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Domenici's daughter was diagnosed with atypical schizophrenia, and Wellstone's brother was diagnosed with schizophrenia as well. Despite earlier failed attempts at parity legislation, the two were successful in introducing a parity bill as an amendment to Veterans Affairs, Housing and Urban Development (VA-HUD) appropriations legislation and in 1996, President Bill Clinton signed the Wellstone-Domenici Mental Health Parity Act (MHPA). The act prohibited large group health plans from placing annual and lifetime limitations on mental health care benefits. However, for the most part, the act benefitted only those persons with severe and persistent mental illness--those persons who would be most likely to have significant yearly and lifetime costs associated with their illnesses. The law was further limited in scope because it lacked a

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mandate for mental health benefits in health insurance plans, was applicable to those plans that already provided mental health care benefits, did not provide coverage for substance abuse treatment, had no rules for co-payments and deductibles, and was applicable only to businesses with more than 50 employees. Furthermore, businesses who did not offer mental health care benefits were exempt from the provisions of the Act, and the Act expired in 2001. Nevertheless, the Act was important shift toward parity (Barry, Huskamp, & Goldman, 2010).

As momentum toward parity at the federal level grew, states were also moving toward parity. As of November 30, 2000, 32 states had enacted mental health and/or substance abuse treatment parity laws of some type. Twenty-seven of these states enacted laws after the passage of the federal law, suggesting that the MHPA actually set in motion parity legislation of those individual states. Some states even enacted parity laws that were greater in scope than the MHPA.

At the federal level, there were repeated attempts to expand the mental health parity benefits to a greater percentage of the population in the late 1990's and early 2000's. However, until 2008, no further federal parity legislation was passed except for repeated extensions of the MHPA of 1996. Nonetheless, support for parity continued to grow. In 2002, President George W. Bush established the President's New Freedom Commission, whose charge it was to conduct a comprehensive review of existing mental health services and make recommendations for improvement. The New Freedom Commission report outlined six main goals intending to assist persons with mental illness on their road to recovery. Included was a goal to advance the "understanding that mental health is essential to overall health." The goal stressed the need to address mental and physical health care "with the same urgency" and more specifically, "the Commission strongly supports the President's call for Federal legislation to provide full parity between insurance coverage for mental health care and for physical health care" (p.21).

Concurrently, support for parity grew as academic research on the cost of mental health and substance abuse parity emerged, demonstrating that parity would not "break the bank." With considerable effort on the parts of Senators Domenici, Enzi, and Kennedy (Edward) and Congressmen Ramstad and Kennedy (Patrick), the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEQ) was approved as part of the Emergency

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Economic Stabilization Act of 2008. The Act closed many of the loopholes left by the expanded scope of the MHPA of 1996 and included substance use disorders. The provisions were still applicable only to businesses with 50 or more employees, and applied only to health plans that include both medical/surgical benefits and mental health benefits. However, it now prevented insurance companies from limiting mental health care by mandating that mental health care parity be expanded to include deductibles, co- payments, number of visits and days of coverage and out-of-network benefits. This landmark bill dramatically affected mental health care benefits for millions of people because, unlike the MHPA of 1996, the act applies to those in need of mental health treatment who do not reach the annual and lifetime limitations. Universal mental health care benefits (either physical or mental) were not addressed in the MHPAEQ.

Health Care Reform and the Patient Protection and Affordable Care Act of 2010 (PPACA)

Efforts to pass universal health care reform bills began as early as 1912 when Teddy Roosevelt campaigned for national health insurance (he lost to Woodrow Wilson). Presidents Truman, Kennedy, Carter and Clinton all supported universal health care (see