The Mental Health Parity and Addiction Equity Act that Congress passed in 2008 was supposed to prevent this situation by pushing for equal treatment of minds and bodies. Obviously, the law is not working. Congress and the Biden administration need to strengthen it. Health insurers should also recognize it is in their financial interest to improve their coverage of mental health and addiction treatments.
The University of Chicago survey reflects the experiences of 2,794 patients who have commercial insurance, Medicaid or Medicare. As the United States grapples with epidemics of opioid abuse, violence, isolation and suicide, these are matters of life and death for many Americans.
The labyrinthine US health-care system is dizzying to navigate. Even when people have insurance, doctors and other care providers whom they need to see often do not accept their coverage. Patients are being forced to choose between debt and despair.
Mental health specialists acknowledge this problem but say they often don’t join insurance networks because the plans put unacceptable limits on care, drowning them in paperwork to justify treatments and reimburse too little to cover their costs. A study of insurance claims showed that, as of 2014, “in network” psychiatrists received 13 to 20 percent lower reimbursement than other doctors providing the same mental health services in the same network. Another study showed that in 11 states, reimbursement rates in 2017 for primary-care office visits were more than 50 percent higher than for behavioral office visits.
Eighty percent of patients in employer-sponsored health plans surveyed by the University of Chicago researchers said they went out-of-network for behavioral health care “all of the time.” Just 6 percent did so for physical health care.
Psychiatrists, psychologists and other behavioral-health-care providers who don’t accept insurance charge prices that reflect their education and experience , as well as market demand. This leaves patients with a choice: pay high prices or forgo treatment altogether.
“There is this big gap between what the market is saying is the relevant price and what insurers are paying,” David Lloyd, chief policy officer of the Kennedy Forum patient advocacy group, told me. “It’s deeply inequitable. You have a different set of access for the more well-off who can afford to pay out of pocket, even if it’s a stretch for them.”
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Staying in-network is cheaper once insurance starts paying, but finding a behavioral health specialist is difficult when insurance company websites list only a few names or include providers who’ve left the plan. Forty percent of the respondents to the University of Chicago survey said they had to contact four or more in-network providers to get one appointment.
Patients who manage to get treated often run into problems getting reimbursed. Fifty-two percent said they were denied coverage three or more times for behavioral care, according to the University of Chicago study. The figure was 33 percent for physical care.
The situation is worse in rural areas because so few providers practice there. As of 2021, one-third of Americans live in areas without enough mental health providers. More than half of US counties didn’t have a single psychiatrist.
This means people often turn to general practitioners for support with addiction, depression and other mental health issues. But 87 percent of people in the recent survey said this wasn’t enough: They needed help from a specialist, too.
How can these many problems be fixed? Through concerted action on the part of the government and insurers.
The Biden administration is off to a good start in recognizing the importance of mental health. It launched the 988 suicide and crisis hotline, it’s poured hundreds of millions of dollars into training and incentives for clinicians to work in rural and underserved communities, it’s investing in scientific research, and it’s funding wellness programs to reduce burnout among front-line health-care workers.
Next, the administration needs to strengthen the Mental Health Parity and Addiction Equity Act with clearer guidelines on how to comply with it. As it stands, the law does not specify what exactly parity looks like for reimbursement rates and provider networks. Insurers take advantage of this vagueness to justify all but the most egregious inequity, Lloyd said. Clarity would enable the state and federal insurance regulators to enforce the law. Lloyd said the Office of Management and Budget is reviewing proposed regulations to do this. Separately, the proposed Parity Enforcement Act making its way through Congress would bolster the law by enabling the Labor Department to issue fines for violations.
Insurers, for their part, should recognize that they have a powerful incentive to improve their coverage: the close relationship between physical and mental health. Untreated addiction and chronic mental illness can cause or exacerbate costly physical ailments. In 2017, people with both behavioral and physical health conditions incurred an additional $406 billion in health-care costs, according to estimates from Milliman, a risk management and health-care consulting company. By ensuring that their beneficiaries receive adequate mental health care, insurers can help reduce the costs of all health care — saving up to $69 billion a year, Milliman estimates.
At the very least, insurers should include more providers who treat behavioral health and pay them as much as providers who treat physical health. To attract more mental health and addiction specialists to underserved areas, insurance companies should raise their reimbursement rates and reduce red tape such as the authorizations to see certain providers.
They would also be smart to reimburse providers more for embracing the “collaborative care model,” in which a primary-care doctor works alongside a mental health care manager and a consulting psychiatrist. This integrated care reduces stigma and increases access to mental health and addiction treatments — and holds the promise of saving lots of money.
The US health-care system is costly to families and the country. Morally, improving access is the right thing to do for Americans in pain. Financially, it makes sense, too.