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Mental Health and Mental Illness: Mental Health Benefits Legislation


What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 30 studies reported in 37 papers (search period 1965 - March 2011). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to improving mental health and addressing mental illness.


In the United States, health insurance benefits for mental health services have been typically less than benefits for physical health services (American Psychological Association, 2010), resulting in potential financial burden for people with mental health conditions (Zuvekas et al., 1998).

A number of state and federal initiatives have aimed to address this issue by increasing parity for mental health coverage.

  • At the state level, forty-nine states and the District of Columbia (Cauchi et al., 2011) have enacted some type of mandate legislation.
  • At the federal level, the 1996 Mental Health Parity Act (Solis, 2012), the 2008 Mental Health Parity and Addiction Equity Act (Employee Benefits Security Administration, 2010), and the Affordable Care Act (Patient Protection and Affordable Care Act, 2010) have led to progressively stronger parity requirements.

Current provisions of the 2010 ACA require state Medicaid programs and insurance plans in state health insurance exchanges to cover both mental health and substance abuse as one of ten categories of essential health benefits.

Summary of Results

Results from the review showed favorable effects for the following outcomes.

  • Access to care: median increase of 13.6 percentage points (8 data points reported in 3 studies)
  • Financial protection: median decrease in out-of-pocket spending per user of 4.6 percentage points (7 data points reported in 2 studies)
  • Appropriate utilization of mental health services: in general, studies reported that mental health benefits legislation increased the following:
    • Visits to mental health specialists (3 data points reported in 3 studies)
    • Receipt of recommended medication, therapy, or treatment duration modeled on evidence-based findings or standard guidelines (6 data points reported in 2 studies)
    • Mental health visits for persons who need mental health care (5 data points reported in 5 studies)
  • Morbidity: the percentage of those in poor mental health decreased, as measured by the Mental Health Inventory Scale (poor mental health = MHI-5 score <67; 1 study)
    • In states that passed parity laws during the study period, there was a decrease of 3.2 percentage points in the proportion of people with poor mental health.
    • In states with parity laws, a smaller proportion of people had poor mental health compared to people in states without parity laws (2.8 percentage points difference).
  • Mortality: benefits legislation was associated with decreased suicide rates (2 studies)

Results were generally more favorable for comprehensive parity legislation than limited parity legislation (10 data points reported in 6 studies).

Summary of Economic Evidence

The economic review included 14 studies; 11 provided evidence on plan cost impacts and 3 provided evidence on other economic effects.

Change in cost to insurance plans was measured as a percentage of insurance premiums per person. Of the 11 studies that assessed the impact on plan costs, four were for the Federal Employee Health Benefits (FEHB) program, two were studies of state mandates, and five assessed plans of individual large employers.

  • One of the plans assessed in three of the FEHB studies showed benefits legislation led to a 0.23% increase in annual premiums.
  • In Oregon, all of the assessed plans had slight increases in their annual premiums; the highest was 0.60%. In Vermont, annual premiums for mental health and substance abuse decreased.
  • Two of the large employers reported premium increases of 0.29% and 1.04%.

In summary, expanding mental health benefits has not lead to substantial cost increases for health insurance plans, measured as a percentage of premiums. Evidence of other economic effects, such as business and employment-related outcomes was limited.


Results should be applicable to the insured population across the U.S., with some evidence for specific outcomes on children, low-income and low-education groups, and employees of small employers. MHBL does not apply to the uninsured population.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • There is limited research investigating the effects of mental health benefits legislation on mental health outcomes. Specifically, more studies are needed to assess effects on morbidity (reduction of symptoms, relapse prevention, remission, and recovery), mortality, and quality of life
  • Further research is needed to clarify the role of mental health benefits legislation in reducing health-related disparities and improving mental health outcomes among important population subgroups (e.g., low socioeconomic status [SES] groups, racial and ethnic minorities, and individuals diagnosed with different types of mental illness).
  • There is limited evidence for those covered by public health insurance (e.g., Medicaid and Medicare). Further research is needed in these populations to confirm the effectiveness of mental health benefits legislation in improving mental health.
  • Evaluations of the effects of the 2008 federal legislation, the Mental Health Parity and Addiction Parity Act, are needed as this law contains more requirements for parity than the earlier 1996 Mental Health Parity Act.
  • Evaluations of long-term (more than three years) effects of mental health benefits legislation are needed.
  • Researchers reported a utilization outcome that often combined measures of inpatient and outpatient utilization. The desired direction for these types of utilization differs with various patient conditions; reporting them separately will better indicate that patients are receiving appropriate care. Another challenge in mental health is the determination of whether care provided is evidence-based or guideline-concordant. In addition, most studies reporting any utilization lacked measures of appropriateness of use, such as descriptions of provider type and patient need for mental health care.

Study Characteristics

  • All of the included studies were conducted in the U.S.
  • Twenty-eight studies examined effects of state or federal mental health/substance abuse parity policies or legislation, and two examined effects of state-mandated coverage.
  • Six studies examined effects of comprehensive parity legislation or policies.
  • Most studies were conducted between 1990 and 2011 and used a nation-wide sample to examine effects of federal legislation or state mandates.