late health maintenance organizations (HMOs) as insurance entities and in terms of the practice of health care (See Table 2.1 in Chapter 2). There is little regulation, however, of insurance or medical care issues in managed behavioral health care companies. This issue will be discussed further in Chapter 6, Process, which includes a description of the accreditation process.

Coverage for behavioral health care continues to change. The history of coverage for alcoholism is a good example. Until relatively recently, most health insurance did not include coverage for alcoholism. In 1968, alcoholics were excluded from 60 percent of the general hospitals, and 40 percent of the Blue Cross and Blue Shield plans explicitly excluded coverage for alcoholism treatment (NIAAA, 1974). NIAAA advocated for the inclusion of alcoholism treatment as a benefit under health insurance and encouraged employers to support treatment for alcoholic employees (IOM, 1990a). The agency also contracted with the Joint Commission on Accreditation of Hospitals to develop accreditation standards for hospitals and specialty treatment services, supported counselor credentialing standards, and had Blue Cross and Blue Shield develop a model benefit package (Regan, 1981). Resistance to the inclusion of alcoholism treatment benefits in employer-sponsored health plans, however, was still strong.

Because a voluntary expansion of benefits appeared unlikely, states changed insurance regulations and laws to mandate coverage for alcoholism treatment in group health insurance plans (NIAAA, 1974; Scott et al., 1992). The first states to require coverage for inpatient alcoholism treatment were Wisconsin (in 1972), Illinois, Massachusetts, Minnesota, and Washington State (NIAAA, 1974; Scott et al., 1992). Massachusetts also required coverage for outpatient care. The National Association of Insurance Commissioners in 1981 adopted a model of benefits for alcoholism treatment —30 days of inpatient care and 30 outpatient visits per year (Scott et al., 1992). A 1991 review found that 41 states either require coverage (23 states) or require that coverage be offered (18 states); most of the states, however, have never altered the original benefit, so the value of the benefits may have eroded (Scott et al., 1992).

Although insurance mandates were an important policy strategy and stimulated the development of many private-sector alcoholism treatment services, health care financing and reimbursement systems evolved to better control the costs associated with alcoholism treatment. The Employee Retirement Income Security Act of 1974 (ERISA) exempts self-insured employers from state insurance mandates; thus, state insurance mandates have decreasing influence on the structure of health care. Employer-purchased managed care plans therefore may not need to be responsive to insurance mandates. As a result, managed care strat-