Acting on an executive order issued by President Clinton, the federal government will offer its 9 million employees, beginning today, improved mental health benefits equal to those for physical ailments.
Federal officials' embrace of equal insurance protection for mental and physical illnesses represents a significant victory for mental health advocates, who have argued for more than a decade that the widespread practice of providing less coverage for mental disorders is discriminatory.
The new policy also offers further evidence that the notion of equality in coverage is gaining wider acceptance. More than half the states have laws that address such insurance disparities, and many large corporations provide equal coverage for their employees, believing that doing so saves money in the long run.
The notion of equal coverage, referred to as parity, was also endorsed by Vice President Al Gore and President-elect George W. Bush during the presidential race.
"There has been definite progress," said Jennifer Heffron, senior director of state affairs for the National Mental Health Association, a nonprofit group.
Yet Heffron, echoing the concerns of other mental health groups, said that despite such advances, true equal coverage, in its fullest sense, remains elusive. She said that many state laws included so many restrictions that they had little effect and that in some cases insurance companies had found other, more subtle ways to limit coverage for mental illness.
In offering equal coverage, federal officials hope to provide a model for employers around the United States. The initiative is also likely to be monitored closely by Congress, which will probably take up the parity issue in its next session.
Under guidelines developed by the federal Office of Personnel Management, private health plans for federal employees will no longer impose higher copayments or deductibles for mental health services, or set limits on outpatient visits or hospital days for mental disorders that are lower than those applied to general medical or surgical care. Treatment for alcohol and drug abuse will also be covered equally under the new policy.
Even a decade ago, equal coverage for mental illness seemed more a pipe dream than a practical possibility.
Opponents, including the insurance industry and business groups, warned that without limits on mental health coverage, the "worried well" would spend endless years on the couch and health care costs would spin out of control, forcing many employers to give up health insurance altogether.
Yet over the past 10 years, much has changed.
Increased understanding of the biological underpinnings of many mental disorders and the advent of better treatments have led to a greater acceptance of the idea that conditions such as manic depression and schizophrenia are illnesses like any other.
The cost-control strategies of managed care, in their infancy in 1990, are widely used. As a result, most insurance companies have been able to meet the requirements of parity laws while keeping cost increases at a minimum.
On Capitol Hill, lobbying by mental health groups - combined with the testimonials of celebrities such as the vice president's wife, Tipper Gore, who last year revealed her struggle with depression - has gained unprecedented attention and bipartisan support for psychiatric issues.
The 1996 Federal Mental Health Parity Act, banning dollar limits on mental health care that differ from those for general medical care, lacks the regulatory teeth to have much real effect. But the symbolic effect has led many state legislatures to address the issue.
And four states - Maryland, Minnesota, Connecticut and Vermont - have statutes that not only eliminate inequalities in reimbursements but also require employers to cover mental health, define mental illness broadly, include drug and alcohol addiction, and require small employers to comply.
Still, health care experts say the reality of parity, as translated by lawmakers and insurance companies, often bears little resemblance to the ideal envisioned by advocates. Some state statues, for example, contain so many loopholes that thousands of employees are not covered. Others limit coverage to specific illnesses. And even where parity legislation is broadest, some critics say, managed care has undercut the goal of equality.
In a comprehensive analysis of parity's effect submitted to Congress in June, the National Mental Health Advisory Council found that on average, parity increased total health insurance premiums by 1.4 percent - far less than the 10 percent or even 15 percent predicted by critics.