By Liane Melendez, Behavioral Health Revenue Specialist, Sunwave Health
The U.S. spends nearly 18% of its GDP on healthcare, yet Americans die younger and are less healthy than nationals of other high-income countries. Healthcare spending, per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Not only does the U.S. have the lowest life expectancy among developed nations, but it also has the highest death rates of avoidable or treatable conditions and the highest suicide rates.
Contributing to these rates is a severe disparity between reimbursement for traditional and behavioral health conditions. It’s been nearly three decades since the federal government first implemented behavioral health parity protections, including mental health and substance use disorder (SUD) conditions, but sufficient coverage for behavioral healthcare continues to be out of reach for many U.S. consumers with health insurance.
As mental health comes into focus in the American cultural conversation and lawmakers debate over and pass legislation regarding behavioral health reform, federal parity law and dialogue have never been more critical. At this inflection point, a reexamination and revamp of national guidance is not only needed but comes at a crucial and opportune time.
Falling Short
Behavioral health leadership organizations like the National Alliance on Mental Illness (NAMI) successfully fought to pass a new federal parity law in 2008. The impetus for the Mental Health Parity and Addiction Equity Act (MHPAEA) was to improve coverage for behavioral health.
Next, in 2010, the Affordable Care Act (ACA) brought federal parity protections to people covered by individual and small-group health plans. The ACA also erased many of the inequities keeping people with mental illness from accessing care by banning health insurance plans from discriminating against people with pre-existing conditions, including mental illness.
However, these federal parity efforts fall short, maintaining many loopholes and restrictions. And to this day, millions of Americans remain uncovered, leaving many excluded from the much-needed behavioral health coverage they deserve.
Eliminating Exclusions
Nearly 90% of nonelderly individuals with behavioral health conditions have health insurance. Despite having coverage, over a third (36%) with moderate to severe symptoms of anxiety and depression did not receive care in 2019. There are many contributing factors, but one of the most blatant is that many behavioral health and SUD exclusions still exist in the current laws. These omissions are a substantial factor in why the U.S. has not achieved the promise of true parity. And insurance providers are still barring many people with behavioral health disorders from essential care.
Some forms of insurance still allow limitations on mental health coverage. The MHPAEA doesn’t apply to Medicare, specific state Medicaid programs, Veterans Administration, or short-term limited-duration health plans, for example. Moreover, federal laws do not require parity reimbursement rates between traditional and behavioral health, resulting in barriers to access as people cannot find in-network providers or affordable care. National guidance must eliminate these exclusions and enforce reimbursement parity to reverse the trends toward worsening outcomes.
Supporting Change
In addition to erasing exclusions and installing reimbursement equity, advocates and regulators alike should consider the following steps to improve the behavioral health paradigm in the United States significantly.
- Streamlining standards
Right now, parity standards are complicated and often vary from plan to plan. Given the differences between behavioral health and traditional medical care, comparisons are typically not black and white.
Therefore, in their 2022 Enforcement Report to Congress, federal regulators suggested more objective and consistent national standards as part of the MHPAEA. This effort would bolster behavioral health coverage and equip consumers with more transparent guidelines to understand and apply, no matter the state where they live or the type of health coverage.
Synthesizing uniform external benchmarks that are at-minimum established on nationally recognized standards of care and evolve with evidence-based research is a great place to start. This standardized approach will go a long way in determining what covered services guidelines consider traditional or behavioral health, simplifying the analysis consumers need to follow.
- Determining network inadequacies and improving access
Assessing what a competent behavioral health network of providers looks like including the whole gamut, from screening to inpatient services, will be critical to creating enforceable standards. And developing a common approach to this assessment will also be crucial.
New regulatory standards for the federal marketplace can play a significant role, including time-distance access and appointment wait time guidelines for behavioral health visits. After its critical role in meeting mental health needs during the public health emergency (PHE), telehealth will continue to be a powerful tool in improving access.
- Utilizing connected data to improve behavioral healthcare
Current regulatory shifts incentivize providers to expand access and enable a “data-informed” approach to program management and evaluation. Moving to an integrated data platform will improve outcomes and accountability at a time when they couldn’t be more essential.
Moreover, 2022 saw an expansion of the Certified Community Behavioral Health Clinic (CCBHC) program, the extension of innovation models, and continued data collection and reporting enhancements. This additional data and reporting will help address disparities between traditional and behavioral health and inform oversight into how plans cover behavioral health services compared to other claims.
Looking Forward
Enforcing behavioral health parity is complicated partially due to the patchwork of state and federal bodies responsible for enforcement. The burden is also primarily on patients to file individual claims, research, and be their own advocates. And many insurance providers want to keep this status quo as it takes the onus off of them to address a chronic, complex, long-term condition that requires multidisciplinary extended care.
Eliminating behavioral health and SUD exclusions and enforcing reimbursement parity will go a long way in accelerating change to this model. Furthermore, streamlining standards, assessing network inadequacies, and implementing a connected data approach will further drive the elimination of behavioral health parity gaps.
The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.
