Hillary Clinton
Credit: Gage Skidmore/Flickr

As Hillary Clinton campaigns for the presidency, she frequently invokes her well-known role in crafting her husband’s ill-fated 1993 health care plan, to demonstrate to progressives who remain uncertain about her ideological instincts that she has faithfully advocated for universal health care for more than two decades.

But it should also be remembered that as part of that effort, Clinton also pushed for broad reforms to how our nation treats—or mistreats—people with mental illness. It’s a cause she has championed for just as long.

Early on, as the leader of the Clinton administration’s health care task force, the first lady enlisted Tipper Gore, wife of Vice President Al Gore, to serve as its mental health adviser. Tipper, who had a master’s degree in psychology and had long been involved in mental health advocacy, due in part to her own bouts of depression, recommended a policy of “parity”—that is, that the government should require insurance plans to offer coverage on an equal basis to both physical and mental illness. Gore articulated the problem in simple terms: “Why should a woman with diabetes who needs insulin have it covered by insurance, whereas a woman with manic-depressive illness who needs lithium not be covered in the same way, when both diseases can be managed and controlled?”

At the time, Hillary Clinton agreed. “It’s a problem that permeates the whole system,” she said. “We have to do something. I don’t think there is a choice anymore.” Mental health practitioners and advocates were ecstatic. As Congressional Quarterly put it, “For the first time in history, they see a chance that mental illness will get the same insurance coverage as physical illnesses.”

As we all know, this entire effort came crashing down, due to industry and congressional opposition, as well as Hillary Clinton’s own miscalculations. The chastened first lady retreated from her push for health care reform—mental health reform included.

Or, at least, so it seemed. The full story is that, starting in the mid-1990s and continuing for the next two decades, Clinton kept up the fight, both in public and behind the scenes, for parity. And it paid off with a series of small-bore advances that—while there’s still a long way to go—have added up. That narrative sheds light on the continuing challenges presented by the parity issue, and usefully illustrates Clinton’s broader public philosophy—that is, that incremental reform is worth fighting for, and can produce real change over time.

Only two years after the defeat of the health care bill, President Bill Clinton signed, with Hillary’s backing and advocacy, the Mental Health Parity Act in 1996. That law was extremely limited in scope. It secured the same lifetime and annual dollar limits to mental health coverage as for coverage of medical and surgical benefits, but insurers found ways around it by restricting the number of hospital days and outpatient visits for mental health services. As liberal Senator Paul Wellstone, the bill’s cosponsor, put it at the time, “We didn’t even get half a loaf. We just got crumbs. But it’s a start.” And indeed it was; the law raised the profile of the parity issue and prompted states to experiment with parity laws of their own.

Three years later, Hillary and Tipper helped organize the first-ever White House Conference on Mental Health, which brought national attention to the nation’s neglect of the mentally ill—and to the cause of parity. “We must do whatever it takes not only to remove the stigma from mental illness, but to begin treating mental illness as the illness it is on a parity with other illnesses,” Hillary declared. At the same conference, the president announced an executive order providing mental health parity for 8.5 million federal employees, retirees, and their dependents covered by the federal government’s employee health benefits program. That coverage continues to this day.

By 2000, Hillary Clinton was running for the Senate from New York, and again making the case for parity to voters. “The mind is an organ just like the heart or the liver,” she told one woman on the campaign trail, “and I would like to advocate and work towards parity for coverage for mental illness.” Throughout her first term as senator, Clinton pushed for various mental health care reforms that would have impacted the treatment of mentally ill juveniles in the justice system.

At the core of Hillary’s plan will be a broad effort to tackle that same problem she discussed so long ago: the need for parity in our treatment of people with mental illness.

But it wasn’t until 2008 that she played a role in another, more significant advance on parity. In that year, she cosponsored the Mental Health Parity and Addiction Equity Act, which went much further than its 1996 predecessor by requiring employers with more than fifty employees to provide equal mental and physical benefits if employee insurance plans covered mental health treatments. While the law—which was signed by George W. Bush as part of the big bank bailout package—did not require mental health coverage, and did not apply to the individual insurance markets, it did lead most insurance companies to eliminate separate co-pays and reduce unequal limits on outpatient visits and inpatient stays.

That same year, Clinton ran for president behind a health care plan that featured mental health parity, along with coverage for substance abuse treatment. Though she lost the primary fight to Barack Obama, health reform finally became a reality in 2010, with the passage of the Affordable Care Act. That law brought still more parity reform: it mandated mental health coverage as part of required “essential benefits” packages for some small group plans and on the individual market.

Despite that progress, however, there’s still a long way to go. Insurers have found new ways to get around the parity mandates in the 2008 law and the ACA—by denying claims, for instance, based on their not being “medically necessary.” Federal and state enforcement has been lax. And, as the National Alliance on Mental Illness (NAMI) points out, Medicare and some Medicaid plans are not subject to the 2008 parity law, with the result that many Medicare and Medicaid beneficiaries find that mental coverage is lacking compared to physical coverage.

“Basically what we have now, thanks to all this incremental progress, is that the vast majority of Americans are now covered by federal parity law,” says Timothy Clement, the policy director of the advocacy organization Parity Track. “But we still have huge problems. The law is not adequately enforced, and very few people are aware that there even is a law. The result is that prevalence of mental illness is high and treatment seeking is low.”

Clinton has continued to talk about these and other problems on the stump during the current election cycle. And while she has not yet rolled out a comprehensive plan for overhauling the way our nation treats those with mental illness, campaign aides say she will soon. Her plan will include expanding access to mental health care, greater emphasis on early intervention (treating mental illness in early stages to reduce serious outbreaks later) and suicide prevention, and more investments in efforts to treat low-level offenders with mental illness rather than throwing them in jail.

But at the core of her plan, her aides say, will be a broad effort—once again—to tackle that same problem she discussed so long ago: the need for parity in our treatment of people with mental illness. Her proposals, one aide tells me, will be anchored by the “basic belief” that “mental health is a part of a person’s general health, and mental illness should be treated no differently from other medical conditions.”

It’s unclear whether Clinton’s proposals will end up being as ambitious as her campaign indicates. But advocates are cautiously optimistic that the Oval Office could soon be inhabited by someone who has demonstrated—for decades—an understanding of the need for a fundamental change in the way our society views mental health, one that treats it as fully equal to physical health. As Angela Kimball, NAMI’s director of advocacy and public policy, puts it, “We need a paradigm shift.”

If Clinton does become president, she may be in a position to finally get parity done and complete that paradigm shift. Or, at least, to get us a whole lot closer to completing it than ever before. The current Democratic primaries have been framed as a choice between a candidate with a bold vision (Bernie Sanders) and one promising only incremental reforms (Hillary Clinton). But in the case of mental health, at least, Clinton has revealed that she harbors a vision that is quite bold indeed, but, tempered by experience, she has also demonstrated the value of advancing incrementally toward it, one hard-fought step at a time.

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Greg Sargent

Greg Sargent writes the Plum Line blog for the Washington Post. He covered Hillary Clinton’s Senate years for the New York Observer and New York magazine.