Parity? More Like Parody

How U.S. mental health parity laws are mostly a joke

Most people don’t know how complicated navigating health care and their health insurance is until they are in the middle of it. We have all heard the stories. Not knowing where to go. Not knowing what all those pesky line items in your bill really mean. Or, even worse, when your health insurer denies something you thought they would pay for. There’s a reason our friends at Kaiser Health News have an entire feature on “bill of the month.” And this issue gets even trickier when you consider that there are separate rules and benefits for our mental health.

Mental health conditions are extremely common, and are among the leading causes of disability in the U.S. Yet I continue to find that frighteningly few people are aware that health insurers are required – yes, as in by law – to provide coverage for mental health and substance use disorders that is comparable to the coverage they provide for physical health care.

This stems from the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, a federal law that prohibits most Medicaid and commercial health plans from imposing financial requirements (such as copays or deductibles) or limitations on treatment (such as numeric caps on visits and utilization review practices) that are not equitable between behavioral health and physical health. For example, if your plan requires prior authorization for mental health or substance use disorder services for inpatient services, these requirements must be comparable and no more stringent than prior authorization requirements for physical health inpatient treatment.

Tricky right?   

The MHPAEA officially was enacted in 2008, and yet a 2014 survey found that only 4% of Americans were aware of the Act’s existence, and only 7% even understood the meaning of the term “mental health parity.” Unfortunately, a large majority of states have done little to enforce MHPAEA’s requirements, meaning that few health plans have been held accountable for discriminatory coverage practices.

Just last week the U.S. Departments of Labor, Health and Human Services and the Treasury released a scathing MHPAEA report to Congress, outlining failures of health plans and providers to ensure parity in coverage. One example from the DOL report showed an insurer provided coverage for nutritional counseling as part of a treatment plan for diabetes but did not provide the same coverage for a mental health condition like anorexia or bulimia. Imagine being the family in the middle of a crisis with your child and being told that your health insurance wouldn’t cover the treatment!

When asked about the MHPAEA report, Labor Secretary Marty Walsh noted, “We’re going to use every tool that we have under the ability that Congress gave us, and also with [the Department of Health and Human Services], to enforce this and push this law forward. And not just push this law, push this coverage forward, quite honestly.”

This isn’t the first time that mental health parity - or lack thereof - has been in the spotlight. In 2019 Well Being Trust co-authored a report to evaluate the strength and quality of individual states’ mental health and addiction parity statutes, which are important because they can function in tandem with, and bridge gaps in, MHPAEA. Much to our dismay, and perhaps no one’s surprise, the report identified a myriad of deficiencies in state parity laws across the nation, with 43 states receiving a final grade of D or F. At the time, only one state, Illinois, received an A grade in the analysis.

As we continue to anxiously await much-needed additional enforcement of MHPAEA by both federal and state governments, I find myself reflecting on Carmen, and her incredible firsthand experience dealing with the frustrating complexities and ugly realities of America’s insurance system. Carmen was a working mom in Maine, and by her own admission, not well versed in the realm of health insurance. That quickly and tragically changed when she came home one day to find her son in dire condition after a suicide attempt. Her journey to find effective treatment for him was quickly met with roadblocks in the form of insurers questioning everything from the specifics and severity of his condition to his need for ongoing treatment.

Stories like Carmen’s happen every day. Families in desperate need for help simply are not prepared for the gargantuan task of navigating the insurance system to advocate for care, especially when care is denied. After hearing Carmen’s heart-rending story at a speaking engagement in early 2020, we began collaborating on an accessible, comprehensible, plainly worded resource to help individuals and families better understand the health insurance landscape, and specifically where it related to mental health and substance use coverage. We released our family parity guide, Health Care Coverage for the Relentless, and my friends over at the Kennedy Forum also released an appeals guide, but even with these great resources, the fight is far from over.

The promises of parity continue to be vague and elusive for people who struggle with their mental health, and the results of the recent MHPAEA Congressional report are discouraging, to say the least. While Departments within the government are being more aggressive with health plans, and some states are taking much more appropriate action, there remains work to do. How can we expect our elected leaders to pass the type of systemic, policy-changing mental health legislation that our nation so desperately needs when the current laws designed to bridge those equity gaps aren’t even being adequately enforced? I say we must look to people like Carmen as an example and become educated advocates for those who are most in need. If we all speak up for change, our voices unified, we will be heard.