It has been nearly a decade since Congress passed the Mental Health Parity And Addiction Equity Act, with its promise to make mental health and substance abuse treatment just as easy to get as care for any other condition. Yet today, amid an opioid epidemic and a spike in the suicide rate, patients are still struggling to get access to treatment.
That is the conclusion of a national study published Thursday by Milliman, a risk management and health care consulting company. The report was released by a coalition of mental health and addiction advocacy organizations.
Among the findings:
- In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.
- Insurers paid primary care providers 20 percent more for the same types of care than they paid addiction and mental health care specialists, including psychiatrists.
- State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-of-network. In Washington, D.C., it was 63 percent.
The researchers at Milliman examined two large national databases containing medical claim records from major insurers for PPOs — preferred provider organizations — covering nearly 42 million Americans in all 50 states and D.C. from 2013 to 2015.
"I was surprised it was this bad. As someone who has worked on parity for 10-plus years, I thought we would have done better," says Henry Harbin, former CEO of Magellan Health, a managed behavioral health care company.
"This is a wake-up call for employers, regulators and the plans themselves," Harbin says, "that whatever they're doing, they're making it difficult for consumers to get treatment for all these illnesses. They're failing miserably."
The high proportion of out-of-network behavioral care means patients with mental health or substance abuse problems were far more likely to face the high out-of-pocket costs that can make treatment unaffordable, even for those with insurance.
In its statement issued with the report, the coalition of mental health advocacy groups, which included Mental Health America, the National Association on Mental Illness and The Kennedy Forum, called on federal regulators, state agencies and employers to conduct random audits of insurers to make sure they are in compliance with the parity law.
Harbin, now a consultant on parity issues, said the report's finding that mental health providers are paid less than primary care providers is a particular surprise. In nine states, including New Hampshire, Minnesota, Vermont, Maine and Massachusetts, payments were 50 percent higher for primary care providers when they provided mental health care.
Because of low reimbursement rates, Harbin said, professionals in the mental health and substance abuse fields are not willing to contract with insurers. The result is insurance plans with narrow behavioral health networks that do not include enough therapists and other caregivers to meet patient demand.
For years, insurers have maintained that they are making every effort to comply with the 2008 federal mental health parity law, which was intended to equalize coverage of mental health and other medical conditions. And previous research has found that they have gone a long way toward eliminating obvious discrepancies in coverage. Most insurers, for example, have dropped annual limits on the number of therapy visits that they will cover. Higher co-payments and separate deductibles for mental health treatment have become less of a problem.
Still, discrepancies appear to continue in the more subtle ways that insurers deliver benefits, including the size of provider networks.
Kate Berry, a senior vice president at America's Health Insurance Plans, the industry's main trade group, says the real problem is the shortage of behavioral health clinicians.
Health plans are working very hard to actively recruit providers and offer telemedicine visits in areas with shortages, says Berry. "But some behavioral health specialists opt not to participate in contracts with providers, simply because they prefer to see patients who are able to pay out of their pocket and may not have the kind of severe needs that other patients have."
"This is a challenge that no single stakeholder in the health care infrastructure can solve," she adds.
Carol McDaid, who runs the Parity Implementation Coalition, counters that insurers have been willing and able to solve provider shortages in other fields. When, for example, there was a shortage of gerontologists, McDaid says, insurers simply increased the rates and more doctors joined the networks.
"The plans have the capacity to do this," she says. "I just think the will hasn't been there thus far."
The scarcity of therapists who accept insurance creates a care landscape that is difficult to navigate for some of the most vulnerable patients.
Ali Carlin, 28, says she used to see her therapist in Richmond, Va., every week, and had a co-payment of $25 per session. But in 2015, the therapist stopped accepting her insurance and her rate jumped to $110 per session.
Carlin, who has both borderline personality disorder and addiction problems, says she called around to about 10 other providers, but she couldn't find anyone who would accept her insurance and was taking new patients.
"It's such a daunting experience for someone who has trouble maintaining their home and holding a job and friendships," says Carlin. "It makes me feel like no one can help me, and I'm not good enough and it's not an attainable goal."
In Virginia, the Milliman report found that 26 percent of behavioral health office visits were out-of-network — more than seven times more than for medical care.
With no alternative, Carlin stuck with her old therapist but now has to save up between sessions. She has just enough to cover a visit once every few months.
"I make $30,000 a year," Carlin says. "I can't afford an out-of-pocket therapist or psychiatrist. I just can't afford it. I'm choosing groceries over a therapist."
Angela Kimball, the director of advocacy and public policy at the National Alliance on Mental Illness, says she worries many patients like Carlin simply forgo treatment entirely.
"One of the most common reasons people give of not getting mental health treatment is the cost," Kimball says. "The other is not being able to find care. It's hurting people in every corner of this nation."
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation. KHN senior correspondent Jenny Gold is on Twitter @JennyAGold.