Stigma and Public Support for Insurance Parity and Government Spending on Mental Health: Findings from a 2013 National Opinion Survey

Abstract

Objective

The goal of this study is to gauge current attitudes among Americans about policies to: (1) require insurance parity for mental health, drug and alcohol abuse benefits and (2) increase government spending on mental health treatment.

Methods

A web-based public opinion survey (N=1,517) was conducted with a national sample of Americans, and examined how respondents’ socio-economic characteristics, political predispositions, personal experience, and attitudes toward persons with mental illness were associated with policy support.

Results

Sixty-nine percent of Americans supported insurance parity and 59 percent supported increasing government spending on mental health. Democrats were more supportive than Republicans or Independents. Personal experience was associated with higher support, and those expressing stigma in their attitudes toward persons with mental illness were less supportive of both policies.

Conclusions

Most Americans favored policies to expand insurance and funding for mental health treatment, but stigma was associated with lower support for both policies. This finding reinforces the importance developing robust anti-stigma efforts, particularly in an era when mental illness is increasingly linked to dangerousness in news media portrayals.

INTRODUCTION

Current policy initiatives being implemented under the Affordable Care Act (ACA) extend health insurance to approximately four million previously uninsured persons with serious mental illness (1) and many more individuals with other mental health, alcohol, and drug problems. One provision of the ACA expands the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity (MHPAE) Act of 2008 to the new health insurance exchanges. The intent of the law as it was originally enacted was to require group commercial insurers that offered coverage for mental health and substance use services to provide it at a level equivalent to other medical services. One major change under the ACA was to extend insurance parity to the individual and small group market, and to mandate that insurers comply with an essential health benefit requirement that includes provision of mental health and substance use disorder coverage at parity.(2) In addition, state Medicaid expansions will newly insure low-income groups and substantially increase the role of government in funding mental health care.(2) These policy changes have been accompanied by heightened attention to questions about the adequacy of funding for mental health treatment in the wake of multiple mass shootings in recent years where shooters appeared to suffer from a mental health disorder.(3)

Despite this flurry of attention to mental health policy, we know surprisingly little about Americans’ support for policies aimed at improving access to mental health care. One prior paper, published by Hanson in 1998,(4) provided an in depth review of public opinion about mental health insurance coverage. This paper compiled and analyzed questions asked by polling firms in the period (1989–1994) leading up to the universal health insurance debate during the Clinton Presidency. This study found relatively high support for inclusion of mental health services within a mandatory benefit package; however, data reported are nearly two decades old, and limited in important respects. Most notably, the study relied on data collected by polling firms where key survey methodology details are not disclosed (e.g., sample size, response rate). Another study conducted using 1996 data, found that support for increasing government spending on mental health treatment was dependent on a respondent’s group identification with persons with mental illness. Almost two decades have elapsed since these data were collected, and it is important to understand whether personal experience continues to play a role in determining attitudes about the appropriate role of government in funding mental health services in the current political environment.

To fill this research gap, we conducted a national public opinion survey in January 2013 to gauge current public attitudes about support for insurance parity and increased government spending on mental health treatment (N=1,517). We examined how socio-demographic characteristics and political partisanship influence support for these policies. We hypothesized that personal experience with mental illness would be associated with support for both policies, and that stigmatizing views about persons with mental illness would be associated with lower levels of policy support.

METHODS

We conducted a national public opinion survey of adults ages 18+ between January 2–14, 2013 (N=1,517). The web-based survey was fielded using the survey research firm GfK Knowledge Networks (GfK). GfK has recruited a probability-based online panel of 50,000 adult members, including persons living in cell phone-only households, using equal probability sampling with a sample frame of residential addresses covering 97% of U.S. households. The survey was pilot-tested December 28–31, 2012. Order of the survey items was randomized. To avoid priming, respondents were asked to answer “some questions about public affairs.” The survey completion rate, defined as the proportion of GfK panel members randomly selected for this study who completed the survey, was 70%. The GfK panel used probability sampling at the first stage of recruitment when individuals are approached to participate in the panel, and the panel recruitment rate was 16.6%. To make estimates representative of the U.S. population, all analyses used survey weights adjusting the sample for known selection deviations and survey nonresponse.

Dependent variables were support for: insurance parity and increased government spending on mental health treatment. For insurance parity, using a 5-point Likert scale we asked respondents: [D]o you favor or oppose requiring insurance companies to offer benefits for mental health and drug and alcohol abuse services that are equivalent to benefits for other medical services? Response categories were: 1=strongly oppose, 2=somewhat oppose, 3=neither favor nor oppose, 4=somewhat favor, 5=strongly favor. For government spending, using a 5-point Likert scale we asked respondents: [W]ould you like to see more or less government spending on mental health treatment? Response categories were: 1=spend much less, 2=spend less, 3=spend the same as now, 4=spend more, 5=spend much more.

Socio-demographic characteristics included respondents’ gender, age, highest level of education completed, race, household income, region of the country, and work status. Respondent political party affiliations were Republican, Independent, or Democrat. Respondents were defined as having personal experience with mental illness or substance use if they reported that they themselves, an immediate family member or another relative or close friend had been hospitalized, in counseling, or received prescription medication to treat a mental health, drug or alcohol abuse problem. We constructed a stigma scale based on the responses on 5-point Likert scales to four questions: “Do you agree or disagree that locating a group home or apartment for people with mental illness in a residential neighborhood endangers local residents”; “Do you agree or disagree that people with serious mental illness are, by far, more dangerous than the general public”; “Would you be willing or unwilling to have a person with a serious mental illness work closely with you on a job”; and “Would you be willing or unwilling to have a person with a serious mental illness as a neighbor?” The first two measures related to dangerousness come from a public opinion study conducted about attitudes toward persons with mental illness under the Robert Wood Johnson Foundation Program on Chronic Mental Illness.(5) The last two measures on social distance come from items include in the mental illness module of the General Social Survey.(6) The Cronbach’s alpha was 0.77 suggesting that the items formed a reliable scale, so we included this scaled stigma measure – ranging from 1 (low stigma) to 5 (high stigma) – in analyses to examine how stigma attitudes are associated with support for the two policies.

We estimated ordered logit regression models to examine the associations between support for the policies and respondents’ socio-demographic characteristics, political affiliation, person experience with mental illness, and stigmatizing attitudes. Results were consistent when we collapsed the ordinal scales into dichotomous dependent variables and re-estimated the models using logistic regression (see Reviewer Technical Appendix). All analyses incorporated survey weights to produce nationally representative estimates by accounting for panel selection deviations, panel non-response and attrition, and survey-specific non-response.

RESULTS

Sixty-nine percent of Americans favored insurance parity and 59 percent supported more government spending on mental health treatment. Fifty percent of respondents had personal experience with mental illness or substance use. The average stigma score across respondents was 3.1±0.02. Insurance parity was favored significantly more by older adults and by those with more education compared with other age groups (Table 1). Older, better educated, and female respondents were more likely to support increased government spending on mental health treatment. Democrats were more supportive of both insurance parity and increased spending than Republicans or Independents. Having personal experience with mental illness was associated with significantly higher levels of support for both policies. Finally, holding stigmatized attitudes toward people with mental illness was associated with significantly lower odds of supporting insurance parity (.71±0.06) or supporting increased government spending on mental health treatment (.76±.07).

Table 1.

Ordered Logit Regression Results on Americans’ Support for Policies Affecting Persons with Mental Illness, 2013

	Insurance Parity1 N=1,347		Government Spending on Mental Health Treatment2 N=1,343
	OR	SE	OR	SE
Male	.74	.10*	.82	.11
Age	1.01	.01†	1.01	.01†
Education (ref=less than high school)
High school degree	1.52	.41	1.35	.40
Some college	1.83	.51*	1.74	.53†
Bachelor’s degree or higher	2.06	.61*	2.47	.77**
Race/Ethnicity (ref=non-Hispanic white)
Black, non-Hispanic	.96	.22	1.65	.44†
Hispanic	1.20	.27	1.08	.25
Other, non-Hispanic	.69	.32	.73	.29
2 or more races, non-Hispanic	.78	.22	.65	.24
Household income (ref=<$10,000)
$10,000–24,999	1.27	.48	.86	.22
$25,000–49,000	1.28	.50	1.07	.41
$50,000–74,999	1.20	.46	.89	.33
$75,000+	1.09	.41	.82	.31
Health Insurance Coverage (ref=uninsured)
Insured	1.18	.28	1.12	.26
Region (ref= Northeast)
Midwest	.76	.15	.61	.13*
South	1.10	.62	.99	.20
West	.94	.19	1.30	.28
Work status (ref=paid work)
Self-employed	1.01	.37	1.15	.49
Temporarily laid off	.63	.44	.83	.66
Unemployed	1.23	.37	1.76	.49*
Retired	.70	.16	.71	.15
Not working – disabled	.75	.20	1.09	.34
Not working – other	.72	.23	.89	.32
Political party affiliation (ref=Democrat)
Independent	.71	.11*	.68	.11*
Republican	.53	.09***	.35	.06***
Personal experience with a mental illness or substance use disorder	2.00	.28***	2.29	.32***
Mental illness stigma scale	.71	.0.06***	.76	.07**

Note: GfK sample weights used in all models.

^†≤0.10;

^*≤0.05;

^**≤0.01;

^***≤0.001 from two-tailed tests

¹Attitudes about insurance parity were measured on a 5-point Likert scale (1=strongly oppose, 2=somewhat oppose, 3=neither favor nor oppose, 4=somewhat favor, 5=strongly favor)

²Attitudes about government spending on mental health treatment were measured on a 5-point Likert scale (1=spend much less, 2=spend less, 3=spend the same as now, 4=spend more, 5=spend much more)

DISCUSSION

Findings from this national survey indicate that Americans support two policy approaches to broadening access to treatment for persons with mental illness – insurance parity and increased government spending. Support for these policies was partly ideologically driven, with Democrats significantly more supportive than Republicans or Independents.

Public support for government spending was 10 percentage points lower than support for insurance parity. In keeping with research on attitudes about the role of government,(7) this finding is consistent with the idea that, for certain subgroups of Americans, policies involving a large government role in addressing social problems are inherently less attractive. Looking deeper, we find that those respondents who supported the insurance parity policy but did not support the increased government spending policy were significantly more likely to affiliate as Republicans compared with other respondents (p=0.004). One implication is that mental health policies that appear to rely on a strong role of government will be less attractive to some. Continuing erosion of levels of trust in government among the American public(8) speaks to the importance of developing a diverse set of policies engaging both the public and private sector to address the weaknesses of the current mental health delivery and financing system in the US.

We found that personal experience mattered in respondents’ attitudes with regard to both policies. Respondents with personal experience with mental illness – either their own or a close family member or friend’s – supported insurance parity and increased government funding for mental health treatment at significantly higher rates than those without such personal experience. The role of personal experience among respondents is consistent with the fact that the critical champions of these policies in Congress over the years such as Senators Pete Domenici and Paul Wellstone and Representatives and Patrick Kennedy and Jim Ramstad have attributed their own involvement to personal motivations.(9) Our finding is encouraging given that half of our national sample had some personal experience – either directly themselves or through someone close to them – with mental illness. However, while it is not possible to ascertain the precise clinical diagnoses of the people these respondents had interacted with, we would expect based on disease prevalence that most have personal experience with more prevalent conditions (e.g., anxiety or depression), and far fewer have personal experience with certain less prevalent severe and persistent mental illnesses such as schizophrenia, which occurs in about 1.1 percent of the U.S. adult population.(10) To the extent that people do not have personal experience with more disabling mental illnesses, they may in fact be just as susceptible to media portrayals – in particular, images linking mental illness to violence – as the general public. For example, we found no difference in the proportion of respondents reporting personal experience with mental illness agreeing that “people with serious mental illness are, by far, more dangerous than the general population” (45 percent) compared to those with no personal experience with mental illness (46 percent).

These findings should be considered in light of several limitations. First, our survey instrument did not gauge “willingness to pay” or support relative to other policy priorities for either policy option. Both questions could provide important additional information related to the strength of respondents’ attitudes. Second, web-based surveys have been criticized due to concerns about incomplete coverage and selection.(11) GfK attempts to minimize these issues by recruiting probability-based samples and providing web access to those without it.

Our finding that respondents with stigmatizing attitudes toward persons with mental illness were significantly less supportive of both policies reinforces the importance of developing and evaluating anti-stigma efforts. This is a critical moment to re-focus efforts on stigma reduction given the current political environment in which gun violence is increasingly linked to mental illness, and recent evidence that stigma toward those with serious mental illness – in particular, perceptions about dangerousness – is on the rise.(12–14)