America’s mental health is under siege — Congress can help now
For years now, the American psyche has been under siege. Well before COVID-19 arrived, our suicide rate was the highest it’s been since World War II and drug overdoses were killing more people than car accidents. Now, though, we must also contend with a deadly virus, the worst unemployment since the Great Depression and isolating lockdown measures, as well as the national trauma of George Floyd’s horrific death at the hands of police.
To help overcome the effects of this emotional onslaught on our minds, making high-quality mental health and addiction treatment services available to anyone who needs them is essential.
For this to occur, insurers’ longstanding discrimination against those with mental illness and addiction must end. Now, as Congress considers passage of the Mental Health Parity Compliance Act, bipartisan legislation to improve mental health parity law enforcement and transparency, reaching that goal might soon become easier.
The Mental Health Parity Compliance Act, which has already been subject to bicameral negotiations and added to a bill in the Senate called The Lower Health Care Costs Act, would improve upon the Mental Health Parity and Addiction Equity Act, which requires insurers to manage mental health and addiction benefits no more strictly than physical health benefits. When the MHPAEA was passed in 2008, hopes were high that insurers would finally put mental and physical health on equal footing. While some progress has since been made, the law’s impact hasn’t met expectations, since insurers openly disregard it and continue discriminating against customers with mental illness, while reaping billions in profits.
As psychiatrists, we see how pervasive this discrimination continues to be. Insurers create bureaucratic labyrinths to deter us from prescribing life saving medications, while using aggressive utilization review tactics — often below standards of care — to justify denying payments for psychiatric hospitalizations. Amid the opioid epidemic, they cover methadone — a painkiller that’s also our best treatment for opioid addiction — only when it’s used to treat pain. When it comes to potentially deadly eating disorders, they often refuse to cover residential treatment, forcing families to shoulder the costs of fighting for their loved ones’ lives.
Insurers continue such behavior since parity laws are poorly enforced, especially at the federal level. States have picked up some of the slack, with some even passing their own parity legislation. However, some types of health plans are primarily regulated federally, limiting effectiveness of state efforts. Given these challenges, nonprofit groups and influential employers have spearheaded their own parity efforts by forming the Path Forward initiative, which uses market-based strategies to encourage insurers to create parity-compliant insurance plans. Such efforts are important, but improving federal enforcement remains essential to achieving true mental health parity.
Multiple federal agencies regulate insurers and they all face enforcement challenges. The Department of Labor is the most important though, overseeing health insurance plans covering more than 130 million Americans. However, it lacks adequate regulatory authority or resources for such a responsibility.
Parity investigations are complicated and time consuming. With less than one investigator for every 12,500 insurance plans, it’s no surprise the Department of Labor’s enforcement efforts have been so limited. The American Psychiatric Association and others recently asked Congress to commit $15 million to these efforts, a small price to pay for protecting America’s mental health.
Passing the Mental Health Parity Compliance Act would strengthen parity enforcement by the Department of Labor and other federal agencies by streamlining investigations of potential violations, while also incentivizing insurer compliance by improving transparency of their health plans for regulators.
As currently written, the act would require insurers to analyze their plans’ use of treatment limitations such as prior authorizations and medical necessity requirements — which are often at the root of parity violations — and, depending on the type of plan, submit results to state or federal regulators for inspection upon request. Federal agencies would have to exercise this new authority by requesting at least 50 such analyses from insurers annually. They would also have to incorporate findings from subsequent investigations into insurer guidance on compliance, as well as share them with state regulators and provide an annual summary to Congress to guide future parity legislative efforts.
Though it has strong backing from the mental health care community and robust bipartisan support thanks to the efforts of Congressional committee leaders and its sponsors, the Mental Health Parity Compliance Act has not yet passed Congress. Rather than waiting months or even longer to vote on it, we urge Congress to pass the act, as well as boost funding for federal parity enforcement, as part of its next pandemic relief package.
People are hurting, and there’s no time to waste. Though Congress can’t relieve all the pain Americans are feeling right now, the least it can do is help ensure that if we need mental health care to help address it, our insurers won’t be standing in the way.
Brian Barnett is a psychiatrist in Cleveland, Ohio. Andrew Carlo is a psychiatrist at the University of Washington. Bruce Schwartz is immediate past president of the American Psychiatric Association and deputy chairman of the Department of Psychiatry and Behavioral Sciences at Montefiore Medical Center. The views expressed by the authors are their own and do not necessarily represent those of their employers.
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