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Introduction
The Mental Health Parity and Addiction Equality Act (MHPAEA) of 2008 was a landmark legislative document that sought to establish parity of mental health care and standard care. It forced insurance companies to cover mental health conditions, such as substance abuse, treatment, and other illnesses pertaining to ones psychological well-being (Beronio et al., 2014). According to the Act, they were supposed to be equally covered, just like any other conditions. Prior to the introduction of the bill, mental health services were paid largely out of pocket and not covered by many (if any) insurance plans (Beronio et al., 2014). MHPAEA pushed to include these concepts as laws on the federal and state levels.
Nevertheless, despite some progress having been made, the implementation of MHPAEA 12 years after its introduction had not been systemic and sporadic at best. Davenport et al. (2019) report that between 2013 and 2017, the likelihood of out-of-network patient services, when compared to their medical and surgical counterparts, increased by 85%. The disparity between both types of visits in the same time period increased by five times, and reimbursements for standard care vs. mental health care increased by 50% in 11 states and by 30-50% in 13 more states (Davenport et al., 2019). These tendencies are explained by the differences between federal and state interpretations of the act and a lack of facilities to offer mental health services. These issues, combined together, allow for insincere insurance companies to avoid providing the services they owe through various means. The purpose of this lobbying proposal is to provide a basis for increasing the number of mental health medical facilities on a state level and promoting standardization of policies on that level as well.
Description of Settings
The settings in which the lobbying efforts will focus include the general public, health, and educational settings. Choudhry et al. (2016) indicate that public support is crucial to lobbying efforts, and these settings are the ones that allow for reaching the most individuals potentially interested in supporting the issue. The public setting will include various means of reaching for support, including traditional advertising channels as well as social media and the internet. Healthcare setting includes hospitals and other facilities where patients can be reached by the personnel. Finally, educational settings such as universities may influence students, who are some of the most active political proponents.
Plan Objectives
The objectives of the plan are as follows:
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Provide a solid evidence-based foundation for the proposed legislative changes;
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Provide a plan of action for the promotion of goals lobbied for;
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Achieve the increase of mental health facilities in the chosen state over the next 5 years;
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Promote the attention to the inefficiencies of the existing Act in the federal government.
Should these goals be achieved, the situation for the patients may change on both the legislative and ground levels, resulting in better availability, quality, and reimbursement rates.
Argument Section
State of Knowledge About the Issue
The backbone of knowledge about the issue was accumulated in the Milliman report by Davenport et al. (2017), which provides data from 37 million employees and independent practitioners from all 50 states. Some of the major findings include disparity in the use of out-of-network inpatient services, disparity in office visits, reimbursement rates, and the utilization of SUD facilities. It has been found that since 2013, people have been using out-of-network inpatient services 2.8 times more than in-network services (Davenport et al., 2017). Since then, that proportion increased to 5.2 times in 2017, and even more so during the COVID-19 pandemic, as many individuals lost the means of supporting their insurances, thus being barred out of any legitimate ways of using network-based services (Davenport et al., 2017). Overall, despite the law, nowadays we have a more than 85% increase in the use of mental health services not covered by insurances since 2013.
Office visits, which are an integral part of clinical practice and supervision, are also heavily skewered in favor of out-of-network services. The report states that the difference in number between doctors seeing visiting patients as part of network was lower by 5.0 times during 2013 and by 5.4 times in 2017 (Davenport et al., 2017). Thus, patients are more than 5 times more likely to receive the service they need as part of out-of-pocket services than those covered by insurance. Overall, the difference is over 540%, which was exacerbated even more during the epidemic.
The report shows that providing mental health services at a decreased cost is not financially rewarding for organizations. Davenport et al. (2017) state that in 23 states, the reimbursement rates for mental healthcare were actually lower than those provided for regular healthcare services. The difference varies between 30-50% for these 24 states, with 11 states out of them having a 50% difference (Davenport et al., 2017). This kind of practice pushes healthcare facilities to not sign agreements with insurance companies and joining networks, preferring patients to cover the expenditures of the hospital on their own.
Finally, the use of facilities necessary for maintaining and treating mental health patients is skewered unfavorably towards out-of-pocket agreements. Between 2013 and 2017, the likelihood of patents being forced to use out-of-network facilities increased from 4.7 times to 10.1 times (Davenport et al., 2017). This tendency shows that the in-network facilities are either too few and far between or too underequipped to deal with the needs of patients. Likewise, many insurance companies still do not offer comprehensive mental healthcare plans despite the introduction of the Act in 2008.
Current Status of Actions Taken
Some of the actions that have been taken under the premise of the act have included progress in addressing and reducing some of the obvious discrepancies in treatment. These barriers, which have been present before the Act, included stricter limits on the number of mental health visits, including in-patient and outpatient care (Friedman et al., 2018). Other issues involved separate prior authorization requirements, separate deductibles, and copays (Friedman et al., 2018). These issues have been placing hurdles between the patients and healthcare providers, and allowed for insurers to avoid providing these services. On a legislative level, however, many of these barriers for mental health and substance use disorders have either been reduced or eliminated, with insurers being forced to implement more subtle discriminatory practices.
A strong push to improving the status of MHPAEA came in 2010 with the adoption of the Affordable Care Act (ACA). Prior to it, the Mental Health Parity Act only applied to larger employers and the health plans they provided, which was incredibly discriminatory and inefficient (Barry & Huskamp, 2011). Since 2010, this Act was being spread to cover both small group plans and individual plans. In addition, ACA forced the providers of said plans to cover essential health benefits, including mental health issues and substance disorders (Barry & Huskamp, 2011). The prior iteration of MHPAEA did not require a mandatory inclusion of behavioral health plans, making it deficient and pointless, with ACA essentially establishing the Act in a way it was intended to be in the first place.
Other efforts to improve the Act and its effectiveness across the US included better supervision, enforcement, and oversight of corporate practices. However, the efforts to achieve that at a bipartisan level have either died or are currently ongoing. The Florida Senate Bill 360, for example, had failed to go past the committee (Mulvaney-Day et al., 2019). A new bill proposed by the Republican party and looking for bipartisan support is still in the works, and with the speed of how bills are reviewed and approved, it is unlikely for it to become online until 2023. The only example of a successful state-wide enforcement law can be found in Illinois, which provided a stern and rigorous framework to include mental health care coverage at a school, country, and local level (Mulvaney-Day et al., 2019). This legislation is the reason why Illinois is the only state with a mark higher than C in mental health coverage and availability (Davenport et al., 2017).
Evaluation of Effectiveness
As it is possible to see, the earlier engagements with the provisions of the Act at a legislative level worked very well. The ACA of 2010 managed to eliminate most of its major weaknesses at a scope level by including everyone that was supposed to be included in the first place under its provisions (Dave & Mukerjee, 2011). It is possible to consider that this level of improvement was easy to perform, as ACA effectively eliminated glaring weaknesses, leaving only the smaller and more subtle issues to improve. One of these major issues includes the implementation of the Act at the state level.
One of the major problems that currently impedes state-level legislations in regards to oversight revolves around the fact that definitions of various terms in the Act are extremely vague. It has been found that many states lack consistent definition with what constitutes mental health and substance treatment disorders, allowing insurers to utilize these inconsistencies to avoid providing the service by interpreting the existing patient disorders as something that does not fall under the provisions of the Act (Fritz, 2012). In addition, it has been reported that numerous states actually lack the will and desire to enforce the intent of the act by promoting the push for more concrete definitions, much like in Illinois. The failure of the Floridan Senate Bill 360 is a clear example of that, often attributed to having strong insurer lobbies working against it.
Finally, the lack of a clear mental healthcare structure at the local and country levels allows insurance companies to implement a type of ghost network. This is a practice where insurers make up fake organizations and doctors to refer individuals towards (Shana, 2020). Alternatively, they place their networks too far outside of the patients reach, making it that it is more convenient for them to pay out of pocket than travel to another county to see a doctor (Shana, 2020). This malignant practice has been born from a lack of consistent definitions, legislations, and general oversight prohibiting companies from implementing such measures (Winkelman et al., 2016). The justifications often used by insurers to either cover up their network or spread it thin across a state is the perceived lack of mental health facilities and services in their selected location a concern that is partly justified.
Based on these findings, it can clearly be seen that legislations that seek to counter the obvious deficiencies of the Act at a federal level are successful, but promulgating changes at a state level is difficult. The Illinois case can be taken as an example on how to do it right by acquiring extensive public support and providing a holistic solution to a problem. Their experience revolves around seeking to both enhance access to mental health facilities and remove any ways for insurer companies to avoid responsibility for not providing the services as required of them by the Act.
Action Section
Proposed Solutions
The proposed solution is to emulate the Illinois model at a state level and introduce a state-supported program to increase the number of mental healthcare providers and facilities, while forcing insurers to provide these services to the public. In essence, this plan involves lobbying for two actions, which are attached one to another. Government support of mental healthcare would allow for more facilities to be available to the general public (Davenport et al., 2017). Competition between them would help drive prices down, which is a positive outcome in its own accord. At the same time, it will form a basis for insurer companies to create networks out of real and locally-available specialists, rather than implementing ghost-networks or spreading themselves thin (Shana, 2020). The second part involves promulgating a bill on a state level that would provide clear definitions for mental health issues and substance abuse congruent with statutes of the Act, as well as a set of provisions obligating insurers to cover these services for people having insurance, while making them available and reachable. In essence, companies must be restricted to provide services within the area in which the receiver of the insurance lives.
Resources Needed
Resources needed for successful achievement of the plan include financial, lobbying, and professional assets. Instigating a state-wide program for enhancing and providing access to better mental healthcare would require attracting professionals, building and staffing facilities, and encouraging businesses to contribute. This will require money, which could be received by applying for state or federal grants as well as promoting investment from the private sector. Lobbying resources would be required to help promulgate the proposed action in the senate, while counteracting any attempts to take down the bill made by the pro-insurer lobby, which benefits from the status quo. Finally, informational and professional resources are needed to adequately plan and justify with evidence the proposed action before the public and the senators.
Expected Effectiveness
The expected effectiveness of the bill is estimated based on the success of the Illinois model. While most other states without such bills are graded at levels F or E in terms of their accessibility to mental healthcare, Illinois has been boosted to C or higher, through the provision of that legislature alone (Davenport et al., 2017). It is expected that the proposed solution would help improve the quality and availability of healthcare at a county level, by establishing new mental health clinics and augmenting the existing ones to provide these kinds of services. In addition, the clear definitions and provisions of duty for insurance companies would help curtail their practices of trying to avoid their duties to clients and force them to provide support for mental health and addiction disorder patients (Friedman et al., 2018). As a result, the overall state of the issue would be improved patients would receive more and better network-based care, reduce expenditures, and have access to services within their general vicinity.
Measurable Outcomes
Measurable outcomes for the lobbied legislature can be borrowed from the Milliman report framework, which involved 4 metrics: disparity in the use of out-of-network services, office visits (in vs. out-of-network), reimbursement rates, and in-patient facilities (Davenport et al., 2017). As it is possible to see, currently all of these parameters are on the rise, indicating that the system is not working as it is supposed to. Achieving the reduction of these parameters at a state level would indicate that the proposal has been a success. Additional metrics to evaluate the success of the proposal include the increase in the number of mental health facilities, their spread across individual counties, and the overall mental health state of the population (Friedman et al., 2018). The Act and its statutes aim to improve the wellbeing of the general population, making it a metric through which the effectiveness of any measures could be perceived. Overall, these metrics should help the legislators and the general populace understand to which degree the solutions offered serve the public good.
Conclusions
The Mental Health Parity Act of 2008 was an important first step to improving the mental health status of the general populace by offering a legislative standard to force insurers to cover for mental health and substance abuse disorders. At the same time, the provisions of the Act were incomplete. In 2010, ACA removed its most obvious glaring flaws, but the differences between state-to-state legislations left it in a vulnerable position. As it stands, only Illinois had passed a comprehensive set of state legislations to remove some of the major blank spots in their mental health laws. The effectiveness of the Act implementation was greatly boosted as a result. Nevertheless, there is still much to do be done in order to insure real parity between physical and mental health in terms of availability, affordability, and coverage.
The solutions for lobbying as proposed in this paper suggest following their example and focus on two major areas: increasing the availability of mental healthcare providers in general and removing any legislative inconsistencies that allow for either refusing to cover for patients expenditures or partially redirecting them to out-of-pocket payments. The expected results include the increase of the number of providers in the state, the increase in the general availability of services, and improvements in insurance practices. The proposed metrics to be utilized to evaluate the effectiveness of the proposal, should it be accepted, includes the 4 metrics utilized in the Milliman report, the overall number of practitioners and service providers, and the general mental health state of the population on a state level. If the state manages to approach or surpass Illinois in these parameters, then the effort would constitute a relative success. Ultimately, it is up to each state to ensure the best interests of their populace by putting the statutes of the Act into practice in a way its intended purposes are not supplanted by the insurers.
References
Barry, C. L., & Huskamp, H. A. (2011). Moving beyond paritymental health and addiction care under the ACA. The New England Journal of Medicine, 365(11), 973.
Beronio, K., Glied, S., & Frank, R. (2014). How did the Affordable Care Act and Mental Health Parity and Addiction Equity Act greatly expand coverage of behavioral health care? The Journal of Behavioral Health Services & Research, 41(4), 410-428.
Choudhry, F. R., Mani, V., Ming, L. C., & Khan, T. M. (2016). Beliefs and perception about mental health issues: A meta-synthesis. Neuropsychiatric Disease and Treatment, 12, 2807.
Dave, D., & Mukerjee, S. (2011). Mental health parity legislation, costsharing, and substance abuse treatment admissions. Health Economics, 20(2), 161-183.
Davenport, S., Gray, T. J., & Melek, S. P. (2019). Addiction and mental health vs. physical health: Widening disparities in network use and provider reimbursement.
Friedman, S. A., Thalmayer, A. G., Azocar, F., Xu, H., Harwood, J. M., Ong, M. K. & Ettner, S. L. (2018). The mental health parity and addiction equity act evaluation study: impact on mental health financial requirements among commercial carvein plans. Health Services Research, 53(1), 366-388.
Fritz, G. K. (2012). The long road ahead to mental health parity. Journal of the American Academy of Child and Adolescent Psychiatry, 458-460.
Klonsky, E. D., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal ideation. Annual Review of Clinical Psychology, 12, 307-330.
Mulvaney-Day, N., Gibbons, B. J., Alikhan, S., & Karakus, M. (2019). Mental Health Parity and Addiction Equity Act and outpatient behavioral health services in the United States, 20052016. American Journal of Public Health, 109(S3), S190-S196.
Shana, A. (2020). Mental health parity in the US: Have we made any real progress? Psychiatric Times, 37(6), 1-10.
Winkelman, T. N., Kieffer, E. C., Goold, S. D., Morenoff, J. D., Cross, K., & Ayanian, J. Z. (2016). Health insurance trends and access to behavioral healthcare among justice-involved individualsthe United States, 20082014. Journal of General Internal Medicine, 31(12), 1523-1529.
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