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Insurance coverage for mental health and addiction services has traditionally lagged behind coverage for medical and surgical services. But the gap has narrowed over the last 20 years—most recently with the Affordable Care Act (also called Obamacare) and insurance plans in the marketplaces it created, which are open to individuals and small businesses.
A recent report confirms that, as required by the law, such plans began to offer equal coverage of behavioral and medical services in 2014. That means covering prescription drugs for both mental health and medical needs, for example, or emergency department visits related to mental health as well as medical issues.
Investigating whether insurance companies complied with the law is a first step in ensuring that patients receive better mental health care, a critical mission as society grapples with the opioid epidemic and rising rates of suicide.
“We know insurance is important for getting treatment and services, so I would implore the current administration to maintain the parity protections we have in place,” says the study’s lead author Alexander Cowell, a senior research economist at the nonprofit research institute RTI International. “It really could harm access to treatment if they remove some of the protections from the ACA.” If marketplace plans reverted to levels of coverage before the mental health care rules took effect, 20 percent of plans in the sample would no longer cover those conditions.
Insurance companies have historically been less generous with behavioral benefits than medical benefits, says Colleen Barry, a mental health policy expert at Johns Hopkins Bloomberg School of Public Health, who was not involved with the research. From an economic standpoint, patients who seek mental health care tend to use more services across the board. Insurance companies seek to select the least expensive patients, so they discourage people with mental health needs by providing weaker mental health benefits, Barry says.
To address this problematic incentive structure, the mental health community has fought to pass legislation that requires equal coverage for behavioral and medical services. The first step forward was the Mental Health Parity Act of 1996. The law was limited in scope but valued as a symbol of change. Congress passed a stronger law in 2008 that required parity for employer-sponsored insurance. In 2014, the ACA designated behavioral health as one of 10 essential health benefits and mandated that marketplace plans cover the two categories equally. Marketplace plans cover 7 percent of the United States population, according to the Kaiser Family Foundation. (Employer-based plans cover 49 percent and public insurance programs like Medicaid and Medicare cover more than a third.)
In the new study, researchers compared 60 plans from 2013 to 78 plans from 2014 to assess whether insurance companies adapted plans to abide by the ACA’s provisions—which is not always a given.
“While the passage of federal legislation is undoubtedly an important step, implementation can be complex. It’s always important for us to understand the ways in which legislation is, or is not, being effectively translated into tangible changes,” says Yale University postdoctoral fellow Emma Peterson, who was not involved with the research.
The researchers gathered a collection of insurance plans from across the country. Some states made their plans publicly available online, but others did not, so the investigators reached out to the states, insurers, or submitted Freedom of Information Act requests. Due to these differences, the sample was not nationally representative. The group reviewed the documents to determine which services were explicitly included or excluded.
The percentage of plans covering behavioral health services rose from 80 percent to 100 percent between 2013 and 2014. The result suggests that, at least on paper, the two benefit categories are covered equally.
“These results are very promising about what legislation like the ACA can do and why the listing of essential health benefit is so important,” says David Mandell, an associate professor of psychiatry at the University of Pennsylvania and the director of the Center for Mental Health Policy and Services, who was not involved with the research.
But complying with legal requirements does not necessarily translate to better treatment or more affordable care. “This study is important and an encouraging finding, but it’s nowhere near providing the full story of whether individuals with mental health and substance use disorders who are seeking treatment are really getting services that are at parity,” says Barry, of Johns Hopkins.
Insurance companies can eliminate restrictions but still make it more challenging to access mental health and addiction care than medical care. The corporations leverage three key tactics, Barry explains: strictly limiting the in-network providers in a given region, requiring authorization before accessing services, and reviewing requests before granting approval.
“Health insurers are a smart bunch, and there are still opportunities to practice the old methods of rationing care for mental health and addiction,” she says.
Research suggests that parity laws do produce a small increase in service use, but not as large as one would hope, Barry says. The same goes for parity’s effect on lowering costs for patients. To move forward, researchers can continue to examine loopholes and outline ways to eliminate them.
Parity also has the benefit of helping to reduce stigma. “Requiring equity essentially moves mental health and addiction care from the sidelines into the mainstream of medical care,” Barry says. “Depression sits alongside diabetes as a chronic condition rather than being segmented into a separate and lower-level silo.”
Now, though, the landscape for mental health care protections is changing. The Trump administration has gradually chipped away at the ACA since 2016. For example, the Justice Department refused to defend the ACA, which could endanger protections for preexisting conditions, many of which are chronic mental illnesses. The Department of Health and Human Services encouraged work requirements for Medicaid recipients, which could threaten coverage for people with debilitating mental illnesses. The administration also proposed expanding short-term insurance plans, which can limit or exclude behavioral health coverage. “All of these changes have the potential to really roll back the important gains we’ve seen over the last few years,” Barry says. “They’re under threat.”
