Laws since 1996 have sought to assure that coverage of behavioral health treatments does not take a back seat to physical medicine. Amid a national crisis in mental illness and addiction, that new world of equality has not arrived. But is it on the way?
If a reincarnated Charles Dickens were to describe the state of America’s mental health today, he might use only half of the paradoxical opening line of “A Tale of Two Cities.” He might call this “the worst of times” and leave it at that.
Beset by bitter political division, economic uncertainty, a threatened climate,the opioid crisis and the lingering effects of the COVID-19 pandemic, the United States is a tormented place in 2023. Among adolescents, reported depression nearly doubled from 2009 to 2019, from 8.1% to 15.8%, according to the National Survey on Drug Use and Health — and that was before the pandemic’s social distancing pushed people into isolation. COVID-19’s first year saw drug overdose deaths more than double among adolescent males.
As for adults, Gallup reports that as of last year, 29% had received a diagnosis of depression, nearly 10 percentage points above 2015’s figure; this year, the share of folks with depression increased by 7 points to 17.8%. Data from the Centers for Disease Control and Prevention show that the nation’s suicide rate (adjusted for age and population growth) rose 37% from 1999 to 2022; in 2021 there was a suicide every 11 minutes. The Kaiser Family Foundation (KFF) notes that suicides still may be undercounted, as “it can be difficult to determine whether drug overdoses are intentional.” Says KFF: “Increases in the number of suicide deaths follow high levels of mental health symptoms during COVID(-19), rising financial stressors, and long-standing difficulty accessing needed mental healthcare — particularly for some populations.” It is not a pretty picture.
This sad state of affairs cannot be fully blamed on either the providers of mental healthcare or the payers who fund it; many factors are responsible. But clearly there is a job that is not being done with full success. One root cause may be stigma. Getting help for a mental health problem is not as socially or professionally risky as it used to be. Politicians, sports stars and public figures of all types talk more freely about seeking help. Still, fear of discovery or repercussions — or people’s own denial — still keep many from seeking help. “You have to remember,” says Tim Clement, M.P.H., director of legislative development for the American Psychiatric Association, “we’ve been facing extreme headwinds in the form of prejudice.” Another reason is a provider shortage that makes it harder to find help once a person reaches out. But in the view of some provider organizations, some of the causes of that shortage circle right back to the stigma.
As far as health insurance coverage, mental — or “behavioral” — health has long been a stepchild, and treatment for addiction a stepchild even within it. Efforts have been underway for decades to achieve “parity,” a level playing field between mental and physical ills. Advocates’ goal is for insurers to act on the conviction that President Joe Biden voiced this summer: “I don’t know what the difference between breaking your arm and having a mental breakdown is. It’s health. There is no distinction.”
A tortuous path
Parity has a complex legislative and regulatory history. In 1961, at President John F. Kennedy’s request, the Federal Employees Health Benefits Program began, as Colleen L. Barry and co-authors wrote in The Milbank Quarterly in 2010, “to cover psychiatric illnesses at a level equivalent to general medical care.” But after that advance came retreats. Mental health benefits were scaled back until, by 1975, the Blue Cross Blue Shield High Option Plan was “the only plan remaining that provided parity-level psychiatric coverage.”
Drawing a swarm of high-cost subscribers, it too was permitted to cut back. The Mental Health Parity Act (MHPA) of 1996, sponsored by U.S. Sens. Pete Domenici, R-N.M., and Paul Wellstone, D-Minn., barred employer-sponsored group health plans with more than 50 employees from imposing stingier annual or lifetime coverage limits on mental health benefits than on medical or surgical ones. But tougher proposed measures had been discarded in the Senate-House conference committee; the final MHPA was a comparative Swiss cheese that did not address treatment limits, cost-sharing differences or, as Sarah Goodell wrote in Health Affairs in 2014, “the application of managed care techniques that continued to make coverage for mental health benefits less generous than coverage for other health benefits.”
Even the vaunted Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 — hailed by consumer advocates because it forbade mental-physical distinctions in treatment limits, as well as cost sharing and in- and out-of-network coverage and also for the first time included substance use disorders — did not actually require health plans to offer mental health benefits or cover specific conditions. But a co-sponsor, former U.S. Rep. Patrick Kennedy, D-R.I., marveled nevertheless at the confluence of political events that allowed passage of the law, noting that its projected cost of $3.4 billion over 10 years was dwarfed at the time by a far costlier rider attached to it — the Troubled Asset Relief Program designed to rescue the endangered economy at a possible cost of $700 billion over 10 months.
“For anyone to claim credit for this would be an insult to the fates,” wrote Kennedy in “A Common Struggle,” his 2015 memoir. “It was a miracle.”
The fates got a further assist, though, when in 2010 the Patient Protection and Affordable Care Act extended the parity requirement from large-group plans to small-group and individual coverage and identified behavioral healthcare as an essential health benefit. State parity requirements also were enacted over the years, and legislation and regulation have continued to try to tweak true parity into being. New rules proposed by the Biden administration this July would require insurers to do an analysis of the outcomes of coverage to ensure full and meaningful compliance, evaluating provider networks, prior authorization rates and out-of-network-provider payments.
In remarks delivered on July 25, 2023, the president lauded the MHPAEA and the progress made during the Obama administration toward its full enforcement but added that work remains. “We must fulfill the promise of true mental health parity,” he declared. “Insurers still make it far too difficult to get mental healthcare. Their networks of providers are badly inadequate. … And as a result, even with private insurance, patients are often forced to seek out-of-network care at significantly higher costs, if they can find it.” Domestic policy adviser Neera Tanden added that in 2020, “less than half of Americans with mental health needs receive(d) the mental healthcare they needed most. And too many Americans struggle to get that care covered. It’s not supposed to be this way.”
AHIP, the health insurance industry’s trade group, replied to “these significant new proposals” mostly with safe sentiments, agreeing that “everyone deserves access to mental healthcare, and that access should be on par with physical health.” AHIP cited “a shortage and lack of clinicians” as a reason why access to mental healthcare has been “challenging,” citing a study showing that the number of private insurance claims for behavioral healthcare services had increased by 108% from 2007 to 2017, proof that “more people are getting treatment.”
Lynn Bufka, Ph.D., associate chief, practice transformation, of the American Psychological Association, lists two causes for the provider shortage: pay and red tape. She says there has been “an exodus from payment networks by psychologists and other providers in large part because of low reimbursement and administrative hassles.” Psychologists in private practice need to pay off their student loans, she says. “If we want people to use their insurance for mental healthcare, we need to pay providers what they’re worth.”
Bufka believes that “we’re not quite there yet” in terms of actual parity, and Clement agrees. A mental health policy expert who once worked for
Kennedy, Clement says we know progress is incomplete because of what federal and state regulators have found in evaluating health plans’ compliance with parity rules. “Every single investigation over the last five years has found violations in every insurer that they’ve looked at,” he says. “That’s not to say that employers and health plans haven’t been getting better. They certainly have. It’s just that there’s still a ways to go.”
A passionate spokesman
Kennedy’s 2015 book chronicled both the struggle to achieve parity legislation and his own personal battle with bipolar disorder and addiction to alcohol and drugs. He remains a fierce advocate for behavioral health treatment, one who sees the concept of parity as a useful prod to further reform. He plugs his Kennedy Forum website, alignmentforprogress.org, as a tool in that effort.
The “beauty” of 2008’s MHPAEA, says Kennedy, was that it “really framed the problem of mental health and addiction care, which was that it was siloed and separate and apart from the rest of the house of medicine.” In his view, however, that landmark law and its recent successors have been a cue to go further. If mental health were given the same proactive model of care that is now applied sometimes to cancer or cardiovascular illness, he says, we would see not only better health for more people but potential savings as well. Because data drive healthcare these days, he calls for more data to inform that effort.
“We all know that less than 20% of the population eats up over 80% of the healthcare dollar,” says Kennedy. “I guarantee you that that 20% has mental health and addiction comorbidities that are not treated as part of their holistic care. There are cancer patients who aren’t compliant because of their depression, cardiac disease patients who aren’t improving because of their depression, and diabetes patients who are not getting well because of their underlying, undiagnosed alcoholism.”
If AHIP “had any sense in the last decade,” Kennedy continues, it would have taken some of the “oodles of money” the industry takes in and “put a little bit of it aside to come up with new payment models, reimbursement models and a structure to pay for a larger percentage of premium going into mental health than the 4% that goes into it today.”
It will not happen, Kennedy says, until it must happen — until not providing true parity becomes as unthinkable as selling a car without seat belts.
“There’s no liability on the insurance side (prompting people) to do the right thing because they’re not losing market share. Good people, many friends of mine who work in the insurance field, are caught in a system that in itself is designed to undermine mental health and addiction care,” he says. “The incentives are not to cover early. Why? Because insurance companies have to deal with the bottom line quarterly and annually; they can’t invest in evidence-based interventions that we know have a big return, because those things come over a series of years.”
Parity for a new age
New payment models that are changing the entire healthcare industry need to be fairly applied to behavioral health, Kennedy argues. “The fundamental frame of parity is as relevant as ever,” he says. “But we’re going to need to really modernize parity for it to effectively apply to the new world of value-based contracting. You have ACO (accountable care organization) models of value-based contracting in the rest of physical care. Why don’t we have it in mental health? Because CMMI (Center for Medicare and Medicaid Innovation) has never done a demonstration on mental health.”
So, is this a good news-bad news joke in which true parity can be achieved, but only when all of healthcare delivery is transformed? No, insists Clement. Asked whether true parity is even possible, he replies: “Absolutely. Right now,” he insists, “it’s just the will of the insurers and the health plans” that stand in the way. In terms of things like prior authorization, concurrent review, and how networks are designed and maintained, plans could institute parity if they chose.
“I used to work for Patrick (Kennedy), and I understand what he’s saying about upstream things,” Clement says. “But when we’re talking about the concept of mental health parity, it’s very narrowly focused on insurance coverage.”
Clement has worked closely with state regulators, he says, and new findings not yet published (with specifics he says he therefore cannot disclose) show that “in some states insurers have achieved parity.” In general, smaller health plans have been more effective at this than larger plans, he says, which is logical because they have a smaller universe of factors to control but also surprising because the “multibillion-dollar behemoths” have more resources for the task.
Some health plans have requested more clarity on how to respond to new parity regulations, says Clement. “But there’s enough clarity out there already so that if insurers and health plans really wanted for mental illness and substance use disorders to be on par with medical and surgical, they could do it. It’s not an impossible white whale.” Plans that have embraced parity have worked with regulators, he says, “because they wanted to. Rather than saying, ‘You’re not giving us enough guidance,’ they’ve said, ‘This is what we’re thinking of doing to prove we’re in compliance — are we on the right track?’ ”
Indisputably it is a rough time for this country in many ways. But in past national crises —the 1930s Depression, for instance — heartbreak and diminished lives were not conceptualized as mental health problems. Clement, for one, does not hark back to any past golden age.He and the psychiatrists he represents are grateful that “it’s not like the bad old days, when you got 30 days of inpatient treatment and that was it. You got 20 outpatient visits and that was it. You were on your own after that." Fifteen years ago, he says, “the idea that substance use disorders would even be covered by insurance was anathema. Now, with the opioid epidemic, it would be unimaginable that you wouldn’t cover them.”
Will parity ever work perfectly? Clement says quest has already made a difference. Compared with 2008, when the MHPAEA was enacted, he says “things are a lot better today for people seeking mental healthcare. I don’t want that to get lost in the shuffle.” That Dickensian “best of times” for mental health? It would be hard to argue that it has arrived. But it turns out we can almost see it from here.
Timothy Kelley is an independent journalist in New York City