we're here today to move an important piece of legislation known to most of us is the paul wellstone mental health and addiction equity act as vi colleagues know it's named after one of its chief proponents the late senator paul wellstone of minnesota who spent a champion for all people and especially those who suffer from mental illness and addiction more more to the point for today one of its chief proponents in the house is our esteemed colleague jim ramstad minnesota who serves with us here on our subcommittee and who is recently announced that he will retire after this term in office and as many of you know he will be missed by all of us and acting this legislation is important to millions of americans who suffer from these illnesses and it's a fitting tribute to senator wellstone and representative ramstad service to our nation as a senate are hearing on this bill we've come a long way in our diagnosis and treatment of mental illness and substance abuse but unfortunately the laws governing mental health treatment of not progressed as quickly health insurers typically discriminate against people who need mental health or substance abuse treatment by imposing higher co payments limited hospitalization periods loran ulan lifetime caps on mental health and addiction benefits and other limitations to deny access so that the members in these plans don't get the health care they need this bill stops that discrimination it does so by requiring health plans to provide parity for the provision of mental health benefits plans to offer mental health or addiction benefits they'd be prohibited from imposing discriminatory and your has already provided better health parity for ourselves in the federal employees health benefits program the house recently passed the children's health and medicare protection act which will extend mental health parity in medicare paul wellstone mental health addiction acts simply finishes what we've begun to extend those protections to the private health insurance market as well it has broad based bipartisan support with two hundred seventy c sponsors in the house and is endorsed by literally hundreds of organizations representing patients families mental health and addiction treatment providers pleased to be part of this progress toward mental health parity and i'd be happy to yield to our ranking member dave camp for any comments you care to make well thank you very much mr chairman i also want to echo that this legislation is really here before the committee because it has been championed by a member of the subcommittee congressman ramstad who has really been a leader on issues of substance abuse and addiction and has recently announced that he will be retiring from the congress after completing his one term it has been a pleasure and honor to have him as a member of the subcommittee as well as a member of the class that i came into congress with and and more important than that one of my very good friends in congress so you know i just want to say that we all support parity for mental health and substance abuse related disorders and we all know that effectively managing the treatment of these  diseases an individual suffering from mental illnesses and substance abuse will mean that they can get the appropriate medical care that leads to better health outcomes and lower costs in the future the senate unanimously last night passed a mental health parity bill that will allow us to achieve these goals and if that bill were before this committee i'm confident it would still receive the unanimous support of this subcommittee both the senate and house bill include a requirement for employers and health plans to cover treatment for mental illness on the same terms and conditions of other illnesses mental health advocates employers and insurers all support the senate bill because it balances the needs of patients with the ability to provide quality affordable health insurance unfortunately the bill before us today does not reflect the priorities of the senate bill mandates in the house bill will significantly expand the number of and services that insurers must cover whether large or small these costs will  pass along to the purchasers of health insurance these additional costs will in turn make it more difficult for for employers to continue providing affordable health care coverage for working americans the ho also exposes employers to new liabilities by allowing states to establish new rights and remedies under arista this is a significant departure from current law one that was rejected by the senate and as a result employers may question the feasibility of continuing to purchase insurance for their employees the kaiser foundation recently reported how private health insurance premiums increased by over six percent last year while other researchers have reported how increasing health care costs are forcing many employers to drop health care coverage this in turn makes it more difficult for their employees to obtain any health insurance let alone mental health and substance abuse benefits we recognize the importance of achieving parity for individuals suffering from mental illnesses and substance abuse and for this reason we should support a bill that establishes parity protects access and enjoys the support of mental health advocates employers and health insurers take a long time to reach consensus on a bill that all stakeholders can support it would be a shame if we had to once again limit ourselves to another one year extension when there's an opportunity to provide significant improvements in parity if we were to concentrate  after our efforts on passing the senate bill it's my firm belief we could have a bill on the president's desk by the end of the week with that in mind i look forward to working with my colleagues and mr starke on this important issue and i thank the chairman and yield back my time colleagues for your kind words chairman stark thank you for elian for your strong leadership in moving this life saving legislation i've said many times before that expanding access to mental health and addiction treatment is more than just another public policy issue it's a life or death issue for eighty million americans right today fifty four million americans are suffering the ravages of mental illness twenty six million suffering from chemical addiction and most are unable to access treatment and i'm alive and sober today only because of the access i had to treatment twenty six years ago but too many people don't have that access today last year alone three hundred thousand americans were denied access to treatment who were ready to take their first step and wanted help one hundred fifty thousand of our fellow americans died directly as result of chemical addiction thirty three thousand americans committed suicide as a result of i'm treated depression last year it's truly a national crisis that untreated addiction and mental illness cost our economy in dollars and sent over five hundred fifty billion dollars last year and that's according to the business groups that have studied this so i'm grateful that this legislation is here finally after working on this since one nine hundred ninety six paul wellstone got me started they got me involved in this effort and nobody fought harder for people with mental illness and addiction than our beloved former colleague now deceased from minnesota paul wellstone and i'm proud to have co author this legislation with my  friend and colleague patrick kennedy plain and simple our bill prohibits health insurance companies from discriminating against people who need mental health or addiction t our legislation say no more limited treatment stays that you don't apply to physical diseases no more higher co payments you don't apply to physical diseases whether it's an appendicitis or a heart problem or enroll in toenail treat the same treat diseases of the brain the same as of the body last time we checked the brain is part of the body so we're trying to get rid of the discriminatory barriers that don't exist for other diseases we think expanding access to treatment is not only the right thing to do but it's also the cost effective thing to do and i would wish we had more time i wish we had all day so we could compare the r and pericles data with our worthy opponents who say this is going to raise cost premiums because believe me we have all the actuarial studies and empirical data in the world to prove that equity for mental health and addiction treatment will save billions of dollars nationally while not raising premiums more than one percent who was the authority not less than the c b l the congressional budget office predicts a net increase of two tenths of one percent or so for the price of a cheap cup of coffee we could treat eight million more americans for the price of a cheap cup of coffee would you treat eight more eight million more americans and don't just take c b o's word for it look up the rand corporation study look up the california study the minnesota study the columbia study the new england journal of medicine study this past fall and on and on and on in the literature and of course the nationalist suit on drug abuse found that every dollar that we spend on treatment saves twelve dollars in health care and criminal justice costs alone the average untreated alcoholic or addict has health care costs hundred percent higher than i do as a treated alcoholic and that doesn't even take into account savings from social services that are there going sky high because of addiction and mental health lost lost productivity absenteeism and injuries in the workplace let me conclude mr chairman by saying the families of millions of americans suffering from mental illness and chemical addiction simply can't afford to wait any longer we as a nation cannot afford not to act on this legislation not to provide greater access to treatment for people in desperate need it's time to pass this critical life saving bill we have two hundred and seventy house co sponsors including al significant number of republicans and i'm certainly grateful for the bipartisan support this bill has and i urge my colleagues to pass the strongest bill without delay i know noted that education labor passed it on a bipartisan vote of thirty three to nine and i hope our bipartisan vote is just as resultingly strong for true equity in treatment th much the subcommittee will now consider h r fourteen twenty four and without objection the bill is considered read and open for amendment and the point is customary the chair offers an amendment in the nature of a substitute and without a direction the amendment is considered as read the amendment mr chairman we will have an opportunity to question the witnesses about little legislation after as soon as i finish reading this tony q this is the a member of the nature of a substitute before the members with a green sheet explaining it i'd recognize it we have of our health staff and mr black's is here for the joint committee on taxation to walk us through the bill and answer questions i'd ask the slacks to briefly go through the bill and if we could withhold our questions until she's completed her run are in the chairman's substitute as introduced the deputy chairman ken mehlman and the nature of assessed to amend section four which are the changes to the internal revenue code there are basically four broad changes in section for the s the the provision also provides a minute minimum benefit requirement for a plan that to provide mental health parity mental health benefits this requirement would would provide that plans that do provide mental health benefits must provide benefits that are equivalent to the benefits under that b p plan with the highest annual enrollment the bill also expands the parity requirement so that treatment limits and beneficiary financial requirements must meet the parity requirement in that plan that have limits plans can only have limits on mental health and substance related to sort of benefits that are on parity with the medical and surgical benefits that those plans require and these new parity requirements are applied in five categories it looks at inpatient in network inpatient out of network outpatient in network outpatient  network and emergency care so that the parity requirements apply within the five categories the provisions also immense a small employer exception and the increased cost exception provide and it also provides disclosure requirements and so that plans have to tell participants why they have denied certain claims the provision is effective after january one two thousand and eight and it also provides language so that the present on mental health parity requirements will not have any period of expiration so that they will continue moore is it correct that this bill before requires all group health plans cover all d s m four conditions that's correct and is that provision included in the senate bill that unanimously passed the senate last night  i understand that the senate bill was amended and i haven't seen the amendment but the bill as introduced did not include that did not include d s m for now is the requirement that all d s m four conditions be some are but not not the d s m four in its entirety is not included in athy h p p it does if the gentleman would yield that's not our understanding but it seems to me this is an issue that would it not that is correct the house bill also requires plans and employers to provide out of network mental health benefits if they are provided medical and surgical benefits out of network is that correct yes that's the definition of parity now the f d a however does not require plans to have out of network mental health benefits even if out of network medical and surgical are provided is that correct that is correct so this legislation before us well actually exceeds what the b p does in terms of out of network at the present moment that's correct so why is that the case why is this provision more expansive than what we require for federal employees the the diagnosis d s m four the categories are required because it is as i understand it it is also understand is required in other parts of federal law and because it is what members of congress receive then it is it was expected to be the minimum standard for all health plan but the out of network is far far exceeds what if each b p provides now did see below say anything about this increased cost sharing for out of network and surgical that they say any effect that this might have in their letter regarding and analyzing this legislation that you can recall miss flex maybe that's better directed to you we just have the that we have coordinated with l but i don't know their opinion on that that well in fact they did say that there would be reductions in the number of employers offering insurance to their employees or the number of employees and rolling in employer sponsored insurance changes in the type of health plans that are offered including eliminating coverage for mental health benefits altogether and or substance benefits also reductions in the scope or generosity of health insurance benefits as well as increased deductibles higher co payments behavioral responses that employers may have as a result of this legislation whether we agree to this and we need to know the effect of this bill that's all i'm trying to get at what is going to be the effect of this bill i very much would support the senate mental health parity bill  in regard to a risk subsection h of the bill the bill states that it does not preempt any state law that provides greater protections etc however concerns been raised that the section would allow states to apply additional remedies against a risk of lannes now current arista federal preemption does apply uniform administration of covered benefits would states can you describe the arista effect of this legislation the arrest or effect is not before that little today there is no subsection h in section flat i realize it's not germane before this committee but the bill in it totality i'm not offering an amendment on that issue i'm just asking us to discuss this issue would states be able to take regulatory actions against a recent plans now i would guess then asked mister stark this has been raised as an issue and i would like to work with you on clarifying language with regard to this aspect because as this bill moves to conference clearly the senate has passed a bill if this moves through the committee in the house yes we certainly will need to address this because with the risk of potentially of lawsuits employers and after raising premiums even further and that would be a concern that i would certainly we have no jurisdiction in that area we could have some input when the bill comes to conference and at that point i'd be glad to have the gentleman who would be participating would raise it there but it is pretty exclusive lee i'm not so sure i wish it weren't our jurisdiction but it's not in so i think that's an area in which i can i can't help you much but at this point own on or after january first two thousand and eight that's correct we've heard that this affected dates unworkable for plans because the timeframe would create substantial compliance problems for the for your very helpful counsel all the way on this important legislation first of all the distinguished ranking member my friend says it disputes the use of d s m for that which is the manual used by medical professionals for diagnosing diagnosing and classifying mental disorders is it not that's the manual that's right next book same same protection we're calling for is offered to members of congress is that correct that's correct so it seems to me if it's good enough for members of congress it should be good enough for people in health plans in the general public about other federal employees they're covered the same way under the d correct how about medicare d s m i i believe that's correct it is and medicaid yes tri care beneficiary just to name a few correct and we're saying no we're saying no to people in private health plan that is simply wrong and it is cost ineffective not to try to treat those people secondly my friend claims that although using d s m four may be a common practice it's not codified well this is simply not the case if you look at the journal very respected medical journal health affairs more than six hundred fifty four one the mentally ill offender act and two americas law enforcement and mental health project thirdly the arguments been made about the lack about we should not have parity in out of network benefits that the corollary of that says we should allow discrimination against mental illness and addiction and out of network benefits even  plans offer out of network benefits for medical and surgical benefits that's the whole point of this legislation the brains part of the body we're trying to treat brain disorders i e mental health disorders chemical addiction the same as medical and surgical benefits my friend from rhode island who i see is sitting in the islands whose audience who has worked tirelessly on this legislation he and i conducted fourteen field hearings throughout the nation  and we heard testimony after testimony about plans claiming that there are adequate numbers of trained specialist in their networks when in fact plans often lack specialist in child and adolescent and other types especially especially care that was a point made repeatedly in those those hearings so i look forward to debating the amendments that are coming on their merits and appreciate the time  a gentleman for rhode island i remember the hearing where they were witnesses and other compelling testimony we heard that made me a believer even more so that i agree with the gentleman when the gentleman says and i wrote down we should treat diseases of the brain the same as disease of the body i agree i think the ranking member agrees and as the gentleman also talked about the federal employee health benefits plan members of congress are privy to other federal employees i agree on that front as well but let me follow up with a question and either ms flack's or ms and as your isn't it true that the federal employee health benefits plan are allowed to offer medical management programs to determine whether a treatment is medically necessary the health plans are allowed to do medical management under current law and yet the specific bill does not to my question is the bill does not specific justify medical management is that a true statement i've just made that's correct thank you mr can't talk about the possibility at the state level regulatory agencies possibly judicial decisions is there any provision in this bill that protects plans from either report things that better let's just be very straight and honest during the course of this hearing personally i think the bill can be improved and we'll see that through the amendment process  my experience with the diagnostic statistical manual goes back to my days when i was prosecuting violent criminal cases and often there would be a claim of some sort of mental illness this serious mental illness is to which my friend refers addiction substance abuse a whole host of things that are based on diagnosis on access one and access to and yet you acknowledged that in the diagnostic statistical manual there also include in the d s m four are they not miss moore they are and so if it's in this book if this bill were to become law we would require it to be covered by providers to share information about the specific diagnosis and underlying issues that could be affecting the patient well and again maybe perhaps we can discuss this a little further during the process just as i think my friend from minnesota would agree i think he would agree that if there was a minor physical malady health plans are not necessarily going to cover and i hate to even suggest something because it's such an emotional issue people will say that if i were talking about a scraped knee but my seven year old may not be or should not be required to be covered by a particular health plan and if you had something similar as far as a relational problem like bereavement or some parent child relationship problem is actually in the d s m four should we then mandate that coverage or should we explicitly put into questions if not then the bill would be open for amendments and  mr chairman my amendment would a limit the requirement in h r fourteen twenty four that employers who offer out of network medical and surgical care have to offer out of network mental health care mandate in this legislation is very concerning not only does it go far beyond the requirement included in the bipartisan senate bill it's a greater mandate in the federal employees health benefit plan the apparent gold standard being used to justify the use of d m s d s m four and other parts of the bill i certainly agree that there should be parity among out of network services mandating employers to offer this coverage could force employers to drop any out of network services and dropping coverage would not only hurt those who need services as this bill tries to do it will also take away out of network benefits potentially for millions of americans i urge the committee to adopt this amendment to ensure that employers keep the flexibility they need to offer competitive and affordable health benefits also bringing parity to the services they  offer i guess i would respond this to camp that adopting this amendment would allow planes to continue to discriminate against people with mental illnesses or addictions and allowing plans to cover out of that work services for physical health but only in that work services or mental health doesn't seem to hit the definition of parity restricting access only to those services work limits treatment options particularly with less sophisticated and plans extending parity to out of network providers prevents them from creating those who might do this phantom that works which are essentially lists of providers who are neither who are either inappropriate for the patient or unable to take new patients in other words it gives it creates a loophole to block the intent of the of the legislation if we defeat your amendment it means that plans will be required to treat mental illness and addiction like the treat surgical or medical conditions covered by that play and so i would oppose your amendment  just briefly mr chairman i to oppose the camp amendment to the provision would allow plans to discriminate by offering both in network and out of network benefits for medical and surgical but only in network benefits for mental illness and chemical addiction treatment that is pure discrimination and this bill is about ending discrimination in terms of treating mental illness and chemical addiction it's not that difficult mr chairman the bill before us simply says if a plan offers both in and out of network coverage for medical and surgical treatment it must offer the same for mental illness and chemical addiction in other words don't discriminate that's what this bill is all about to knock down the barriers of discrimination to treatment among people in health plans so i would urge a no if there's no one else like well ok i just want to clarify what this amendment does this amendment says if they offer there has to be parity in the services that are offered what this bill does is mandates out of network mental health services benefits the senate did not do this the senate bill which passed unanimously did not do this and the reason they didn't do this is because of the mandate on private insurers all across america now they offer out of network benefits for physical there will be parity for mental this amendment the gentleman misunderstands is a meme of this amendment does not take away parity this amendment takes away the mandate that employers must offer out of network mental health benefits so this is really a commonsense amendment to not have this house bill go further than even the b p goes by mandating out  i think the amendment will be passed i'm proud to say i have been looking into this issue of mill health parity since two thousand and two in fact march of that year i was chairman of the subcommittee that held the very first house hearing which focused on this topic i heard back then and i've continued to hear over the years of concerns of mental health advocates about access problems to critical services you also heard from employers and benefit managers about what effect parity may have on their goal to provide good quality health care insurance to all their employees and customers there's a related mental health bill in the senate that is a result of employers health plans and patient advocate groups working together to address various concerns as a result of this collaboration the senate bill has been endorsed by both the health plans and employers and was passed unanimously unfortunately the legislation we're marking up today does not include the changes negotiated by the senate and therefore faces an uphill battle in any conference negotiation today m r an amendment to change the effect date in h r fourteen twenty four both employers and plan managers have voiced concerns that the current date of january the first two thousand and eight or the beginning of the plain years not practical if this bill is passed in its current form i believe it may impose an unrealistic start i'm concerned that plans will not have enough time to adjust their policies and products to be successful in bringing quality health care to the market i believe this time frame would create a substantial compliance problem for the states employers and health plans since most employers and health plans have already finalize their contracts for two thousand and eight they are now gearing up for enrollment where employees have the opportunity to learn about and make choices regarding their benefit options for the upcoming gallon or year i'm also concerned that h r fourteen twenty four provides no time for the issuance of regulation employers and health plans would essentially be flying blind by having to implement this legislation before better can be released in contrast the senate bill compels regulatory agencies to issue regulations for the compliance date so that companies can be better informed on how to effectively implement these new benefits i believe it's in everyone's best interest to see that the benefits are successfully implemented so that patients that need access to mental health are able to receive it and i asked my colleagues to board this amendment mr chairman i was a gentleman yield yes for impression is mr chairman that they need time to formulate the regulation and to comply and i'm not sure that if we put even july timeframe on there that that there's going to be time because we don't know when this one is going to pass finally and i i think i would i would submit to the gentlemen are that it for some reason we found ourselves in a conference committee next year i would be inclined at that point to extend the time as well but if if it were to pass quickly i think this would give sufficient time for the regulations of well to be adjusted i appreciate your offer and i thank you for your consideration but you know it seems to me that the senate idea of a years is really more focused on what the real problems are and i would that being one one zero nine would be consistent with the senate bill and i understand that several senators have made public statements that this bill will the bill before this committee will not be a bill that they will far but i would just ask the chairman to consider that i'm afraid it's been so long since i've been in a conference i'd say to my ranking member that i'm just dying to get back to see what it's like for him to we have a lot of fun gentleman is recognize distributes it thank you the page to which this amendment refers in your amendment in the nature of a substitute page thirty seven the amendment let me let me begin mr chairman by applauding you again in this committee hearing that we had the fact we're marking up this bill i'm glad we're taking up mental health parity support mental health and substance abuse parity again i think the consensus on this committee is that we all do but there are a few details on the chairman's mark that i would like to change via this amendment and a second one if the chairman would allow me a bit later on because i think we need to look at true parity as the final result of this legislation and again as my colleagues have already pointed out as the senate has voiced voted legislation that was i think a consensus product there was input agreement between mental health advocates policy experts health providers employers author ing legislators and i think is is is a good bill and i'm concerned as we continue to get away from that  diagnostic statistical manual for t r in the few minutes that we've had since my questions and your answers i've quickly looked through the chairman's mark and i find no distinction or any imposes a broad mandate to cover all mental illnesses listed in the d s m four required to provide coverage for all conditions and which exceeds the stated objective of achieving parity in my view because it requires coverage of conditions if a plan decides to cover any mental health or substance abuse conditions at all and there is no similar federal requirement  any other category of benefits there is no federal definition of the scope of medical surgical benefits that plans must offer therefore in my view this is not true parity i think that the underlying bill overreaches by attempting to achieve mental health parity again acknowledge and i agree and on the record state once again i accept the gentleman from minnesota when he says that the concept of parrot lies with the basic principle of mental illness being a disease like any other a man i agree with that therefore the objective is to require insurance coverage that is equal to but not superior to other medical conditions such as cancer diabetes or heart disease and group health plans should be allowed to exclude mental conditions that are not appropriate for coverage and whether or not they are included in the d s m four as is the case under current law h r four hundred twenty four eliminates the discretion of employers to determine what benefits they may cover for their employees and and under current law employers are allowed to define the coverage criteria for medical and surgical benefits true parity would allow the same thing for mental health benefits and what this legislation i'm afraid the unintended consequence is going to be a message to employers that the only discretion they have over decisions about what benefits they cover is revive no coverage at all and i think that this unintended consequence unfortunately isn't an acceptable alternative and so i would urge that we modify the underlying bill by including the language in the senate bill and i would go back my time i would respond to the gentleman by saying that i  oppose his amendment replacing the d s m four standard with the scope of benefits provided in the senate bill would codified in effect discrimination by diagnosis by allowing plans to use arbitrary nonscientific criteria in determining what mental illness and addictive disorders the plans would cover studies on the federal employees health but of the plan showed virtually no premium increases using d s m four criteria to define the scope of coverage and  a cost containment tool for plant the c b o's scores of h r fourteen twenty four and senate five five eight are virtually identical which would indicate that using the d s m four does not increase costs and for those reasons i'd urge my colleagues to defeat the amendment from it health plans are not criteria widely accepted by the medical community to determine what illnesses will be covered by the plan mr m said very briefly mr chairman one of my major concerns with the amendment is that eating disorders would be the first to go the leading cause of death among young women in america today anorexia bulimia eating disorders are going on treated the fastest increasing cause of death and a lot of other diseases of the brain that should be treated now i understand that the author of the distinguished author of the amendments concerns the relatively minor conditions  cites in the d s m anecdotal evidence while a challenge to distinguish author or any other person to find instances of abuse in the countless areas where the d s m is used as a scope of coverage treatment still have to meet medical necessity requirements before a claim is filed is that not correct ms or if the plan has medical necessity as part of its process for determining benefits that is correct and the vast majority do before supporting this amendment think about these young young girls the rising epidemic in america of eating disorders and you know you know eating disorders are going to be the first to go all and what they're going to do is cover the big three mental disorders are going to cover schizophrenia anxiety and depression period and that'll be well that's not what access to mental health treatment should be about for people in health plans who are being discriminated against offer coverage for eating disorders they say it's a medical necessity and their plans for example one plan says for members with anika or anorexia hospitalization is considered medically necessary under the following conditions one of the problems of the d s m code is it does cover caffeine withdrawal that would be a mandated cover throughout every private plan in america and jetlag now the vicodin only occur if there a secondary diagnosis and to implement this into statute is just hasn't completely rejected by the senate let me just as you read the d s m code it talks about the d s m four being for clinical research and educational purposes it's a useful useful for clinicians it's a helpful guide to clinical practice you read further in  they're in this in the d s m and d s m four is a classification of mental disorders that was developed for use in clinical educational and research settings this is a diagnostic tool that's what its name is this is not meant to be air lifted whole cloth into statute and that is where i think the problems occur when these when we have the potential to move dramatically forward on mental health parity with the senate bill and could do so quickly to get hung up on putting a several hundred page document into statute that really was designed as a diagnostic tool not a payment or scope of benefits measure is really taking a useful tool for clinicians and misapplying it in a legislative arena so  chairman i think my good friend from michigan basically makes the case in opposition of the amendment by citing the fact that there is wide variation already in the insurance field over what's being diagnosed and what's being covered for mental health services and the question really becomes now who's going to make this to side with the insurance plans and allow discrimination by by diagnosis to be codified in this legislation or are we going to side with the expertise of the medical community which is already reflected in exemplified in the federal employees health plan under d s m four standards and i for one would rather go with the medical community expertise rather than living up to the individual insurance plans to make this determination through what type of diagnosis they're going to allow cover for so i would encourage opposition to the american side with my friend from minnesota on this point you'll back if there's no further discussion the vote would this amendment and let me acknowledge what several of you have said on previous discussion other men about the federal employees health benefits plan  missouri is correct that there is other law that's out there regarding medical management programs to determine whether or not a treatment is medically necessary or not my concern however is that the bill that we're considering does not specifically talk about medical management there is no provision to protect medical management practices of the senate bill again we continue to refer to it scuse me specifically puts medical management within that underlying bill and what we're talking about are including such things as coordinated disease management care management initiatives health coaching patient support tools to improve the quality and the accessibility of mental health benefits the use of medical management allows plans to provide the right course of treatment to avoid expanding resources on ineffective or unproven treatments of the senate bill protect those plans ability to manage mental health benefits in this way even even if the management is more intensive than the management of other types of medical services the reason that federal employee health benefit plans have been able to keep costs down and several of you of reference cost the reason that federal employee health benefits plans cost remains workable and is because they're allowed to offer medical management programs to determine whether a treatment is medically necessary or not in fact i would state for the record the principal investigator who evaluated parity for federal employees stated in his testimony to the energy and commerce committee that quote these findings suggest that parity of coverage of mental health and substance abuse services when coupled with management of care is feasible and quote  its present form h r fourteen twenty four in my view will limit the ability of group health plans to offer a full range of medical management tools including provider networks contracting all tools that are essential in controlling costs of in opposing your amendment i not only would suggest that it is unnecessary perhaps redundant but nothing in the bill before us prevents payers from medically managing their health benefit plans as they do today but putting this language in the  statute in effect sends a signal supporting the use of benefit management particularly and specially for mental health and addiction benefits says well it's silent on acute care surgery and other physical so that it could in fact send a signal that we intend to encourage medical management in the mental health area where we would not in the physical and that would move us it would create it my concern my concern a movement toward getting away from parity and because i think it's unnecessary i would oppose it on the basis that it sends a signal that we might we went through this on the patients a rights issue some time ago and i would not like to create any prejudice that would lead to planes or those few planes that might not want to do the best thing for their members but more for their stockholders to encourage them to find a way around the intent of this bill so i would oppose your amendment chairman i would just say that i don't think we should have the state or federal law undercut diminish health plans that are trying to ensure that health services received are actually medically necessary and appropriate for their conditions this legislation exceeds the f d a which we've heard is the standard in other areas where there isn't any there's really parity only for in network services and in two thousand and six the congressional research service indicated that because of medical management there was little impact little adverse impact on the federal health plans in terms of access and quality and cost because of the parity programs work coupled with medical management plans offered to federal employees so i think this is an important men it's one that i think will ensure that as we've agreed parity should move ahead as parity moves ahead that it moves ahead in the right way so that the appropriate and necessary services are provided and i would urge support for the amendment what you said and i want the hearing record of the markup record to be very clear about our thinking on this amendment benefit management is contemplated under the language of the bill is part of present law so we don't as a rule restate what is already present law one might say well what's the harm of that or the potential harm here is that we're creating possibly an appearance when the statute is subsequently interpreted that a different level of benefit management would be allowed for mental health benefits than other benefits because we specifically know it relative to mental health benefits and we don't know that relative to and of any other benefits we contemplate that benefit management will proceed on both sides of the ledger and as it does today as a fully allowed by today's law so you don't need to create the subsequent interpretive confusion that could exist by adding this language we do anticipate there will be benefit management of mental health benefits as already allowed thank you mr chairman i yield back further i recognize the author of close well i appreciate that and let me say to those of you that say that this medical management is a necessary to protect medical management programs we've already seen where one state has restricted the use of utilization review on certain treatments and not to put my colleague to my right and in a difficult situation but the state of pennsylvania restricts the use of utilization review and drug and alcohol treatment services so i think by requiring medical management  fact a a definitive statement by the as of us here at the federal level that we insist upon having these types of management practices and determination of the legislation that we're considering in my view actually exceeds what is required under the federal employee health benefits program where parity is required only for services on an in network basis and so again i would i would urge adoption of the amendment if there were no further discussion the vote would occur on the amendment and all those in favor please signify by saying i know suppose when those appear to have it like this mr chairman the amendment i'm offering is the text of the senate bill drafted within the internal revenue code the senate really has worked closely with the mental health community to carefully craft a compromise that has overwhelming bipartisan support and passed the senate unanimously last night the idea of mental health parity has been something the congress has been grappling with for years we finally have an opportunity to approve legislation in a bipartisan way that provides for equity for mental health and substance abuse treatments but that's not what we're doing today instead this committee is poised to pass a bill that risks jeopardizing medical care for every american by rejecting provisions to protect the management of mental health services and including including unreasonable mandates in this bill i fear that we will be forcing employers either accept significant cost or stop offering mental health services altogether adopting this amendment will show that most will show mental health groups employer's health insurers and most importantly millions of americans suffering from mental illnesses and substance abuse disorders that we stand ready to quickly finalize bipartisan mental health parity legislation that enjoys as i said widespread support throughout the community mr m said thank you mr chairman sharon i oppose this moment by a by a good friend from michigan let me lay out several reasons first the lack of coverage for all clinically significant disorders by the way i  save as chairman and in good natured jesting that i've never heard the senate paid higher respect and more deference by any two years i've been in the united states congress today what is a need all deferent stay in the ways and means committee but it is unusual and i certainly understand and don't say that by way of criticism with good humor but let me lay out some reasons the lack of coverage for all clinically significant disorders the senate bill essentially codified discrimination by diagnosis it allows plans to use arbitrary nonscientific criteria to determine which mental illness is which addictive disorders will cover now we saw we heard kitty weston sit in that chair right there we heard her tell about the project death of little anna weston because that insurance plan eliminated eating disorder and her daughter as a result die so eloquently said at our hearing that decision has been deadly for thousands of young americans thousands of young americans the hospital on the other hand covers all disorders and the scientifically accepted widely used d m for we as has been said today the manual used by medical professionals for diagnosing and classifying mental disorders the same protection we get as members of congress or other federal employees medicare medicaid  just to name a few why not these good hardworking americans and health plans who by the way if you're close to these people and i'm sure everybody on this committee is and you hear from them at the time of crisis when their daughter been eating disorder and they call us say well we thought we were covered and we're not covered we don't have the money the thousands of dollars well think of those people here today as we vote also we allowing the plans the so called flexibility to cover whatever mental illnesses they choose that's all that does is result in cost shifting to the federal government a recent study by sampson found that private insurance payments for addiction services accounted for only nine percent of substance use disorder spending and twenty four percent of total mental health spending while the public sector paid for ninety one percent of chemical dependency treatment and fifty eight percent of mental health spending during the same period so clearly private plans are shifting the cost of the tax payers to the federal government and not adequately covering these illnesses finally mr chairman i oppose the camp amendment the senate bill because it lacks disclosure of medical necessity terminations people with addiction people with mental illness often lack information about their plans definition of what's medically necessary care they're unable to receive this definition from the plan administr now arista plans are required to make this information available to their participants but it isn't enforced we know it's not enforced out there in the real world so that some providers cannot access this information prior to contracting with the plan so there are too many dis the sept of and misleading insurance practices and the senate bill would institutionalize i dare say would institutionalize many deceptive and misleading practices and perpetuate the lack of clarity and benefit description of the senate bill is not true parity the senate bill continues to allow discrimination because of treatment of mental illness and chemical dependency visa be surgical e my opposition could be half as eloquent as a friend from minnesota so i would ask my colleagues to oppose the amendment and recognize its author nation again mr chairman i would just say that this legislation mandates benefits and mandates that employers and insurers cover all conditions listed in the d s m four which includes jet lag caffeine addiction phase of life problems but doesn't give the tool of medical management  two private insurers to manage that your house bill also mandates plans employers must provide out of network medical men and mental health benefits if they provide out of network services for other medical and surgical services but none of this is provided in the senate bill this is the third congress that this legislation's been introduced and really hasn't gone anywhere and i think this bill as it's written isn't going to go much further than the house i think the senate has been fairly clear about the direction they'd like to see the bill go and have very much unanimous support in terms of moving that forward so i guess the issue is is this something that people are personally invested in or do they really want to move the issue of mental health parity forward in a real way and i think i think if we want to move the issue of mental health  forward in a real way and i guess i would say yeah this is probably a rare opportunity to praise the senate because they work things out in a bipartisan way something as simple as the effective date the senate bill was able to move forward to give insurers at least a year to adjust to these new changes these have significant costs associated with them and i think the goal clearly for all of us is to try to extend mental health parity where it doesn't exist this is a major step forward and either bill would be a major step forward and i think that clearly the senate bill is one that we could mary question and it's consent to be recorded on the votes that i previously missed that would not change the outcome of the votes as i understand without objection and so do i need to have those votes repeated or and will i be able to how do we make sure that on the record i am we were just the clerk to consult with you and see that you recorded it as you would choose thank you and  the question is on the amendment in the nature of a substitute and all those in favor please say i those opposed to the pin you the chair the eyes have of the amendments agreed to before i and the rest of our staff for the work on this bill and to mention that joy on the minority staff is leaving tomorrow for her wedding and we wish her the best wishes for that and with that i'd reckon as to doget mr chairman first i don't believe we've done it previously but i'd like to recognize our colleague patrick kennedy who's here  d to salute him and our colleagues as we already have jim ramstad for their leadership this is an important day in moving forward towards equity for those who suffer from  a report ten years the bill is reported favorably in the bill will be reported to the full committee all members will have two days to file an additional views and without objection the staff is authorized to make a technical correction i want to thank my colleagues of the staff for their cooperation this morning and the markup