managed mental health care are on the rise on many fronts, including allegations that it could adversely affect quality of care, access to care, the physician/patient relationship, and informed patient choice. Given the heterogeneity among managed mental health care organizations--each with differing practices--it is difficult to sift the ethically defensible concerns from the indefensible ones. In this paper we identify and examine the different moral concerns about managed mental health care and mark which problems have been addressed or are in need of resolution. We also identify which problems are unique to managed mental health care.

Historically, state mental health authorities have dominated public mental health services, operating with fixed resources and responsible for a large population. A good public mental health system has many of the attributes of a well-managed private mental health system. Unfortunately, public systems are not flexible enough to contract creatively with multiple providers; they lack many of the tools of modern managed care. As a consequence, state mental health authorities have begun to contract with private managed care firms to assist them in managing their health care reform efforts, particularly reform of Medicaid. This paper examines the forces shaping managed behavioral health care in the public sector and describes strategies for managing care, such as contracting, utilization review, and monitoring.

Private employers and state Medicaid programs are increasingly writing risk contracts with managed behavioral health care companies to manage mental health and substance abuse benefits. This paper analyzes the case for a carve-out program and makes recommendations about the form of the payer-managed behavioral health care contract. Payers should consider using a "soft" capitation contract in which only some of the claims' risk is transferred to the managed behavioral health care company. To avoid incentives to underserve seriously ill persons, we recommend that payers not allow choice by enrollees among risk contractors.