PURPOSE: As of December 2000, 31 states passed mental health parity statutes, laws requiring a health plan, insurer, or employer to provide mental health benefits``equal'' to physical health benefits. With parity, lawmakers are for the first time legislating their own state definitions of mental illness rather than leaving the definition up to insurance plans or covering all disorders in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) as legislation has traditionally done. My research examines definitions of``mental illness'' used in state parity laws and implications of these definitions including what populations are getting increased access to care. METHODS: I reviewed the statutory language in 31 state parity bills and conducted a series of interviews with stakeholders participating in the national and state mental health parity process. Interviewees included mental health advocacy groups, provider organizations, legislative bill sponsors, health plans, and employer groups. Interview data was supplemented with extensive literature review. RESULTS: The definition of mental illness varies significantly across states, but falls into one of three categories:``broad-based mental illness,''``serious mental illness,'' and``biologically-based mental illness.'' Broad-based mental illness includes all disorders listed in the DSM-IV and/or World Health Organization's ICD-9.``Serious mental illness'' and``biologically-based mental illness'' include from three to eleven specific DSM-IV mental disorders. Several factors influence a state's definition of mental illness including the cost of parity, the leadership role taken by state advocacy group(s), the strength of insurance interests, the reliance on antidiscrimination arguments, and the political feasibility of parity in the state. CONCLUSION: With parity, state lawmakers are not relying on clinically accepted definitions or previous federal and state definitions of mental illness. It appears that political and economic factors influence the statutory definition, rather than needs-based strategies or clinical judgement. Insurers argue that legislating parity for all mental disorders results in tremendous healthcare costs and necessitates the development of definitions that target only the most seriously mentally ill. However, using a``pick and choose'' approach to the DSM-IV as most states have done has little (if any) clinical basis, and can potentially limit access to care. Increased reliance on clinician judgement and further studies measuring the access implications of current parity laws are needed to identify those who would most benefit from parity. PURPOSE: Ethnic culture ± the basic beliefs an ethnic group uses to interpret experience ± affects patients' views on dying. But views within an ethnic group are not all alike. The genders within an ethnic group may share some views but differ on others and, thus, be distinct subcultures for advance care planning purposes. METHODS: We explored this possibility by asking Mexican Americans (14 men, 12 women), Euroamericans (7 men, 11 women), and African Americans (7 men, 7 women) their views on advance directives (ADs). All subjects were inpatients aged 50 to 79. RESULTS: While believing ADs improve the chances a patient's wishes would be followed, the genders within all three ethnic groups differed over the power and trustworthiness of the health care system, treatment wishes and the willingness to express them, and beliefs about ADs. Among Mexican Americans most men but few women believed the system controls treatment (79% versus 33%), believed patients should be allowed to die when treatment is futile (57% versus 42%), wanted no life support (71% versus 42%), had not told anyone their wishes (64% versus 42%), and believed ADs are needed for when a patient is brain dead or cannot function (57% versus 33% for both themes). But few men and most women trusted the system to honor written ADs and believed ADs help the staff know a patient's wishes (43% versus 67% for both themes). Among Euroamericans most men but few women distrusted the system (57% versus 18%) and disliked ADs (57% versus 36%). But few men and most women expressed wishes not to suffer during terminal illness (0% versus 55%), believed patients should be allowed to die when treatment is futile (0% versus 55%), and believed the system honors written ADs (43% versus 73%). Among African Americans most men but few women distrusted the system (57% versus 29%) and wanted to wait until very sick to express their wishes (57% versus 43%). And few men but most women said that the patient deserves a say in treatment (43% versus 57%), wanted no life support (29% versus 57%), and believed ADs help staff know the patient's wishes (0% versus 57%) and can prevent life support (14% versus 57%). CONCLUSION: While sharing some views, men and women of each ethnic group differed on others. Unlike men, women tended to trust the system and to believe ADs will help realize their wishes. Providers should consider gender-specific values within an ethnic culture when doing advance care planning with patients. PURPOSE: Ethnic culture ± the beliefs an ethnic group uses to interpret experience ± affects patients' views on dying. But views within an ethnic culture are not all alike. Age groups within an ethnic culture may share some views but differ on others and, thus, be distinct subcultures for advance care planning purposes. METHODS: To explore this possibility we interviewed Mexican Americans, Euroamericans, and African Americans. Younger subjects (ages 50 ± 64) numbered 15, 11, and 10 respectively; older subjects (ages 65 ± 79) numbered 11, 7, and 4. RESULTS: While all ethnic groups liked some aspects of advance directives (ADs), age groups within each ethnic group differed over trust in the health care system, treatment wishes, and beliefs about ADs. More younger than older Mexican Americans wanted to be allowed to die when treatment is futile (60% versus 36%), had not told their wishes to anyone (60% versus 45%), believed ADs are needed for when a patient cannot voice decisions (60% versus 27%), and trusted the system to honor written ADs (60% versus 45%). Fewer younger than older Mexican Americans expressed wishes unrelated to life support (for example, where or when they wished to die) (33% versus 64%). More younger than older Euroamericans described unacceptable outcomes (55% versus 43%) and believed that ADs help staff know a patient's wishes (91% versus 29%) and are needed for when a patient is brain dead (64% versus 29%). Fewer younger than older Euroamericans disliked some aspects of ADs (36% versus 57%), had not told anyone their wishes (18% versus 71%), and doubted ADs change treatment (27% versus 57%). More younger than older African Americans believed the system controls treatment (80% versus 25%), distrusted the system (50% versus 25%), said the patient deserves a say in treatment (60% versus 25%), wanted no life support (50% versus 25%), doubted ADs change treatment (50% versus 25%), and said ADs just mean the patient is dying (70% versus 0%). Fewer younger than older African Americans trusted the system to serve patients well (30% versus 50%), had not told their wishes to their physicians (10% versus 50%) but planned to tell someone before becoming too sick (0% versus 75%). CONCLUSION: While sharing some views, intraethnic age groups differed in their trust of the health system, their willingness to express treatment wishes, and their confidence in ADs. Providers must consider age-specific beliefs within an ethnic culture when conducting advance care planning with patients.