“We always hope for collaboration, but the rule also has sticks,” Neera Tanden, head of President Joe Biden’s domestic policy council, told POLITICO. “We hope that insurers will change their behavior in the future without the sticks, but we will continue to fully enforce the parity law. »
Those sticks include fines of $100 per policyholder per day if insurers don’t close loopholes the administration says it uses to limit what they pay for mental health care. The administration says these schemes include requiring doctors to get approval from insurers before providing care, lower reimbursement rates for providers who treat mental illnesses, and deliberate efforts to limit the number of network doctors available to patients.
Insurance companies say Biden is scapegoating them and that they are already doing their best to rely on technologies like telehealth to improve access to care, expand their provider networks and increase what they pay to these providers. They are also trying to better integrate mental health into primary care.
“No one has a magic wand to create a number of mental health providers that matches the number of physical health providers,” said Craig Smith, a partner at the law firm Hogan Lovells and former general counsel for the Florida Agency. for health care administration. “You can enact regulations. You can pass laws. No amount of government oversight or enforcement can magically solve the problem.
The real problem, insurance companies say, is a lack of qualified mental health providers. Nearly half of the U.S. population lives in a region facing a shortage of mental health professionals, according to health policy research group KFF.
Still, the White House points to a 2022 report to Congress from the Departments of Health and Human Services, Labor and Treasury, which found that none of the 156 insurance plans and issuers studied complied with rules requiring them to measure their compliance with the 2008 law.
The problem is actually quite simple, supporters of Biden’s rules say.
“Insurers are cracking down on reimbursement for mental health care in order to save money,” the senator said. Chris Murphy (D-Conn.).
A decades-long campaign
At the Capitol, Democrats and Republicans are alarmed by the state of mental health of their constituents. Some lawmakers even talk about their own struggles.
The Covid-19 pandemic has brought the issue to the forefront, as concerns over illness and social isolation due to government-imposed lockdowns have exacerbated mental health issues and use disorders of substances.
More than a third of adults reported experiencing symptoms of anxiety or depression during the pandemic, and 90% of U.S. adults believe the country is in a mental health crisis, according to KFF.
Suicide rates increased to their highest level in decades, up to 14.1 per 100,000 people in 2021, according to the most recent data from the Centers for Disease Control and Prevention.
However, access to care is lagging behind.
Estimates vary, but the latest HHS data indicates that more than half of adults with mental illness do not receive treatment. Treatment levels may be even lower for substance use problems like opioid use disorder: Only 1 in 5 American adults received medication-assisted treatment in 2021, according to the latest data from the National Institute on Drug Abuse.
And although barriers to treatment for mental health and substance use disorders vary by condition, stigma is common, experts say.
The American health care system has always treated mental and physical health care differently. Insurers generally did not cover mental health care until after World War II. Insurance coverage was originally fragmented and separate from the broader system, said Colleen Barry, dean of the Brooks School of Public Policy at Cornell University.
“For so long, mental health has been the dirty child of health care,” said Maureen Maguire, the American Psychiatric Association’s associate director for parity implementation and policy. “There was a lot of shame in that. People didn’t want to get help. If you couldn’t find help, you didn’t mean you couldn’t find help.
Administrations for decades have made improving access to care a priority.
John F. Kennedy was the first president to take significant steps to achieve mental health parity in 1961. He asked the federal employees’ health insurer — which offered limited mental health care — to cover it at the same level as other treatments.
From then until the 1990s, efforts to increase parity largely took place at the state level, according to Barry’s research.
The Mental Health Parity Act of 1996, signed by former President Bill Clinton, required plans to cover mental health equally, but only in terms of annual or lifetime maximum benefits.
In 2008, President George W. Bush signed the Mental Health Parity and Substance Abuse Equity Act, whose lead House sponsor was then-Rep. Patrick Kennedy (DR.I.) used his own struggles with mental illness to convince his colleagues to support him.
The law required deductibles and copayments, as well as treatment limitations, to be equivalent to those for physical health care, and its enactment was considered a historic victory.
Since choosing not to run for re-election in 2010, Kennedy, the youngest child of former Sen. Ted Kennedy (D-Mass.), has worked to ensure his law works.
“The most insidious fight over the years that explains why these rules are so important has been discriminatory medical management practices by payers,” he said. “It’s much more difficult to understand the myriad ways insurance companies can limit access.”
The new regulations proposed by HHS and the Treasury and Labor departments are open for public comment until October 2.
If finalized, they would require insurers to analyze their coverage to ensure equivalent access to mental health care based on outcomes.
Companies should examine how they respond to doctors’ requests to authorize treatments for mental illnesses, versus physical treatments, as well as audit their provider networks and review how much they reimburse out-of-network providers.
“This is something that one would have expected issuers and plans to do as part of their own internal analysis to ensure compliance,” said JoAnn Volk, co-director of the Center on Policy Reforms. health insurance at Georgetown University.
One of the major issues targeted by Biden’s proposal is “ghost networks” — an insufficient number of mental health providers taking out insurance — forcing subscribers to leave the network and pay more.
The rule would also establish cases in which health plans cannot require doctors to obtain prior authorization to prescribe a drug or procedure, or otherwise erect barriers to patients seeking mental health care, as well as drug treatment.
Insurers could face fines of up to $100 per day per patient if they don’t offer comparable mental health coverage.
But enforcement could be a challenge, and it’s unclear how aggressive the administration would be. Previous enforcement actions have been largely collaborative, not punitive.
The Department of Labor had limited resources to enforce existing regulations, prompting Murphy to seek more in new legislation.
The ally of insurers
Insurers agree that access to mental health care should be equivalent to physical health care.
But AHIP, the insurer lobbying group, says the situation is more complicated than Biden makes it out to be, and that workforce shortages are at the root of the barriers to care.
“Access to mental health has been and continues to be difficult, primarily due to the shortage and lack of clinicians. This is why, for years, health insurance providers have implemented programs and strategies to expand networks and increase access,” said Kristine Grow, AHIP spokesperson. said in a statement.
The group said those goals include strengthening telehealth coverage and integrating physical and mental health care. And he points to the increase in mental health care use since the 2008 law as proof that the law is working.
Insurers also have a key ally in making their case: companies that buy insurance plans.
Last month, ERISA’s Industry Committee, which represents the interests of large employers and counts some of America’s largest companies among its members, joined AHIP in writing to administration officials to request that the comment period on the proposed rules be extended.
The companies and their insurers warned that the rules could create “unnecessary burdens” on providers, insurers and patients, and “unintentionally” hinder access to care.