During the midterm election, voters sent several clear messages. Two in the health sphere were that they want equitable, affordable, and comprehensive health care coverage; and they want solutions to address the opioid epidemic.
The newly constituted Congress has a tool with vast — and sadly untapped — potential to address both issues: the federal Mental Health Parity and Addiction Equity Act, also known as the Parity Act.
That law, which has just marked its 10th anniversary, requires health insurers to provide the same level of coverage for mental health problems and substance use disorders that they provide for medical and surgical care. All too often, though, insurers ignore the law, erecting numerous hurdles that prevent people from accessing the treatment they desperately need and are legally entitled to receive.
These practices are a central reason for an unconscionable treatment gap: Of the 22 million Americans who need addiction treatment, only about 10 percent are getting it.
The time has come to demand equality and accountability from health insurance companies.
An investigation of a private insurer by New York’s attorney general found that its denial of coverage was nearly twice as common for mental health claims than it was for other medical claims, and nearly four times as common for addiction treatment. Another New York insurer denied inpatient addiction treatment seven times as often as it denied inpatient medical services. And the Pennsylvania Insurance Department found that an insurer imposed multiple treatment limitations on mental health and substance use disorder benefits. More oversight like this is needed to help protect patients.
One overarching problem is that insurers often require policyholders to be “pre-authorized” for urgently needed treatment. This process can take time, which people with mental health and addiction issues often don’t have. The delays in care that result can be fatal. In addition, people with substance use disorders who need medications and behavioral health services are frequently required to get less comprehensive (and less expensive) levels of care, and to “fail” them before they get access to proven, evidence-based, lifesaving treatments.
The story of Bill Williams, his wife, Margot Head, and their son, William, illustrate the tragic ramifications of these policies.
Bill and Margot always made sure that William had proper health insurance. But when they sought inpatient medically supervised treatment for William’s opioid addiction in 2012, their insurer allegedly refused to cover the care, telling Bill and Margot it was “not medically necessary.” A few days after being denied access to treatment, William overdosed on heroin in the family’s living room, and died six weeks later after being removed from life support.
At the time, Bill and Margot weren’t aware of the legal requirements that guaranteed parity in coverage, nor did they know about the remedies they were entitled to under the Parity Act and state law.
When consumers are denied coverage for substance use and mental health care, they are generally left to fend for themselves to defend their legal rights. Rather than filing complaints with the state insurance department or attorney general, they generally turn their attention to figuring out how to immediately get their loved ones the help they need, even if it means facing financial ruin.
State insurance commissioners are the ones who should be ensuring parity. They are in much stronger positions to enforce the law by ensuring plan compliance with parity standards before plans are sold. Unfortunately, too few of them are living up to that obligation.
In the absence of oversight from regulators, individuals in need of treatment for a mental health issue or substance use disorder, or their families, must engage in a protracted process of appealing insurance determinations and filing complaints. Few have the time or emotional capacity to take on this administrative burden in the midst of an urgent and life-threatening health crisis. The complaint process can take months to resolve and often consumers don’t have access to the health plan information or the legal knowledge required to put forward a successful parity complaint.
Given this obstructive process, it’s no wonder that in the decade since the passage of the Parity Act, addiction and mental health treatment has not substantially increased through private insurance, despite the worst opioid epidemic in U.S. history and an upsurge of deaths from suicide.
Adequate health insurance is only one weapon in the battle against overdose and unintentional death. There are several steps that could help make health insurance parity a reality.
First, state regulators should require every health insurer to submit a report including the data and analysis that proves it is complying with the Parity Act before it is permitted to sell plans to consumers. At present, insurance carriers are required to conduct analyses of their plans, but aren’t required to submit those analyses to state or federal regulators.
Second, the plans themselves must do more to inform consumers of their parity rights and make it easier for them to fully access mental health and substance abuse care under their insurance contracts. No one should die or lose a loved one because they cannot get through the red tape and receive treatment.
Third, we need stepped-up enforcement of the Parity Act at the state and federal levels. This act was the product of bipartisanship at its best. Now the same spirit of bipartisanship is needed to ensure that the law is fully implemented and enforced.
We are long overdue for making sure that the Parity Act fulfills its promise of ending discriminatory and illegal barriers to treatment. With nearly 400 Americans dying every day from either a drug overdose or suicide, we cannot wait any longer.
Patrice A. Harris, M.D., is president-elect of the American Medical Association and chair of its Opioid Task Force. She works as a psychiatrist in Atlanta. Ellen Weber, J.D., is vice president of health initiatives at the Legal Action Center and directs the national Parity at 10 Campaign.
I think it is further noteworthy that with this parity law that is not being followed there is the second piece of payment. When they do allow individuals to seek needed treatment, the true cost of treatment for SUD and Mental Health services is not covered. SUD is paid at such a low rate that small free standing agencies have to struggle to survive thus limiting the clients choices in where to go for life saving care as well as limiting the level of qualified practitioners in the field. This is creating another crisis in the recovery world!