Latest / The Mental Health Evolution / Ep 9: Understanding Mental Health Parity with Deborah Steinberg

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Ep 9: Understanding Mental Health Parity with Deborah Steinberg · The Mental Health Evolution

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(Transcribed by TurboScribe. Go Unlimited to remove this message.) Welcome back everyone to the Mental Health Evolution podcast where we are
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talking about how the landscape is quickly evolving in the mental health
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industry.
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And today we are talking to Deb Steinberg who is the Senior
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Health Policy Attorney at the Legal Action Center in Washington D.C.
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where she advocates for state and federal policies to expand access to
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comprehensive and equitable substance use disorder and mental health care.
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Deb works in policy advocacy which fits into the topic of all
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the changes in the mental health space currently.
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She also co-leads the Center's Medicare Addiction Parity Project which is
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an initiative to expand Medicare's coverage of substance use disorder treatment
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and ensure the Parity Act is applied to Medicare.
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As always, I want to give a little background here to set
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the stage for our conversation to our listeners so you all have
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some information about the topics that we are addressing.
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So here are some things that have been in the news recently.
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This article is called Mental Health Care May Be Harder to Obtain
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After HHS Meaning the HHS Rule Reversal and that is from the
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STAT News link.
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This article talks through the original legislation the Mental Health Parity
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and Addiction Equity Act of 2008 and the law was supposed to
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prevent private insurance companies from instituting unequal coverage for
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mental health and physical health services.
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If you've listened on this pod before we have talked about how
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sometimes there's unequal reimbursement rates for mental health care versus
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physical health care and that's kind of what we're talking about here.
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Instead insurance companies found loopholes and in 2024 the Department of
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Health and Human Services and two other federal agencies attempted to sew
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up these loopholes but on May 9th three federal agencies including HHS
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notified the judge that they will not enforce companies or force companies
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excuse me to comply with the current regulations including potentially
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modifying or rescinding the regulation.
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Short story, this means that insurance companies can continue to provide
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unequal coverage and in another article this one is from the AMA
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they are collaborating with the Kennedy Forum and Third Horizon to launch
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the Mental Health Parity Index which is an index that creates transparency
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to see what is being reimbursed for medical doctors versus those providing
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mental health care.
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Specifically the tool analyzes commercial insurance plans based on access
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coverage and payment for mental health and substance abuse services as compared
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with physical health services using the transparency and coverage data
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published by individual insurance plans.
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This is being piloted by the way in Illinois they're piloting a
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lot of things advocacy wise and so far data has shown about
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a 27 percent difference between payment to physicians who provide physical
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health care compared to physicians who deliver mental health care and substance
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use disorder care.
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And lastly I want to highlight this article this one happening in
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Georgia Commissioner King fine insurers over 20 million in mental health parity
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and this story is insurance and fire safety fire commissioner John F.
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King announced today that he will fine health care insurance companies over
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20 million dollars for violating mental health parity laws saying I was
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there when Georgia's mental health parity act was signed into law in
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2022.
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Three years later our initial examinations show that insurers have turned a
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blind eye to the rules and continue to deprive Georgians of the
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essential behavioral health resources they deserve said Commissioner King.
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So I know that was a lot of information kind of updating
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you on where the parity laws are now and what's happening but
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mental health and addiction parity laws do exist but it seems like
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enforcement is somewhat questionable some people seem to be able to ignore
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those laws and Deb I'm really eager to hear some of your
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perspectives and updates on equity and also parity for provider protection in
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the field of mental health.
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So I want to start with a very basic can you explain
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what mental health parity truly means and why it's important?
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Sure thank you.
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So mental health parity is an anti-discrimination law and it says
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that health insurance plans cannot discriminate against people with mental
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health conditions or substance use disorders and essentially they have to cover
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mental health or substance use disorder care in a way that is
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comparable to how they cover medical care or surgical procedures.
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So without parity people may have to pay more to see a
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mental health therapist than to see a physical therapist or they may
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have medications for opioid use disorder excluded from their health plan even
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though their plan covers medications for the treatment of pain or residential
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treatment for an eating disorder might get cut off after seven days
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but residential treatment for a physical injury may be permitted for 30.
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So parity is important because it ensures that people can get the
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mental health and substance use disorder treatment they need.
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It's important because mental health and substance use disorders are health
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conditions so our health insurance needs to cover them in the same
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way it does for any other health condition.
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Hmm that is incredibly helpful to understand and and the parity there
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really is medical versus mental health or substance abuse and those should
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be equal that's kind of what I'm hearing is the bottom line.
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Exactly it's really that comparison because the parity law by itself does
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not actually require health plans to cover mental health care or substance
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use disorder care.
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The parity law just says that if you do cover those benefits
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then the way you do it has to be equal.
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However we also have the Affordable Care Act and the ACA says
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that mental health and substance use disorder benefits are essential health
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benefits.
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So when you have the laws together they say that most plans
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do have to offer mental health and substance use disorder benefit and
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then those benefits have to be comparable to medical care and surgical
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benefits.
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Okay that's really helpful.
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So what is exactly happening with this HHS rule reversal and how
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is this affecting people?
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Yeah so it's it's a weird time.
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The rules were finalized in September of 2024 and then most of
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the rules that were part of this like giant rule were not
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even scheduled to go into effect until January 1, 2026.
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So we haven't even seen them go into effect yet.
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And then on January 17th of this year 2025 a lawsuit was
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filed by the ERISA Industry Committee or EIRIC that thought that these
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rules were too burdensome and too vague but also too prescriptive and
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all of the things that made it impossible for these insurance plans
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to comply with providing equitable care.
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So obviously that lawsuit was filed right before inauguration when a new
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administration was coming in which newly heads up these agencies who had
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written the rules and also are responsible for defending the rules.
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So in this case the agencies when they responded to the lawsuit
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they didn't respond to say yes we're going to defend the rules
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we agree they're important and said they basically said you know actually
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we're going to revisit these rules so you don't even need to
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proceed with the lawsuit right now.
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So the lawsuit is on hold while they are going to revisit
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these regulations and in the meantime they've said that they are not
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going to enforce those 2024 regulations.
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So most of the rules hadn't even gone into effect yet but
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at the same time the regulations really reflected decades worth of efforts
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by advocates and regulators to really figure out the best way to
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oversee and enforce parity.
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They may not be perfect but they really reflected a knowledge of
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the gaps that had been happening they were closing the loopholes but
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also in the meantime there was a statutory change the law actually
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changed a little bit back in 2020 that required health plans not
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only to just amorphously comply with the law but actually to show
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their work to perform and document a comparative analysis comparing mental
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health and substance use disorder benefits to medical benefits.
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So to show their work to prove that they comply with the
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law.
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So these regulations were also helping to implement that statutory change.
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They were saying okay here's how you do that analysis they were
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like giving kind of explanation and guidance.
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So without these regulations plans still have to comply with that change
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they still have to perform and document these analyses but now they
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don't have the guidance for how to do it in a way
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that will you know allow regulators to review it in the same
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consistent way.
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So it's not only harmful for consumers and advocates who no longer
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have these stronger protections and closed loopholes also problematic for the
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regulators and the plans who now don't have consistent information and
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structure for how they're supposed to actually comply with this law.
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I mean that just sounds very confusing to me.
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I mean I understand everything that you just said right but what
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is what is underneath maybe that lawsuit and that desire to take
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away these regulations if there's already that 2020 mandate in place?
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That is a great question.
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I think what we what we saw in the lawsuit was really
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sadly an unwillingness to comply with parity.
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The kind of threat that was not even implicit was quite explicit
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in the court filings was that this was such an unworkable structure
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that plans would be unwilling to even offer mental health benefits.
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And rather than saying like hey this is unworkable but we actually
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do care about mental health and we want to make sure that
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people have the care that they need because this these regulations they
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came out of a you know notice and public comment process where
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consumers the public as well as the the public insurance companies and
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the regulators everyone was submitting comments and those comments were taken
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into account.
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And the agencies came out with their interpretations of the law and
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the health plans didn't like it because ultimately they would rather apparently
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threatened to withhold mental health care from the public than provide it
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in a way that is equitable.
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So that was that was really disheartening because I felt I feel
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like the advocacy community has made a ton of progress in de
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-stigmatizing these health conditions and making sure that they are as available
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and as accessible and as affordable to treat as other medical conditions
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and seeing these like large companies and employers that represent a large
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swath of the United States say that they were unwilling to continue
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to comply with this law was was really devastating.
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Well and I'm kind of reading between the lines a little bit
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here I guess but to me that's also maybe an acknowledgement of
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how different the pay is for mental health care right because if
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if it's such a hardship to create parity for insurance companies then
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that seems to indicate that there is such a huge discrepancy already
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that changing that would have a dramatic impact on their revenues.
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That is definitely accurate.
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There is a great study that was conducted by RTI International that
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came out back in April of last year that really looks at
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some of those pay disparities for even the same codes when delivered
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by a mental health professional versus a physical health provider and you
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can see how it plays out.
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They pay much less for those providers and then patients have to
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go out of network more so the cost just gets shifted back
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to the individual.
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If the individual consumer is paying their premium assuming they can get
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the care that they need but when they actually need mental health
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care they're forced to go out of network because the health insurers
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are not paying those providers enough for them to be in network
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and they're going to claim it's a shortage of providers and don't
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get me wrong there is absolutely a shortage of mental health providers
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that needs to be addressed and also there are much starker shortages
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of other health providers that they've still been able to figure this
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out for and it's because you have to figure out what the
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strategies are to recruit enough providers to meet the network's needs and
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sometimes that is financial incentives other times maybe it's reducing
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paperwork or burdens but they're ultimately taking those steps for the medical
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providers and not taking those steps for the mental health providers but
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reimbursement is only one component of parity.
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Parity is also prior authorizations it's also day limits it's also coverage
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exclusions so I think some of this is also recognizing that it's
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not just the reimbursement rates it's all of those other barriers that
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health insurers are putting up that prevent people from getting treatment and
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ultimately if they have to do this whole comparative analysis they might
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have to show that they are not actually complying with this law.
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Yeah and as the law was written which I realize is in
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flux right now what were some of the consequences for not complying
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or was that part of it or not?
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So this is where it gets a little wonky parity is a
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little different for different types of health insurance so the reason this
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was like three different agencies doing this rule together and then defending
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it is because each agency oversees a different type of plan so
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with the department of labor there is no explicit authority for the
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department of labor to find health plans whereas there is that kind
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of authority for a lot of states that are reviewing it which
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is why you pointed out these great fines that were just levied
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in Georgia we've seen fines like that in a number of other
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states though I will call out Georgia because this was I think
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the largest fines I've seen for parity which is really wonderful and
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also very sad that it's still remarkably low compared to the cost
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of doing business for these plans but nonetheless so you'll have kind
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of different state mechanisms for enforcement than you do for the federal
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government and it's because the enforcement mechanisms aren't really tied to
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the parity law itself they're tied to the agency that oversees them
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but you can add in enforcement penalties when you're doing this kind
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of work especially in states if you're doing state advocacy so what
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we saw in Georgia was Georgia put into their law these are
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the fines not just for failing to comply with parity but also
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for failing to submit that complete and sufficient analysis so those are
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the kinds of things that really create some accountability and oversight in
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a way that's meaningful because that slap on the wrist isn't going
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to do it when they realize that the cost of doing business
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is you know maybe a different balance for them as compared to
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actually just complying with the law yeah it feels like there are
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just so many layers to this as we are talking but I
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guess I am also curious I don't know if you know the
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answer to this question but it's popping up for me is how
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did we get to this place where there are such severe discrepancies
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between mental and physical health reimbursement rates yeah it's a really good
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question and it's a saga that I will not tell the whole
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story of but essentially it reflects how how insurance was created in
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our country and if you look all the way back to like
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the 1930s or wherever we were I mean insurance started more to
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deal with hospital situations right and then as we were kind of
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building in some of the outpatient care and all that stuff that
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was all happening at a time when we didn't really have community
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-based mental health and substance use disorder care we were institutionalizing
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folks or we were putting them in jail right like we were
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not doing a very good job of treating mental health conditions and
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substance use disorders and so our insurance system was evolving at that
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time and then now adding in the mental health and substance use
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disorder stuff as those fields were evolving they didn't feel the need
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to do it in a way that was equitable because that reflected
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the stigma and discrimination against those conditions and now it's kind of
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making the insurance field catch up to where we've come with the
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science and making regulations catch up with science is it's a challenge
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it often is and it's going to be slower than science evolves
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but now we are here now we know these are health conditions
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that need to be treated just as any other health conditions and
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that's what parity is for it's to root out that underlying discrimination
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that is still in our health plans so if parity is done
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right those all of those underlying discriminatory barriers are supposed to go
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away they're supposed to be corrected for you wouldn't even need these
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fines because insurance would just be equitable but unfortunately we still have
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those underlying problems and new ones are being created every day it's
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like whack-a-mole a lot of the time but we have
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to keep trying because for every barrier we remove we know that
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that is increasing systemic access to mental health and substance use disorder
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care so that's why we keep fighting this as lawyers and as
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advocates and policymakers we know we can make insurance better and we're
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committed to doing so okay i love that for the other argument
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maybe i i don't know this argument very well but i'm hearing
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this piece of like maybe insurance companies are coming forward and saying
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we we literally can't afford to do this what is your response
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to that um yeah i think it is a
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concern that has been raised and never proven as part of this
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notice and public comment period for these regulations they asked questions how
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much more would it cost you would it be a barrier there's
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actually a provision in the law that says if it costs more
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than such and such percent of your you know plans financing then
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you don't have to comply that's never been used no one was
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able to show that this really was going to be like detrimental
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to their plans financing that they couldn't afford to do it it's
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the threat that we always hear but it's not what we've actually
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been able to see or demonstrate so i if if you are
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a health plan who wants to make that argument please show your
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work because that is part of complying with the law you can
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be exempt from the law if you can show that this really
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is a financial barrier but ultimately what we all know is that
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by providing this access to mental health and substance use disorder in
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community-based settings at a reasonable reimbursement rate you're doing the
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same thing that we do with all other health conditions you're making
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it so your consumers the enrollees in the plan can thrive can
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live their best lives so that those conditions aren't exacerbating other health
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conditions it's all about just creating this like equal playing field for
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people with these conditions to achieve health and well-being and ultimately
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we all know that actually leads to cost savings in the end
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but it's a it's a short-term investment that needs to be
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made but it's worth it for people with these conditions who deserve
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to live lives that are healthy and with dignity and where they
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can thrive yeah and to to your point about that investment on
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the front end i just think about all the aces work that's
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been done to show how much trauma impacts physical health right not
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just the two are not separate they are very interrelated and if
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you're treating trauma if you're treating mental health then you're also seeing
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benefits to physical health absolutely yeah so from an advocacy perspective
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what would you say are the greatest risks to good care out
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there just from a legislative perspective maybe things that both impact people
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seeking care as well as providers themselves what are you seeing um
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well some of the like policies that we've been advocating for lately
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are really thinking through how to make sure that people can find
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providers that they need because oftentimes someone has their health directory
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from their plan that lists all the providers and maybe they're looking
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for an adolescent trauma specialist and they call everyone who's tagged as
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trauma or they call everyone who's tagged as adolescent but there's no
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one at that intersection or maybe it's not even that specific maybe
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they're just trying to find a therapist who's within you know 20
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miles of their house because they need to be able to drive
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there after work oftentimes you can't find that and we know that
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that's a huge challenge for folks and it's it's part of several
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reasons maybe it's this like ghost network issue where a lot of
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those providers aren't actually in network anymore maybe they're no longer even
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alive at this point and other times it's that the plan actually
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does have an inadequate network to meet your needs and so there
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there are solutions to problems like that you can strengthen the network
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adequacy standards and make them specific enough that there are trauma
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specialists and there are eating disorder providers like not just one broad
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category of behavioral health because we know those providers are not the
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same people even though there are way too many misconceptions that they
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are so you can do things like that you can also require
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like secret shopper surveys you know making sure that someone's actually
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auditing those network directories to make sure they're accurate to make sure
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that they are reflecting the network that's available to you so that
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it's not on the consumer to try and fail at 20 numbers
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only to feel like their condition isn't worth treating because that's the
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message that you get you try all these numbers and just keep
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failing and that's not right and that's not fair so we've been
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doing a lot of work on like that network adequacy side do
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a lot of work on data collection as part of parity we
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want to make sure that folks realize that parity isn't just about
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what's like written in your plan documents you know where it says
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like yes we require prior authorization for all medications okay let's say
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that that's true they require pre-approval for every medication but maybe
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the pre-approval for the mental health medication takes like seven days
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to go through whereas the health plan always gets the medical ones
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after one day or maybe all of the mental health ones come
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back and say actually I need you to try and fail at
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this cheaper medication first whereas all the medical ones let you get
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that one those are parity violations but oftentimes you can't see those
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until you have the data and so data collection is a very
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important part of parity but it's one that um has kind of
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not been as as much of the center of attention it's a
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little it's a little bit more difficult but it's so so important
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because it shows what those real barriers are and it allows you
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to fix the root causes once you can identify the barriers so
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we've been focusing on data collection network adequacy another one is just
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the standards of care that health plans use sometimes like their coverage
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criteria are not exactly based in science they're based in how to
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preserve their profits and so that's problematic when they're using different
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standards to decide what treatment as what the provider is using who's
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thinking what is the best care for my patient what aligns with
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what I learned in my you know practice and through research and
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all this stuff and your health plan is imposing different criteria that
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means the patient can't get the treatment that they need so there's
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another big effort that's really trying to align the coverage criteria that
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plans use with the standards of care that providers are using so
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a lot of different efforts some of which are parity with a
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capital p and some of which are parity adjacent but all are
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leading to getting more equitable coverage of mental health and substance use
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disorder care yeah so how can people get involved with this if
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they're either a client patient or a provider what do you recommend
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a great question so what I always recommend first and foremost if
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you are a patient or a provider don't forget to submit complaints
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and I know it's annoying and I hate telling people to do
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this when you don't have the assistance especially if you're in a
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time of crisis but if you get a denial or if you
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notice that your plan is reimbursing like a provider at a very
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very low rate submit a complaint both to the health plan and
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to the like regulator of the health plan which might be a
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state agency it might be a federal agency either way it should
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be on like any sort of denial notice or an adverse notice
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you get from your plan you have to submit those complaints and
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they don't have to be that detailed obviously it's better if they
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are but flag that you think something is a parity violation and
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ask it to be investigated as a parity violation because that is
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how you can put that burden back on the plan because again
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they have that requirement in law that they're supposed to perform and
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document that analysis that comparison so ask for that analysis make them
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send it to you make them prove that they did their work
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and then flag it for the regulator because the regulator probably isn't
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going to investigate it unless it's raised to them they they don't
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know what they don't know right so make sure you're raising this
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to the people who can do something about it that is one
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very important thing the other thing get involved in some state-based
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advocacy if you haven't already a lot of states have you know
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different chapters of the like national organizations so there's like NAMI in
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every state there's the American Foundation for Suicide Prevention in all of
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the states there's chapters of the provider associations like the American
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Psychiatric Association Psychological Association social workers there are all
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of these groups that are doing a lot of this state-based
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advocacy already find out what sort of coalition they have or what
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their priorities are and see how you can help there might be
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like a state capital day where you can go and help advocate
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for some of these changes get some of these laws in place
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in your state just do a little bit of googling see what
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exists because they really do need the stories of people with lived
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experience it's the best advocacy is really this combination of stories and
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data because you want to show that this is a systemic problem
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that it's a huge barrier but also put the face to it
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show that these are real people it's not just numbers that are
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being harmed so it's that combination that can make a really big
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difference and it means that even just one voice your story can
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make a difference and help us change some of these laws that
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still perpetuate this discrimination yeah I really like that so I know
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that this conversation has been somewhat brief but there has been so
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much content here if there's something that you would just highlight or
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something that we didn't cover yet that you think is really important
29:58
before