Low-income children's access to mental health care, mental health parity and patients' right to privacy are some of the issues on the APA Practice Organization's advocacy agenda for 2006.

Two large bills held over from last year-the 2006 budget reconciliation bill and Patriot Act reauthorization legislation-could affect the kind of mental health care that children receive under Medicaid, Medicare reimbursement for health practitioners and health records privacy. Congress is also considering a bill to promote mental health parity that the APA Practice Organization supports, as well as a health-care reform bill that the APA Practice Organization opposes.

"We will continue seeking opportunities in Congress to ensure patient access to high-quality psychological services through mental health parity and other forward-looking legislation," says Russ Newman, PhD, JD, APA's executive director for professional practice. "But we also recognize that we will need to continue challenging legislation that could be harmful to our patients and our profession."

Although some of these bills will go to a vote after the Monitor goes to press, the issues they raise will impact psychology in the future.

Medicaid and Medicare

The APA Practice Organization has advocated to prevent or at least substantially reduce budget cuts to Medicaid in the Budget Reconciliation Act.

The APA Practice Organization was concerned about language in the bill that could be interpreted to allow states to replace Medicaid's Early and Periodic Screening and Diagnostic Treatment (EPSDT) services with less comprehensive service under the State Children's Health Insurance Program (SCHIP). EPSDT entitles low-income children to comprehensive, periodic physical and mental health evaluations, as well as vision, hearing, dental and other screenings. If these screenings reveal problems, Medicaid pays for treatment.

SCHIP services generally do not provide the same level of coverage as EPSDT does-particularly for mental health care.

About 12 percent of Medicaid-covered children use mental health services, notes Richmond. Without the early intervention and comprehensive services that EPSDT provides, children with mental health problems could be more vulnerable to myriad physical and behavioral conditions, advocates say.

The APA Practice Organization's work with members of Congress to clarify vague language spurred Centers for Medicare and Medicaid Services (CMS)

Administrator Mark McClellan, MD, PhD, to issue an official statement last December confirming that children under age 19 would still be entitled to EPSDT benefits under the budget Reconciliation Act. CMS further stated that it would not approve any state plan that does not include this coverage.

Eleventh-hour efforts by the APA Practice Organization yielded a statement during the debate on the House floor by Joe Barton (R-Texas), chairman of a key health committee, clarifying that EPSDT services would be preserved under the new law. The reconciliation bill was approved on Feb. 1, and the president signed it into law a few days later.

In Medicare legislation developments, Congress inserted language last December into the Budget Reconciliation Act to address 2006 cuts for Medicare reimbursement rates for providers. Medicare annually sets new reimbursement rates using a number of factors, such as gross domestic product. The calculations for 2006 produced a rate that is 4.4 percent lower than 2005. However, the act incorporated a provision that would freeze the rates at their 2005 levels.

Diane Pedulla, JD, director of regulatory affairs for APA's Practice Directorate, notes that psychologists and other health professionals began to receive lower Medicare payments as of Jan. 1 when the scheduled cuts took effect. However, she says that when Congress approved the Budget Reconciliation Act, it included a provision blocking the 4.4 percent cutback, thereby restoring the higher payment rates. The APA Practice Organization and many other health-care associations will continue to oppose further cuts in Medicare reimbursement rates, she notes.

Mental health parity

The APA Practice Organization made progress last year on ending discrimination in private coverage of mental health benefits. This year, the APA Practice Organization will work to expand the Mental Health Parity Act of 1996 for all aspects of coverage. The law prevents insurance companies from imposing lifetime and annual dollar limits that differ from medical or surgical ones. Last year, the House reintroduced parity legislation. In October, the Practice Directorate and 250 other national organizations sent a letter to Congress asking that it pass the Paul Wellstone Equitable Health Treatment Act. Meanwhile, Sens. Pete Domenici (R-N.M.) and Ted Kennedy (D-Mass.) have been working to address business concerns before introducing their bill, expected early this year. The APA Practice Organization will work this year to see the legislation enacted.

Association health plans and health-care reform

In July, the House passed legislation that would encourage more businesses to enroll in Association Health Plans (AHPs), a class of insurance in which small business and professional groups band together to obtain medical coverage. The bill would exempt AHPs from state laws that protect consumers, including mental health parity and mandate laws.

Mental health advocates are concerned that once AHPs are no longer subject to these regulations, they will slash benefits-particularly mental health benefits. People who need these benefits could then be forced into plans at a higher cost. The APA Practice Organization has successfully stopped this legislation in the Senate for several years and will work to do so again this year. But a leading Senate bill would substantially expand the legislation beyond AHPs to preempt state laws for all smaller health plans. This would be a significant reform of the health-care system, says Doug Walter, JD, legal and regulatory counsel for APA's Practice Directorate.

"We are working closely with several other consumer and provider groups to beat this back and to make our case to Congress that strong state mental health laws need to remain in place," says Walter. The APA Practice Organization anticipates that this legislation will be a significant patient advocacy issue in 2006.

Patients' right to privacy

The Patriot Act, which is intended to aid law enforcement officials in investigating possible terrorist attacks, was set to expire at the end of 2005-leading to an effort in Congress to reauthorize the legislation. Mental health advocates saw this as an opportunity to press for improvements to a section of the act that gives law enforcement agencies access to business records, which potentially includes medical and mental health records.

Health-care professionals across the country, including the APA Practice Organization, advocated for stronger privacy protections, citing the fact that the right to privacy associated with patients' health-care treatment is well established, and is especially important for people who receive mental health treatment, because their records often contain highly sensitive information.

Both the Senate and the House voted for increased privacy protections. In July, the Senate approved a reauthorization that addressed many of the APA Practice Organization's concerns. Its version included a requirement that officials show reasonable grounds that the requested records are related to a terrorism investigation and that record owners be allowed to consult an attorney. The Senate bill also potentially restricts law enforcement access to those records, including mental health records, that are otherwise privileged under the law in court proceedings.

The House of Representatives passed a bill that, while still improving the Patriot Act, contained weaker privacy protections than the Senate version. The differing versions were debated in conference committees for months with no resolution. Before recessing for the end of the year, the House approved a five-week extension on the current. Negotiations remained in stalemate as of early February, when Congress passed another five-week extension to expire March 10.

In another matter concerning privacy, Congress is considering a national consolidated health information system. Mental health advocates are seeking to ensure that the system is both useful to appropriate information sharing and fully protective of the privacy of patient records. In particular, the Mental Health Liaison Group-which includes APA, the American Psychiatric Association and other mental health associations-has raised concerns with Congress that the Health Information Technology Promotion Act, a bill introduced in the House last fall, could erode patient privacy. While establishing a uniform health information system that would go in a nationwide electronic database, the bill proposes to preempt the stronger state laws that advocates successfully fought to establish under the federal Health Insurance Portability and Accountability Act. The group sent a letter to congressional leaders asking that any health information technology legislation enacted must not preempt stronger state laws absent strong federal privacy and security standards that replace them.

The privacy issues surrounding the Patriot Act and health information technology will be an important part of the APA Practice Organization's legislative agenda for 2006.

Look for updates on these legislative issues and others in future issues of the Monitor.