Note: This article discusses mental health parity within the context of the U.S. healthcare system; globally, healthcare systems vary and have distinct challenges and strengths.
When someone experiences a mental health challenge or a challenge with using drugs or alcohol, the decision to seek treatment is not an easy one. Stigma and the fear of being ostracized or judged, not knowing where to go or who to reach out to for help, and not being able to afford care are just a few of the many reasons that can affect whether someone gets the care they need and deserve. The U.S. healthcare system has many broken linkages that compound these challenges. Even if someone has health insurance, mental health and substance use treatment can be subject to limitations and restrictions in terms of what their health plan covers. Mental health parity is a way to help address these issues by requiring health insurance plans to treat mental health and substance use conditions the same way they treat all other health conditions.
What is Mental Health Parity?
In 2008, the United States Congress enacted the Mental Health Parity and Addiction Equity Act (MHPAEA), a federal law that requires health insurance plans to provide benefits for mental health and substance use services that are comparable to what is provided for physical health services [1,2]. For instance, a health insurance plan that allows for unlimited doctor visits for a chronic physical health condition, such as diabetes, is also required to provide unlimited doctor visits for a chronic mental health condition, such as depression.
The comparability of benefits also refers to financial requirements such as out-of-pocket costs that patients incur when they use their health insurance to access care. Examples of these out-of-pocket costs include deductibles (what you pay before your insurance coverage kicks in),
co-pays (the fixed amount you pay when you go to a doctor’s office or pick up a prescription), co-insurance (the percentage of a medical bill you pay relative to the percentage that your health insurance pays), and out-of-pocket maximums (the maximum amount that you have to pay during the year before your health insurance covers 100 percent of the cost) [3].
Comparability of benefits also refers to rules that health insurance plans put it in place before someone can access some types of care or services, such as requiring prior authorization to determine whether a particular treatment is medically necessary before it will be paid for by the plan [4].
An important caveat is that comparable coverage does not equal comprehensive coverage. Some insurance plans have high out-of-pocket costs for physical and mental health coverage or other restrictions and limitations to treatment. Still, requiring that benefits be comparable is a necessary (if insufficient) step towards resolving inequities in access to mental health and substance use treatment and services.
Does it Work? The Promises and Limitations of Parity
Research has identified that mental health parity legislation does increase utilization of mental health and substance use treatment as well as strengthen financial protections for consumers [5,6,7]. The 2008 parity law has also provided a framework for subsequent efforts. Since the 2008 legislation passed, additional federal and state laws have been enacted that build upon and strengthen parity laws. The Affordable Care Act required insurers to cover mental health and substance use services as one of ten essential benefits; prior to that, insurers did not have to provide such benefits and were only subject to the parity law if they chose to [8]. Some states have also passed legislation to further enhance parity laws; in 2020, California passed one of the strongest parity bills in the U.S., requiring insurers to cover many more mental health and substance use conditions and changing industry standards for how coverage decisions are made [9,10].
Regulating mental health parity is complex and can be difficult to enforce. The 2021 Consolidated Appropriations Act included amendments to MHPAEA to strengthen parity protections as well as a requirement for the Departments of Labor, Health and Human Services, and Treasury to issue an annual progress report [11]. The 2022 MHPAEA Report to Congress found that health insurers consistently failed to deliver parity for mental health and substance use services. For instance, some insurers did not cover methadone and naltrexone, two highly effective medications for treating opioid use disorders, but did not have similar restrictions or processes for excluding medications for physical health conditions [12].
Parity alone is not enough to ensure access to quality mental health and substance use treatment: not everyone has access to health insurance and, even if they do, their coverage may not be comprehensive and out-of-pocket costs may still be prohibitively expensive. There is also a shortage of mental health providers in many communities, particularly for non-white communities and communities whose members speak languages other than English [13,14,15]. Many mental health providers do not accept health insurance of any kind, due to low reimbursement rates by health plans [16]. Community-based clinics and services that are free or low cost often have limited capacity and long waiting lists. These factors contribute to delayed or inadequate care that can lead to tragic and avoidable consequences, including emergency room visits for people experiencing acute mental health symptoms, unnecessary police involvement, interruptions in education and employment, worsening physical health, financial instability, and homelessness [17,18,19].
The COVID-19 pandemic has reinforced the precariousness of the U.S. healthcare system and underscored the inequities in access to care and treatment capacity. In some cases, it has exacerbated mental health needs, particularly for certain groups such as essential workers, healthcare workers, children and adolescents, and communities of color [20,21,22,23,24].
Drug overdose deaths have increased significantly, and the U.S. Surgeon General issued an advisory on the youth mental health crisis that the pandemic has brought to light [25,26]. Individual and collective loneliness and isolation as well as grief, trauma, and loss that have become rites of passage during this time have highlighted the need for more funding and other resources devoted to quality mental health services and supports. Mental health parity alone won’t fix these issues, but holding health insurance companies accountable is an important step in addressing access and equity issues for individuals with mental health and substance use issues. Americans have many differing opinions about the role of government in healthcare, but the pandemic has underscored that healthcare needs are not always predictable and can arise with sudden and severe consequences. Ensuring that all people can access physical and mental health care when they need it is surely something we can agree on.
-Marit Boiler
Marit Boiler is a public health and health policy professional with over 10 years of experience in government and nonprofit health organizations. She is particularly committed to advocating for mental health and wellbeing for all. She lives in Los Angeles with her husband, son, and cat and loves collecting plants and tattoos.
References
[1] https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet
[3] https://www.nerdwallet.com/blog/health/copay-vs-coinsurance/
[4] https://www.healthcare.gov/glossary/preauthorization/
[5] https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2019.305023;
[7] https://www.journalofsubstanceabusetreatment.com/article/S0740-5472(16)30481-0/fulltext
[8] https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/
[9] https://www.psychiatrictimes.com/view/mental-health-parity-in-the-us-have-we-made-any-real-progress
[15] https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201400351
[17] https://www.psychiatrictimes.com/view/mental-health-parity-in-the-us-have-we-made-any-real-progress
[18] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2935265/
[19] https://www.vera.org/behavioral-health-crisis-alternatives
[20] http://info.primarycare.hms.harvard.edu/review/mental-health-essential-workers
[21] https://www.tandfonline.com/doi/full/10.1080/02791072.2020.1836435
[22] https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2775991
[23] https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.202000424
[24] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243721/
[25] https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm