Mental health parity remains a challenge 10 years after landmark law

This week marks 10 years since the landmark bill, Mental Health Parity and Addiction Equity Act, was signed into law, signifying one of the single biggest achievements over the past decade in the fight to expand access to mental health and substance use disorder treatment services.

While some viewed the legislation at the time as the apex in a decades-long battle for equity in coverage for behavioral healthcare, advocates contend access to care for millions remains elusive.

"Unfortunately, we're still not taking serious mental illness as seriously as we need to," said John Snook, executive director for the Treatment Advocacy Center. "I think the realities around the costs that we incur are still not there when we're talking about covering those costs on the front end."

Chuck Ingoglia, senior vice president of policy and practice improvement for the National Council for Behavioral Health, said while the law is simple in its conceptualization that mental health and addiction treatment should be treated the same way as medical and surgical benefit, attempts to implement it has faced significant challenges.

At the heart of the problem has been a lack of consistency in the oversight and enforcement on the part of federal and state regulators to get insurers to comply with existing parity laws. Though enforcement largely falls on states, many of their laws are not robust, and varying their standards leave wide disparities.

Advocates feel much progress has been made in addressing and reducing some of the more obvious disparities in treatment. Some of those barriers to treatment have included placing stricter limits on the number of inpatient and outpatient mental health visits, separate prior authorization requirements than for medical care services, and separate deductibles and copays.

Angela Kimball, national director of advocacy and public policy for the National Alliance on Mental Illness, said many of these types of traditional barriers on mental health and substance use disorder treatment have been reduced or eliminated because of the Federal Parity Law. "What remained were much more subtle discriminatory practices," Kimball said.

Many of the barriers that still exist come from what are known as insurer non-quantitative treatment limitations, which Kimball said have kept patients from realizing the true intent of the Federal Parity Law.

Such limits include differences in how health plans enact utilization management and how they define medical necessity, separate deductibles and co-pays for mental and medical healthcare, limited behavioral healthcare services offered within their provider networks, and lower reimbursement for behavioral healthcare providers, to name a few.

The impact of such limits on access to mental healthcare has been significant. Behavioral health patients are four times more likely to go out of network to get care, which raises the cost for such services, according to a 2017 report by actuarial firm Milliman. The report found out-of-network providers provided 32% of behavioral outpatient care in 2015 compared to 6% of medical/surgical care in the same setting.

In terms of reimbursement, the Milliman report found behavioral healthcare providers were paid on average more than 20% less than primary care services and 17% less than the average paid for specialist services.

Ingoglia said he has just begun to think about possible ways to improve the federal statute in order to address the gaps in access to mental healthcare and substance use disorder treatment caused by non-quantitative treatment limits.

But the focus over the years has been on improving state oversight and enforcement of parity laws, which many see as facilitators of mental healthcare and substance use disorder treatment coverage parity protections. Evidence has found states lack consistent definitions on what constitutes mental health and substance use disorders, how they are covered by insurance, and how much effort should be given toward enforcing compliance.

"We see disparities in terms of states in their willingness to actually try and enforce that intent," Kimball said. Overall all but a handful of states have statutes in place that provide adequate protections for mental health and substance use disorder.

Such was the finding of a new report released this week by the organization ParityTrack, a group started by former U.S. Congressman and recognized mental health advocate Patrick Kennedy. The report tracked and examined parity laws in all 50 states and gave low marks for 43 while only giving high marks to one, Illinois.

In May Illinois passed legislation that has been touted as one of the toughest parity enforcement laws in the country, which expanded the type of health plans covered under parity requirements to include local, county, and school district health plans. All of those types of plans can opt out of compliance to the Federal Parity Law.

Paul Gionfriddo, president and CEO of Mental Health America, said the federal government had a role to play in helping to create a more uniformed expectation for parity compliance for all states.

"Even though the states really have the roles to regulate insurance historically, the federal government can establish certain boundaries," Gionfriddo said. "The federal government's guidance to the state is critically important in making sure that somebody who lives in Florida gets the same kind of care as somebody who lives in Illinois who gets the same kind of care as somebody who lives in Connecticut."

Kimball said it would make sense if the federal government sent a consistent message on expectations for parity. But she felt the Trump administration's final rule in August to expand access to short-term, limited duration insurance coverage sent the opposite message since those plans under the rule do not have to comply with the Federal Parity Law.

"Despite the gains that we've seen over the past 10 years, we're also seeing a lot of attempts to take us back in time to when people were blatantly discriminated against," Kimball said.

Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness, which represents "payers that manage behavioral health insurance benefits," agreed a more uniformed standard by which states assessed parity compliance would be helpful. She envisioned a standard by which states asked for the same type of documentation from insurers to prove their compliance.

Kate Berry, senior vice president of clinical affairs for the America's Health Insurance Plans, said greater insurance compliance was just one part of achieving mental health parity and contended it also involved engagement with clinicians to provide care for mental illness and substance use disorder wherever it was needed.

She said work on that end has been seen in recent years as more providers have made efforts to integrates behavioral healthcare services within primary care settings, but more needed to be done.

Berry said criticism that has been levied at health insurers for not doing enough to comply with the intent of the parity law was misguided. "I don't think there's any evidence to say that that's not happening," Berry said.

In terms of the impact of nonquantitative treatment limits, Berry said AHIP has been consistent in calling for more clarification in the law, saying the guidance around them has been ambiguous and that it has created complexities.

"I see it as an area that because it's ambiguous it creates confusion form everyone touched by the system." Berry said.

Snook said ultimately, he saw healthcare providers as having a key role in the fight for parity by sharing their stories on the impact limitations of coverage have had on the health of their patients.

He said health insurers needed to reckon with the fact that lack of mental health parity was still a reality many Americans in need of mental health care face. "By not providing that level of coverage they're not saving themselves any money and they're really just hurting themselves," Snook said.