Vanderbilt Law Review

First Page



The two primary problems with providing health care in the United States are cost and access., The cost of health care rose dramatically during the 1970s and 1980s and continues to increase, making coset containment crucial to the availability of care. In addition, many Americans are either entirely without health insurance or are underinsured for catastrophic illness. While individually these two issues are important, equally problematic is the tension that exists between them. Providing greater access to additional services results either in a cost increase or the loss of other services. Ultimately, however, a general plan to contain costs can address the two issues simultaneously because the ability to contain costs can create greater access.

The issues of access and cost are particularly pronounced in insurance for mental health services. For those Americans with private insurance, most coverage is provided by employer-sponsored health plans. In these plans, mental health care is possibly the most common target of coverage limitations on services and illnesses.,' These limitations cap benefits for mental health care at far lower levels than those for traditional medical and surgical care. Both the need to keep premiums affordable and the perception that diagnosis and treatment of mental health is less reliable and effective than treatment of "regular" physical medical care are the primary reasons for the commonality of these limitations.

While commentators have advocated more equality in insurance coverage, the concept of parity between mental health coverage and other medical coverage in insurance plans did not gain national prominence until the 1990s, when the issue came to the forefront of legal scholarship. In addition, mental health parity finally had congressional allies on both sides of the aisle-most notably, Republican Senator Pete Domenici of Arizona. Recent parity efforts have focused on eliminating the use of mental illness limitations-primarily annual and lifetime monetary caps, durational inpatient and outpatient limits, coinsurance rates, and deductibles--that are set at lower levels than limitations on physical health care.