by Alison Mohr
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is one of the most impactful pieces of legislation in recent decades.
Enacted in 2008, MHPAEA was meant to ensure that individuals with a mental health or substance use condition would receive benefits equal to the medical/surgical benefits covered by their individual health plan. The law does not require plans to offer mental health or substance use disorder benefits, but if the plan does so, it must offer the benefits equally with the other medical and surgical benefits covered under the plan otherwise known as “parity”.
The Patient Protection and Affordable Care Act (ACA) requires marketplace plans to provide ten categories of Essential Health Benefits (EHB), which includes mental health and substance use conditions. Through the intersection of MHPAEA and the ACA, many health plans should offer mental health and substance use disorder benefits, creating a new group of individuals in the U.S. who could gain access to treatment if needed.
Yet, seven years later many individuals with health plans still have difficulty gaining access to treatment when it should be legally provided.
The issue of parity under MHPAEA focuses on individuals who have health insurance. Even if a plan covers mental health benefits there are often ways of limiting treatment. Before MHPAEA, insurers would place caps on the quantity of treatment, high copays, or separate deductibles for people seeking mental health treatment. Now some insurers will claim that a mental health visit is not “medically necessary” or require prior authorization to meet with mental health professional, which may not be required for other medical diagnoses.
According to the Department of Labor, to date, the U.S. government has not taken a single public enforcement action against an insurer or employer for violating the laws established through MHPAEA. 
Former Congressman Patrick Kennedy, who helped write the parity legislation, boiled down the government’s enforcement into two words: slow and sparse. Kennedy stated that the ACA took attention away from the newly implemented parity law, which resulted in little enforcement. Insurance companies were on coalitions that helped pass the ACA, which means that enforcing the parity law against the same companies could complicate political ties.
Mental Health America released a report highlighting the challenges faced in achieving true parity. The report found that among the 50 state benchmark plans*, 22 of the plans had quantitative limits on mental health services. Some plans guarantee more coverage than others, while some exclude certain services, like family or marital counseling or bereavement counseling, explicitly in their fine print. Further limitations exist on the type or severity of the condition that qualifies for treatment. Often exclusions occur for “non-biologically based” conditions or certain types of disorders like a learning disability or eating disorders.
Texas was ranked 47th on rates of access to mental health care and 44th on adults with any mental illness who received treatment. When we look at the numbers, it is hard to deny that Texans need the enforcement of MHPAEA for greater access to desired treatment.
Enforcement of current parity laws is both necessary and dire if we want to promote recovery and mental wellness both in Texas and across the country.
*A benchmark plan is a health plan selected by each state as a standard for other health plans. Any health plan that wants to be sold on the state’s health insurance marketplace must cover the same benefits as a benchmark plan, thought it may require higher deductibles and copayments. The benchmark plan is usually based on a typical health plan offered by a large employer in that state.
 National Alliance on Mental Illness. (2015). A Long Road Ahead: Achieving True Parity in Mental Health and Substance Use Care. Retrieved from https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/A-Long-Road-Ahead/2015-ALongRoadAhead.pdf
 Gold, Jenny. (2015). Health Insurers Face Little Enforcement of Federal Mental Health Parity Law. Retrieved from http://www.wbur.org/npr/427464632/health-insurers-flout-federal-parity-law-for-mental-health-coverage
 Mental Health America. (2015). Parity or Disparity: The State of Mental Health in America. Retrieved from http://www.mentalhealthamerica.net/sites/default/files/Parity%20or%20Disparity%202015%20Report.pdf
by Alison Mohr
When in D.C., do as the Washingtonians do: eat, sleep, and drink public policy!
Last month the Hogg Policy Fellows had the opportunity to participate in the Hogg Foundation Federal Policy Institute in Washington, D.C. It was a week-long immersion in federal mental health policy. The Hogg Fellows primarily focus on mental health policy change in Texas, so this week was a welcomed break from the norm. The fellows spent five days engaged in conversations with key stakeholders and policymakers in the field.
The Hogg Fellows met with leaders from both national advocacy organizations and federal agencies related to mental health. Notable presentations included: National Association of County Behavioral Health and Developmental Disability Directors; University of Maryland School of Medicine – Department of Psychiatry; National Association of State Mental Health Program Directors; Bazelon Center for Mental Health Law; National Council for Behavioral Health; The Kennedy Forum; National Association of State Medicaid Directors; Mental Health America; the Assistant Secretary for Planning and Evaluation – U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services Administration; National Institute of Mental Health; and the National Alliance on Mental Illness.
There were several recurring topics, including Medicaid and its role in accessing behavioral health treatment and services, the history of mental health policy in the United States, and cutting-edge research related to recovery. Conversations around the Affordable Care Act (ACA) and the Mental Health and Addiction Equity Act of 2008 zeroed in on existing barriers to treatment. Lastly, the fellows learned more about proposed legislation, such as Congressman Tim Murphy’s Helping Families in Mental Health Crisis Act, and its implications for the nation’s mental health system.
The Hogg Fellows left D.C. with a greater understanding of mental health policy at the federal level and how it impacts Texans experiencing a mental health condition.
Even in an increasingly secular society, faith leaders play a large role in the lives of millions of people. In African American communities in particular, there are many who will discuss their problems with their pastors before ever stepping foot in a therapist’s office. For this reason, the Hogg Foundation and others have begun to recognize the invaluable role that faith community leaders can play as both conduits of useful information as well as facilitators of conversation around mental health issues. But what about faith leaders who have their own lived experience of mental illness?
In this episode of Into the Fold, Pastor A.J. Quinton of Diakonos Ministries in Austin, Texas opens up about his own recovery from mental illness, a journey that included multiple suicide attempts and a diagnosis of bipolar disorder, and dispels the myth that pastors can only be useful by maintaining a stoic facade that denies their own vulnerable humanity:
“This is my journey; I am no different from anyone else, and to be able to make that plain to everybody around me sort of allowed some of that pressure to come off,” said Quinton about the benefits of disclosing his own struggles with mental illness. He then adds pointedly, “Number two, if God still loves me I’m really not overly concerned about whether you do or not.”
“Pastor Q” first entered the Hogg Foundation fold several years ago as a member of the Austin Area African American Behavioral Health Network. Since that time, he has emerged as a powerful voice in favor of judicious self-disclosure for black religious leaders. He also demonstrates how faith in a higher power does not preclude self-advocacy or personal responsibility, but in fact reinforces them.
Want to hear more? Download this episode on iTunes U!
The Hogg Foundation for Mental Health has selected Shannon Johnson, a doctoral candidate in the School of Social Work at The University of Texas at Austin, as the 2015 recipient of the Harry E. and Bernice M. Moore Fellowship. Johnson was awarded $20,000 to complete her dissertation research.
Since its establishment in 1995, the Harry E. and Bernice M. Moore Fellowship has been awarded to students from The University of Texas at Austin to complete a dissertation on the human experience in crises resulting from natural or other major disasters or, in a broader sense, stress and adversity.
Johnson’s dissertation is titled, “A Sequential Exploratory Mixed Methods Study of Post-Homicide Spiritual Change.” The dissertation is a study of post-traumatic spirituality in the lives of homicide survivors — i.e. the loved ones of homicide victims. Johnson believes that her work will yield greater insights into the unique experiences of homicide survivors, and that a deeper understanding of spiritual change among practitioners will lead to more effective interventions.
“The Moore Fellowship’s namesake, Harry E. Moore, had an abiding interest in advancing public understanding of human adversity,” said Dr. Octavio N. Martinez, Jr., executive director of the Hogg Foundation. “At the same time, the Hogg Foundation has an interest in furthering research that results in more effective mental health interventions. Shannon Johnson’s dissertation speaks to both of those concerns.”
We spoke with Shannon Johnson about her research.
Tell us about yourself. At what point did you decide to pursue this particular line of research, and what influenced that decision?
I completed my undergraduate degree in psychology at Kenyon College in 2001, and my masters in social work (MSW) at the University of Michigan in 2008. I have always had a strong drive to help others and a particular interest in mental health, so I fell naturally into these disciplines. After finishing my MSW, I worked as an addictions and mental health counselor for several years. It was during this time that I developed an interest in trauma and spirituality. Many of my clients had experienced severe psychological traumas in their lives. I noticed that, among those who experienced dramatic growth in the process of recovery, spirituality seemed to be the force that was driving change. I was bothered that spirituality tended to be relegated to the 12-step realm and was not something that was systematically addressed in clinical interventions. My desire to enhance the effectiveness of interventions motivated me to engage in the scientific study of post-traumatic spiritual change.
Your dissertation is titled, “A Sequential Exploratory Mixed Methods Study of Post-Homicide Spiritual Change.” What questions are you trying to answer with this work?
The research question that guides my dissertation study is, what is the process of spiritual change in the lives of survivors of homicide victims. My dissertation consists of two phases. The methodology for Phase 1 is grounded theory, an inductive approach that I am using to generate a developing theory of post-homicide spiritual change. In Phase 2, I will use a survey methodology to test the theory that emerges in Phase 1.
What gap in the literature will be filled by your study? Who stands to benefit from it?
There are fairly decent literature bases pertaining to trauma and spirituality and to grief and spirituality. However, there is a complete lack of research looking at spirituality in the lives of homicide survivors. This study will provide much-needed insights into the individual experiences of homicide survivors, insights that can be used to enhance the sensitivity and effectiveness of services. By yielding a theory of the process of spiritual change after homicide, this study will also enable the development of an intervention that is specifically targeted to the homicide survivor population. Such an intervention is sorely needed and will be of benefit to the homicide survivor population.
How do you think your research methods and approach will help you to answer the questions that you’re posing?
Grounded theory is an inductive approach involving the generation of theory from data and is a natural fit for the purpose of this study. Grounded theory will be utilized first with a small sample of participants to develop the theory in Phase 1. Use of a survey methodology in a second phase of the research will enable the testing of the emerging theory among a larger sample. This mixed methods approach is superior to use of grounded theory alone, as it combines the best of both qualitative and quantitative approaches.
Are there any suggested readings you can recommend for those who might be interested in learning more about the topic of post-homicide spiritual change?
To my knowledge, there is no existing research that looks specifically at post-homicide spiritual change. However, I have found literature on post-traumatic growth to be very relevant. Spiritual change is considered a domain of post-traumatic growth, and the constructs overlap quite a bit. An article by Parappully and colleagues (2002)1 explores post-traumatic growth among parents of murdered children. It is highly relevant, and I would definitely recommend it. Armour (2003)2 conducted a great study on meaning-making among homicide survivors. Park (2005)3 provided important perspective on the role of religion and spirituality in meaning-making in general, while Wortmann and Park (2008)4 wrote a great piece on the role of religion and spirituality in the meaning-making among the bereaved specifically. A final article I would recommend is by Armour (2002)5. It provides an in-depth qualitative understanding of the post-homicide experience that I have not found elsewhere.
- Parappully, J., Rosenbaum, R., van den Daele, L., & Nzewi, E. (2002). Thriving after trauma: The experience of parents of murdered children. Journal of Humanistic Psychology, 42(1), 33-70.
- Armour, M. P. (2002). Journey of family members of homicide victims: A qualitative study of their posthomicide experience. American Journal of Orthopsychiatry, 72(3), 372-382.
- Park, C. L. (2005). Religion as a meaning‐making framework in coping with life stress. Journal of Social Issues, 61(4),707-729.
- Wortmann, J. H. & Park, C. L. (2008). Religion/spirituality and change in meaning after bereavement: qualitative evidence for the meaning making model. Journal of Loss and Trauma, 14(1),17-34.
- Armour, M. (2003). Meaning making in the aftermath of homicide. Death studies, 27(6), 519-540.
by Rick Ybarra
This blog post was co-authored by Susan Murphy, Graduate Research Assistant, Hogg Foundation for Mental Health.
The Hogg Foundation for Mental Health is proud to release our most recent evaluation summary report titled Building Evaluation Capacity Among Integrated Health Care Organizations. The report highlights the evaluation technical assistance provided to grantees who received funding to implement or enhance integrated health care within services within their organizations. The Hogg Foundation views program evaluation as a two-fold learning opportunity. Evaluation allows the foundation to assess the outcomes of its grant programs, contribute to professional literature, and promote policy and practice changes. It also promotes strategic learning for grantees to learn more about their own programs, develop evaluation capacity and expertise within their organizations, and provide important feedback for quality and performance improvement.
What did we learn that may benefit you as a funder or as a non-profit organization? We learned that:
- Providing technical assistance with a focus on evaluation is tremendously beneficial. Most non-profits don’t have line items in their budgets for program evaluation. And for those versed in program evaluation, this technical assistance can further the impact of their programs and services. Grantmakers for Effective Organizations (GEO) has highlighted evaluation capacity building as a strategic approach to addressing the lack of capacity for evaluation at many grantee organizations and for creating a sustainable evaluation practice – with the ultimate goal of furthering the impact of nonprofits!
- Increasing evaluation knowledge and skills is important to grantee organizations, and not just a priority of the foundation. The technical assistance provided was originally intended to be more general, but eventually became driven more exclusively towards evaluation as grantees expressed interest and need for support in this area.
- Although the technical assistance for the grantees was not initially exclusively dedicated to evaluation, the focus on building evaluation capacity was a learning process for both the foundation and the evaluation consultant. The brief highlights several lessons learned and recommendations for future efforts towards evaluation capacity building, both from a funder’s perspective and from a non-profit’s perspective.
- Grantees with limited resources and with limited evaluation knowledge prior to the project significantly enhanced their evaluation efforts and developed capacity and expertise, often coming up with innovative solutions to address issues related to limited resources to support evaluation efforts.
The outcomes of the grantees’ work demonstrated evaluation does not need to be approached with an “all or nothing” mentality. Making small changes and doing what you can with the resources you have can create meaningful impact toward future successes.
A thoughtful summary with lots of practical, real world lessons learned. Well worth the read!
And lastly, we’ve learned that “if you don’t know where you are going, any path can take you there.”
Lessons Learned From the East Texas Coalition for Mental Health Recovery: A Q&A With Stephany J. Bryan
by Ike Evans
What was the Hogg Foundation’s motivation for starting the East Texas Coalition for Mental Health Recovery grant program?
The primary motivation for starting this grant initiative was to promote recovery and wellness, and to develop an infrastructure of recovery-oriented services and supports in the East Texas corridor. As a consumer, my experience tells me that many people believe that recovery is not possible. As a foundation, we believe that recovery is possible.
Did any unexpected challenges arise over the course of this grant program?
Yes. The biggest challenge we faced regarding evaluation was the inability of the Local Mental Health Authorities (LMHAs) to collect valuable output data. The system these authorities used for reporting purposes was not capable of offering a data set that identified outcome measures for consumers who received peer support services.
What were the key findings from the ETCMHR evaluation that most stood out to you? Was there anything that came out of the evaluation that surprised you?
First, the key findings regarding the consumers: Recovery is possible. The success of the consumers is a direct result of recovery education and face-to-face positive interaction with their peers. Active involvement in a “recovery community” provided the knowledge, skills and confidence necessary to address any challenges and improve their overall quality of life.
Second, the key findings regarding the providers: It is crucial for the LMHAs to examine their own culture and recovery orientation by employing the Recovery Self-Assessment. To examine their own Recovery Self-Assessment allows for a baseline measure for gauging progress toward a true recovery orientation over the transformation.
What do you think other funders, mental health service providers, policy makers, and/or mental health consumers can learn from the ETCMHR experience?
- Recovery is possible.
- The value of providing recovery education across all disciplines and identity groups.
- To look closely at policies and procedures that limit a shift in the recovery orientation goals and advocate for positive change.
- The model of recovery education used in East Texas is a live model and forever changing.
As a program officer and consumer and family liaison, what do you think is the value of evaluation in your work?
Evaluation data is so valuable because it provides everyone with information that will help shape our decision making now and in the future!
by Rick Ybarra
While attending an annual grantee meeting this past week, I was struck by an insight that is often talked about but surprisingly little seen in the literature. Not only is it something I have seen time and time again, but it has been verified by colleagues who manage projects as well as by those on the ground who are implementing projects and programs. It is a key ingredient that distinguishes successful and sustainable implementation from that which stalls or fails to gain traction.
That ingredient is what I refer to as the “Secret Sauce.”
As a former health care provider who now works in health philanthropy, I can attest to the power of teams. Teams with a clear sense of mission and vision, working toward a common purpose, can accomplish great things!
In light of the health care transformations currently taking place, health care organizations and health care systems are seeking personnel with the right skill mix: experience, credentials, and ability to fit and grow into the new provider roles and functions. There is also fierce competition to hire skilled and credentialed health care professionals to fill immediate vacancies.
There is something else aside from the skill mix — a special ingredient that contributes to making good teams great teams!
Good teams form over time and develop into great teams. The great teams I am familiar with have an additional ingredient. They have the Secret Sauce. Their personalities become the glue or connective tissue as they work in their defined roles. People bring their personalities to the work they do. They figure out how to effectively work together and over time become a fully functional team. They work out a balance of nimbleness and keeping an eye on the goal and purpose. They accept defined roles while showing an ability to work in the space of each other’s “gray zones.” They uphold respect and dignity for all team members, from the physician to the care coordinator. They work off each other’s strengths and maximizing how to engage and interact with one another to achieve the desired result.
The results of this magical interplay for the persons and families the teams serve: better health outcomes, better consumer satisfaction, and maximizing cost efficiencies to reinvest savings into the health care system.
I don’t know if or how we can quantify the Secret Sauce. You just have to believe it exists. I’ve witnessed it. It’s what separates good from great.
The key question in my mind: is having all the key ingredients (positions, skills sets, etc.) enough to naturally bring about the Secret Sauce? Can the Secret Sauce be manufactured? Likely answer: sometimes yes, sometimes no. Something to ponder….