Rice University's premier undergraduate journal of scholarship in domestic and international policy.
Vinay Pattalachinti
Oct 6, 2022
Mental Health Parity: A Requirement for Equitable Healthcare
Introduction
Mental health is just as important as physical health. According to the National Institute of Mental Health (NIMH), ~20% of the U.S. population has a mental illness, with about 1 in 4 having a serious mental illness (SMI) debilitating enough to interfere with or limit activities (“Mental Illness” 2022). Despite so many Americans suffering from mental health conditions, there is still a significant stigma associated with mental illness. This stigma can manifest as prejudice and discrimination against individuals suffering from mental health conditions (Henderson et al. 2013). This, along with a systemic minimization of mental illness as a true illness deserving of the “sick role” (Levine and Kozloff 1978; Edwards and Kotera 2020), is why many health insurance companies are more likely to provide coverage for physical illnesses but not for mental illnesses. Daniel H. Gillison, head of the National Alliance on Mental Illness, accurately frames the pressing issue of parity: “Health plans often deny people with mental health conditions appropriate care or force them to go to out-of-network and pay high out-of-pocket costs, leaving many to go without care altogether…If people had to resort to out-of-network care or were denied coverage for cancer or diabetes, there would be outrage” (Gillison 2021).
Because mental health conditions can be just as debilitating as physical health conditions, mental health parity is an absolute necessity. Mental health parity is defined by NAMI as the “basic idea that mental health and addiction care are covered at the same level as care for other health conditions” (“Mental Health Parity”). Insufficient mental health parity also furthers disparities in patient outcomes for those of different socioeconomic statuses. If the insurance benefits for mental health care are less comprehensive than the benefits for physical healthcare, poorer Americans that cannot afford higher fees will be pushed away from getting the mental healthcare they need. The only way to address this is to fight for mental health parity.
What has the government done for parity?
Since the 1960s, the federal government has been aware that mental health parity is a pressing issue affecting American health. As a result, there has been a push for parity since then (Barry et al. 2010). However, it was not until 1996 that the first federal legislation, called the Mental Health Parity Act (MHPA) was passed. The MHPA worked to ameliorate the issues of mental health parity (Peterson and Busch 2018). Before the MHPA, insurance companies rarely covered mental health and substance abuse treatments. The MHPA was the first step to remedying this. It required that “group health plans with fifty or more employees offered mental health benefits to apply the same lifetime and annual dollar limits to mental health coverage as those applied to coverage for medical/surgical benefits” (Barry et al. 2010). However, the MHPA did not go far enough: it was still fairly easy for insurance companies to evade true parity. For example, many companies decided to enact limits on the number of visits or increased copayments for mental health services compared to surgical benefits (Barry et al. 2010). It is also notable that the MHPA did not extend to substance use disorders (Peterson and Busch 2018).
Despite these recognized issues with the MHPA, between 1996 and 2008, there was no federal legislation extending parity. However, many states recognized the necessity of mental health parity. So, they enacted their own parity legislation rather than wait for further federal legislation (Barry et al. 2010).
Finally, in 2008, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA), ending the lull in new federal mental health parity legislation. The MHPAEA extended the terms of the 1996 MHPA to provide more regulations requiring mental health parity. Rather than limiting parity to only lifetime and annual dollar limits, the MHPAEA extended parity to other financial requirements and treatment limitations, such as copayments and visit limits. It also extended these regulations to substance use disorders as well (Peterson and Busch 2018).
Shortly after the MHPAEA was enacted, the Patient Protection and Affordable Care Act (PPACA, ACA, Obamacare, etc.) was passed. This worked synergistically with the MHPAEA by making it so that the regulations included in the MHPAEA extended to all insurance plans and not just large group insurance plans (Frank et al. 2014). It also provided more people who were previously uninsured access to insurance. Given that individuals with mental health conditions are disproportionately represented in the uninsured population, the ACA extending insurance – and therefore the terms of the MHPAEA – to these previously uninsured people has greatly increased mental health parity (Frank et al. 2014).
Yet, there were still issues with mental health parity post-ACA. As is often the case with policies like the MHPAEA, there were issues with compliance. To partially address this glaring issue, the Consolidated Appropriations Act of 2021 amended the MHPAEA to make it easier for departments to track and prevent potential violations. In essence, it makes it so that whenever insurance companies want to place a non-quantitative treatment limitation on something mental health or substance abuse-related, the company has to perform a comparative analysis that ensures that parity is maintained (Baker 2021).
The Future of Mental Health Parity
Despite this, a recent report from a combined working group from the Departments of Labor, Health and Human Services, and the Treasury suggests that insurance companies are not complying with the parity prescribed by the MHPAEA (Becerra et al. 2022). The report suggests that enforcement of the MHPAEA needs to be strengthened significantly. First, it says that the consumer protections in the MHPAEA need to be increased. Next, the report suggests that the different departments’ abilities to enforce parity ought to be strengthened (Becerra et al. 2022). Both of these changes should be implemented in the next amendment to the MHPAEA in order to further the goal of mental health parity.
However, it is also essential to look for and implement a long-term solution to address the lack of mental health parity that attacks the root cause: mental health stigma. Much of the public still considers substance abuse disorders and mental health conditions to be personal failings. To address this, the next MHPAEA amendment should include a public education effort in an attempt to eliminate that stigma.
Regardless of whether or not these changes are made, mental health and substance abuse parity is of utmost importance. This is especially true in the face of the opioid epidemic and the lasting effects of COVID-19 lockdowns, both of which require strong and effective mental health parity. The only way to ensure equitable access to mental health care is to fight for parity, both at a social and a policy level.
References
Barry, Colleen L., et al. “A Political History of Federal Mental Health and Addiction
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