Physical and mental health services have long been unequal, both in the delivery of care and in the public conversation. Mental health parity carries with it the promise of resolving this disconnect, of realizing (through scope of services, provider access, formularies, co-insurance, etc.) the potential for whole health. Yet the true promise of parity means moving beyond mere regulatory compliance to equitable, accessible and integrated healthcare.
In the hopeful era of the early 1960s, the community mental health system was created to meet the mental health needs of all Americans. As an unintended consequence, mental health care grew increasingly disconnected from other types of medical treatment. These diverging paths traveled on unequal ground to the detriment of people with mental health and substance use treatment needs.
The consequences of treating mental health and substance use conditions differently from physical health have extended beyond the delivery of services. They affect how society invests in, pays for and regulates mental health. At the root of society’s neglect is the misconception that “we don’t know what to do about mental health.” Yet decades of research have produced new insights into mental illness and an array of effective treatments and supports.
We now know poor mental health is linked to poor physical health and vice versa. We now know mental health and substance use conditions are common and affect one in five U.S. adults, as well as children, at some point during their life. We now know “more… about how the brain works and how it affects overall health.” We now know more about what treatments work. We now know the lifelong implications of failing to screen and diagnose early, to treat promptly, effectively and holistically, and to support the long-term recovery of people with mental health and substance use conditions.
As a nation, we must shift from “we now know” to “we now do.”
Congress enacted the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) in October 2008. MHPAEA sought to end longstanding insurance practices that limit mental health coverage more than physical health. MHPAEA, which applied mostly to large employer sponsored plans, did not require coverage of mental health and substance use treatment. But if a plan covered mental health and substance use care, that coverage must be on par with medical and surgical benefits.
Under healthcare reform, parity broadened. The Affordable Care Act (ACA) strengthens MHPAEA’s parity requirements by extending them to most individual and small group plans, Medicaid managed care, the Children’s Health Insurance Program (CHIP), any health plans purchased through the Marketplace, and others. The ACA also requires coverage of mental health and substance use treatment as one of ten “essential health benefits” in all qualified health plans sold through the Marketplace, new individual and small group plans sold outside of it, as well as some Medicaid (“alternative benefit”) plans. It also requires insurance companies to issue a health plan to any applicant regardless of preexisting conditions – called guaranteed issue – resolving a longtime barrier to coverage for many with mental health and substance use conditions.
While these laws represent a huge step forward, there is a long road ahead.
Last fall, the National Alliance on Mental Illness (NAMI) sought to explore the impact of these laws on coverage for Americans living with mental health or substance use conditions. NAMI surveyed more than 2,700 people across the country about their experience of accessing health, mental health and substance use care. For those with coverage purchased through an employer or the Marketplace, the survey found six troubling, but reversible, trends in parity implementation:
1. Consumers and family members reported problems finding mental health providers in their health plan’s network.
The survey found that individuals and family members had a hard time finding in-network mental health providers. The most significant problem identified was finding therapists or counselors for outpatient mental health or substance use treatment, followed closely by difficulties accessing psychiatrists. Once the difficult decision is made to seek treatment it is imperative that treatment be readily accessible, yet all too often people cannot find a mental health provider to begin the journey to recovery.
One way to help reverse this trend: NAMI challenges all payers to monitor which providers are actually accepting clients. Perhaps through electronic technology, with providers reporting on their end and plans conducting site studies, they can work together to maintain real-time, accurate directories.
2. Insurers are denying authorization for mental health services at levels higher than for other types of medical care.
Approximately one third (29 percent) of respondents reported they or their family member had been denied mental health treatment or services on the basis of medical necessity – that is more than twice the percentage who reported being denied general medical care. This, too, is troubling. There already is a strong sense of ambivalence related to accessing mental health services. For some with mental health and substance use conditions, anything that stands in the way of being welcomed into treatment can derail care. Unnecessary barriers may cause some to defer care or scrimp, and often leads to lack of treatment and to potentially avoidable life disruptions.
One way to help reverse this trend: Medical necessity criteria have been deemed proprietary but consumers, their families and providers truly want to understand the basis for these decisions. With greater transparency about the process, education of consumers as well as providers, and early and upfront dialogue on the options, we may end up with less angst at the decision point.
3. There appear to be significant barriers to accessing psychiatric medications through private health plans.
Many respondents reported experiencing difficulty accessing the type of prescription medication they needed, often because of formulary limitations. Particularly for coverage of antipsychotic medications, the survey found more than half of the observed health plans (47) covered fewer than 50 percent of analyzed drugs through their formulary.
4. Even when covered, the out of pocket costs of medications may pose a barrier.
Health insurance plans generally cover prescription drugs on a tiered basis. Tier one medications are most available and affordable. Higher tier medications are more expensive and are frequently not available except through specific requests for exceptions or authorizations. Although a number of plans covered a higher percentage of antipsychotic medications, for example, a significant proportion were available only on a restricted, non-preferred or high tier basis with high out-of-pocket (OOP) costs.
And while psychiatric medications were slightly more likely to be covered fully (10 percent) or partly (87 percent), when compared with medications for medical care (fully, 8 percent; partly, 85 percent), partial coverage of medications still can result in significant OOP costs for beneficiaries. The survey found that costs sometimes are so high that people choose to forego needed prescription drugs.
5. OOP costs may present a greater barrier to inpatient and outpatient mental health services than inpatient or outpatient medical specialty care.
In addition to prescription drugs, respondents reported similar barriers for other types of mental health treatment. More respondents cited OOP costs (deductibles, co-pays, coinsurance) as barriers to seeking inpatient or outpatient mental health services than for primary care or medical specialty care. This was true for employer as well as Marketplace plans.
As psychiatric medications, treatments and therapies advance, we may be able to eliminate the difficult trade-off between the symptoms of a condition and the poor side effects of treatment. But there is another trade-off to be avoided: that of cost and access. Research is producing better-tailored clinical treatments and therapies along with new psychiatric medications that have fewer life-inhibiting side effects. But if access to effective care is stymied by lack of coverage or high OOP costs, we really aren’t advancing anything.
One way to help reverse these trends (#3, 4 and 5): It is a difficult balance to strike but government, payers and plans, drug makers, and therapy providers must ensure affordability does not come at the expense of access – especially for consumers with low incomes. We have to find a way to make these treatments actually accessible and affordable. Otherwise, we open the door to less effective, more costly paths to treatment (civil commitment, the disability system, the emergency room) and less desired outcomes.
6. When selecting health plans available in state Marketplaces, consumers and family members generally do not have access to information needed to make informed decisions.
When shopping for health insurance, NAMI’s survey respondents reported lacking the online information needed to choose the most effective plan for their needs. For example: an accurate up-to-date provider network listing; quantifiable limits on coverage including inpatient and outpatient treatment; medical necessity criteria or other utilization review practices; prescription drug formularies and the policies for approval; information to calculate OOP costs; and types of mental health and substance use treatment benefits covered. While the information may be available, the average person may not know how to access it.
One way to help reverse this trend: Creating opportunities to enable individuals to walk through the choices with a Navigator or other enrollment assister and make these types of assessments before buying a plan. Health plans can take the lead by going the extra mile to assure health plan information is easily accessible, clear and understandable to consumers and their families before enrollment through their own web sites or customer service lines.
Working together to reverse these trends, to implement the letter and spirit of the law and to end health insurance discrimination, will realize the promise of parity, improve the quality of the healthcare system, save costs and – most importantly – improve lives.
As we begin to take stock of parity implementation for private health coverage, the stage now is being set for parity within government-sponsored coverage, including Medicaid and CHIP. The impact may be even greater than for private health insurance.
Many young Americans with mental health and substance use conditions access mental and physical health services through Medicaid and CHIP. The greatest promise of parity is for our young people. The teen and young adult years are often the most vulnerable point for people with schizophrenia, bipolar disorder, depression, ADHD, PTSD – the many mental health conditions that get in the way of a satisfying life.
Under Medicaid and CHIP today, we have requirements for early and periodic screening, diagnosis and treatment (EDPSDT) for children, youth and young adults, as well as mandatory mental health screenings with every well-child visit. Now we will have Medicaid and CHIP parity, potentially as early as summer 2016 following the timeline in the proposed rule.
For young adults with mental health and substance use conditions, the promise of parity – coupled with the broader changes to the healthcare continuum under the ACA – is better, lifelong outcomes. With early
screening, diagnosis and treatment, we can meet the needs of these young people throughout their lives. With the blurring of private and public coverage, the gap between the two systems is not as wide and difficult to cross as in the past. This means access to mental health or substance use care does not have to come at the expense of employment or the exhaustion of personal resources. Young people can launch into adult life, graduate, work, raise families and contribute to their communities.
As with heart disease, the key to successful mental health and substance use care is to detect and treat early - and do everything necessary to help the person stay well, including self-care. We know more about what treatments and therapies work, we know the importance of providing these services on par with other domains of medical care, and – increasingly – we are building the capacity to do so.
This is a time of huge change and immense promise. The promise of parity – to place mental health on equal footing, converged with the rest of medicine – depends on what we do on both the public and private side to achieve the potential before us. We need to move beyond regulatory compliance. The promise of parity rests in equal, not adequate, care and services, and in embracing the principles and spirit – not just the letter – of the law.
Sita Diehl is director of State Policy and Advocacy for the National Alliance on Mental Illness (NAMI) and is a member of the National Advisory Board. NAMI is the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental health and substance use conditions. Among other critical issues, NAMI advocates for full health insurance parity between mental health and other types of medical care.