BY TANNER BOWEN
“Lest we say the obvious; the brain is part of the body, and for too long insurance has played off that stigma and denied coverage for the organ of the brain, where they would not be able to deny that same coverage if you had diabetes or cancer or cardiovascular disease.
So, we’re in the midst of a revolution in bringing mental health treatment to parity, meaning equality, with the rest of physical health care…We want better treatments, and we will demand more, provided we’re covered for this thing called mental health.” – Patrick Kennedy, U.S. Representative and Mental Health Parity advocate
Over the last decade, the Legislative and Executive Branches of the U.S. Government have made great strides in requiring insurance plan mental health benefits to be provided equitably, compared to other types of medical care. This movement largely began in 2008 with the Mental Health Parity and Addiction Equity Act, legislation intended to ensure that if insurance plans offered both mental health benefits and regular medical benefits, both would be on equally covered.
The movement towards parity expanded even further into the 2010 Affordable Care Act (ACA), in which mental health and substance abuse disorder services were one of the ten categories of Essential Health Benefits required for all plans sold through state exchanges or the federal marketplace. But, despite these leaps made to ensure that individuals are insured and can access mental health services, obstacles still pervade.
In a recent report published by the National Alliance on Mental Illness, a lack of parity still exists between regular medical services and mental health services. One of the largest factors illuminated by NAMI’s findings is that many consumers are encounter barriers securing mental health providers through their health plans. After examining 84 health plans in different states, 22% of respondents reported that they could not find a therapist or counselor in their plan’s network, while 26% of ACA recipients could not find an available therapist. This is exacerbated by the fact that numerous psychiatrists and counselors chose to not accept new patients or not even accept insurance coverage.
The New York Times published an article showing that only 14% of psychiatrists are accepting new patients. Furthermore, a JAMA Psychiatry study showed that 55% of psychiatrists accepted insurance from 2009-2010, compared to 88.7% of physicians among other medical specialties. This percentage was even lower for Medicaid recipients,with an acceptance rate was 43%, compared to 73%. This disparity can be explained by insurance plans paying more to primary care doctors than to psychiatrist, deterring numerous mental health providers from accepting new patients or insurance coverage.
Other issues presented within the report mention that nearly one-third of respondents reported that they or a family member had been denied mental health care on the basis of medical necessity. In comparison, only 14% of general surgical or medical requests were denied. These types of denials exemplify blatant lack of parity between physical and mental medical benefits. Another shocking example includes the Beacon Health Options of New York, which was fined $900,000 this year for denying mental health claims at twice the rate of medical/surgical claims and about four times the rate for drug and alcohol claims.
Aside from inpatient and outpatient services, access to psychiatric medications is lacking. Over half of the health plans studied covered fewer than 50% of antipsychotic drugs used to treat schizophrenia and other disorders characterized by psychosis. Drugs covered are often placed at higher cost tiers, which result in beneficiaries paying more out-of-pocket costs for their medication or not receiving medication at all. This was the case for 17% of the respondents who were unable to fill their prescriptions for mental health care, as well as 33% who were unable to fill their prescriptions for substance abuse. But if a consumer cancels their mental health appointments or medications, most therapists note that these individuals are “non-compliant.” And, low-income individuals are often faced with a choice between medication and nutrition, which can constitute most of their disposable income.
Many individuals who need mental health care may not be able to receive a prescription because of the deductibles’ high prices. 20% of ACA plans have deductibles ranging from $2,500-$5,000 and 22% of ACA plans had them ranging from $5,000-$10,000. Evidence systematically showed higher average deductible and copays for mental health services compared to generic medical services.
Aside from the private insurance side, even federal insurance plans can run awry in the access to mental health benefits. One such example is the Federal Employee Health Benefits Program. For Applied Behavior Analysis, one of the leading therapy methods to treat individuals with autism, only 23 states offer federal health insurance plans to cover these costs. Those individuals or family members in states where FEHBP plans don’t cover ABA, they are often the ones footing the bill for tens of thousands of dollars a year where there doesn’t seem to be a push for all states to cover these treatments.
Ultimately, one of the most prominent issues is lack of transparency. Current data gathered tends to show a lack of parity between mental health services and medical services, yet the government does not require health insurance companies to reveal specific details about their coverage offerings, save California. This conundrum was revealed by researchers at John Hopkins University, where when trying to compare non-quantitative treatment limits, they observed that “summary documents do not provide information on how medical management protocols are applied to covered benefits.” With this ambiguity, it is difficult to determine whether insurance companies are complying with federal parity laws or where obvious improvements should be made. Even though there needs to be an increased effort to decrease out-of-pocket costs for medical expenditures, more detailed health insurance plans will assist individuals in choosing the plan with the appropriate amount of coverage.
In a nation where 61.5 million individuals experience mental illness within a given year, one would think that providing coverage to our populace would be at the top of our concerns. Much progress has been made, but there is still much work to be done. Although there can be many solutions proposed to alleviate this lack of parity between insurance benefits, one of the first things insurance companies could do is start revealing more information about their plans so that we can make the best coverage decisions.
Tanner Bowen is a rising sophomore at the University of Pennsylvania. Photography by Rebecca Heilweil.