More than 70,000 Americans died of overdoses in 2017, yet insurers spent only 1% of their total health care dollars on treatment for substance use disorders — a decrease from two years earlier.

This alarming statistic is just one of many in a new report released by Milliman, an independent actuarial firm. The report confirms that insurers have failed to adequately cover lifesaving care even as U.S. life expectancy declined over the past three years, primarily due to overdoses and suicides.

Milliman researchers analyzed five years of insurer claims data from 2013 to 2017 covering 37 million U.S. employees and family members who receive health insurance from their employers. They looked at four categories of treatment — inpatient and outpatient facility services, primary care office visits, and specialist office visits — and compared the level of out-of-network use for behavioral health versus physical health.

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They also examined reimbursement rates for in-network office visits, aggregate spending on behavioral health (mental health and substance use care) as a percentage of total health care spending, and separate disparity details for substance use disorders, children versus adults, and various types of inpatient facilities.

Since most people depend on their insurance to cover health care expenses — which can include mental health and addiction treatment — the disparities uncovered by Milliman are cause for great concern. Insufficient networks of qualified providers and long wait times for in-network care are forcing people to seek out-of-network care, which equates to higher out-of-pocket expenses. Families across the country are depleting savings and retirement accounts, taking out second mortgages on their homes, and just hoping for the best when the money runs out. This lack of parity is inexcusable.

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Consider that in Delaware, a state with one of the highest drug overdose rates in 2017, inpatient mental health and substance use disorder treatment was approximately 29 times more likely to be out-of-network than inpatient medical or surgical care. Pennsylvania and Maine — also in the top 10 states with the highest rates of overdose deaths in 2017 — had high disparities as well.

Nationwide, patients receiving treatment for addiction were more than 10 times more likely to use out-of-network facilities than patients were to use out-of-network medical or surgical facilities. And out-of-network behavioral health facilities were five times more likely to be used than out-of-network medical or surgical facilities — an increase of 85% over five years.

The in-network/out-of-network disparities were even worse for children. In 2017, children’s behavioral health office visits were 10 times more likely to take place with out-of-network providers than in-network providers, more than twice the disparity among adults.

At the root of the problem is the simple fact that, when regulators look for problems, they repeatedly find that insurers are not adhering to the Mental Health Parity and Addiction Equity Act of 2008, also known as the Federal Parity Law. It requires insurers to cover treatment for mental health and substance use disorders no more restrictively than treatment for illnesses of the body, such as diabetes and cancer. We, as a nation, are not doing enough to hold insurers accountable.

Where are the regulators demanding to see proof of compliance? The Department of Labor is responsible for enforcing parity among employer-sponsored health plans, but currently has only one investigator for every 12,500 plans.

Where are the employers who purchase these health plans for their employees? Companies across the nation tout their focus on mental health, but few are actually holding their health plans accountable for covering mental health and addiction treatment services on par with other services.

In an effort to shine a spotlight on this issue, The Kennedy Forum, along with Rep. Jim Ramstad (R-Minn.) and the heads of the National Alliance on Mental Illness and Mental Health America, recently submitted a letter to Chairman Frank Pallone of the House Energy and Commerce Committee and Chairman Bobby Scott of the House Education and Labor Committee calling for congressional hearings on mental health parity. The letter urged these committees to prioritize policy solutions and address implications of the Wit v. United Behavioral Health ruling, which found that United Behavioral Health (the largest managed behavioral health care company in the country), developed medical necessity review criteria that were inconsistent with generally accepted standards of care as well as wrongly influenced by financial incentives to suppress costs.

Sadly, United is not alone in these practices. Without oversight and enforcement at the federal level, wrongful denials of coverage for addiction and other types of behavioral health care will continue.

The Federal Parity Law does not now apply to Medicare, which currently covers more than 40 million Americans, and TRICARE, which covers most of our men and women in uniform. When you consider that 1 in 5 Americans has a mental health or substance use disorder, it is difficult to fathom why these essential programs lack parity protections. That needs to change.

People must be able to access adequate treatment services using their health insurance. This must be a top priority for our elected leaders, not just advocates. It is time for families across the nation to stand up and demand change.

Patrick J. Kennedy is the founder of The Kennedy Forum and Don’t Deny Me, chair of Mental Health for US, a former U.S. representative (D-R.I.) and former member of the Presidents Commission on Combating Drug Addiction and the Opioid Crisis, and author of A Common Struggle: A Personal Journey Through the Past and Future of Mental Illness and Addiction (Penguin Random House 2016).

  • How do I contact the author of this article? I need people to help submit a testimony to help with the testimony for my sister’s bill SB 249 and HB249. This article will help get this bill passed!
    On the Senate side there are 6 co-sponsors. For the house there are 25 co-sponsors and both senate and house have bipartisan support. The bill is called the “Kristi L. Bennett Mental Health Parity Act.” My sister was seeking to enter a treatment facility…any facility that would accept her insurance. My sister, Stephanie Bennett, contacted Blue Cross of Blue Shield of Kansas during the middle part of April to seek the approval to have Kristi admitted to a facility in Austin, Texas that had a room available for Kristi. Stephanie obtained approval from BCBS to have her admitted and she purchased Kristi a plane ticket for Austin to leave the evening of April 16, 2019. The morning of April 16th, the facility from Austin contacted Stephanie and said that BACBS backed out on their approval since this is an ‘out of state’ facility. Kristi tried to get help in other local facilities. She was pushed away, being told she didn’t meet the emergency criteria…such an attempted suicide…to be admitted. She was told this at least three times from different facilities.
    My sister decided to attempt suicide the night of April 18th, 2019 with the intent of being found by her sister in the next room. She intended to meet the criteria set by some set of persons in order to be treated for alcohol and depression. She indicated to a friend this was her plan. We listened to those last phone calls that she was making future plans. Kristi died sometime during the early morning of April 19k, 2019.
    The system failed my sister. My sister paid her premiums every month and they failed her. Kristi paid the ultimate price in order to attempt to be treated for her alcohol addiction and depression. She would have turned 29 years old on May 17th. Stop allowing our young people to die because of the quest to maximize insurance profits.The bill summary points are as follows: The act would require that if a physician/psychologist/psychiatrist determines that a patient needs in-patient treatment for substance abuse, suicidal ideation, or actively suicidal, the patient will get in-patient treatment without “without imposition of prior authorization, concurrent review, retrospective review or any other form of utilization management review for the first 14 days of treatment.” In other words, the mental health provider with the patient is the determiner of need, not the insurance company. The same applies to the first 180 days of out-patient treatment if that is what the physician/psychologist/psychiatrist determines that a patient needs. Clinics and service providers are required to let the insurance company know when a patient has started treatment within 48 hours. “Medical necessity” is determined by the service provider and not the insurance company – in other words medical people are the people who decide what is necessary. Further, the bill requires that if there is no provider available in-network, then the insurance company must provide necessary exceptions to its network to ensure admission in a treatment facility within 24 hours. In other words, a patient cannot be denied access to an out of network provider paid for by the insurance company if there is no in-network provider available. It also doesn’t allow the service provider (an in-patient facility or out-patient counselor/psychologist), etc to demand up -front payment before treatment can begin. So, in a nutshell, if the medical professional determines that the patient needs help, the patient gets help without having to jump through additional insurance company hoops. That help can be for in-patient or out-patient depending on the medical professional’s diagnosis and recommendation.
    We have been talking with some individuals that have spoken to the chairmen of the insurance committee and the insurance lobbyist and this is where we think they will be shifting their focus on. We think they will say the insurance industry is going to argue that the problem is not them. It’s not enough providers. They are likely to ask the committee to set this aside and instead have a summer task force look at how to get more providers in the system. I believe our response needs to be that more providers will come into the system when insurance companies let people get help and the recommendations of the medical professions is what determines treatment. He thinks the insurance commissioner will find a way out that keeps the insurance companies happy so we have to be able to counter that and having physicians speak to that would be great. I asked another mental health advocate and she said there is actually not a shortage in outpatient providers, quite the opposite—more and more are going to private practice. However, there IS a decrease is providers who get on insurance panels and instead they are private pay so they don’t have to hassle with insurance.
    If anyone can include this somehow in their testimony that the insurance company IS the problem that would be great! The talking points honestly are any of the summary points listed above to be part of the testimony. Also if anyone has any information that can be provided that includes private providers that can definitely show the case that insurance routinely denies coverage for care in both the outpatient and inpatient scenerios. Our committee hearing was supposed to be this Wednesday, but I just got informed it will be Monday February, 10 3:30 at the capitol building.

  • What is”mental health care”? Do you mean psychiatry? Effective psychiatric care run by psychiatris to treat patients with psychiatric illnesses has been dismantled by insurance companies. Glad that there is documentation of this.

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  • How much more evidence do Americans need in order to understand that for-profit health insurance exists for the benefits of its CEOs and shareholders over the benefits of its policy holders? Why are insurance contracts that do not provide mental health/substance abuse disorder coverage and treatment(s) not challenged in the state/federal courts system?

  • You find fault with the 1% spending on this category. I don’t find fault because I don’t know how much should be spent. What is the optimal allocation of money for this?

    • Actually it is worse than that. As more services have been provided in fields such as cardiology and cancer there have been dramatic reductions in morbidity and mortality. The opposite has happened in mental health with even greater disease burden, disability, and suicide deaths associated with increased services. As one psychiatrist I know noted, mental healthcare is a black hole that will suck up every bit of revenue you throw at it and still demand more. We simply can’t label all non organic human suffering psychiatric and treat every complex social problem with the medical model. There is not enough money in the world to do that.

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