While the federal parity law and the Affordable Care Act (ACA) have served to remove several of the systemic barriers to equitable addiction and mental health services, challenges ranging from provider shortages to the possibility of small employers fleeing from the mandates of parity continue to cloud the long-term picture for consumers and families. Those are some of the conclusions laid out in a health policy brief issued by Health Affairs and the Robert Wood Johnson Foundation earlier this month.
The four-page brief chronicles the key developments in parity-related legislation from Congress's passage of a limited parity law in 1996 to the ACA's application of the more comprehensive 2008 parity law to individual market and insurance exchange plans, as well as last year's issuance of a final rule for the 2008 law that disallows health plans from imposing different “non-quantifiable treatment limitations” on mental health/substance abuse benefits based on recognized standards of care.
The document states that while the ACA expanded the reach of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) in part by including behavioral health coverage as one of 10 essential health benefits, it will be important to watch the extent to which parity is enforced via close monitoring of insurance company practices.
According to the brief, “State insurance commissioners have primary enforcement authority over health insurance issuers, but they are busy with ACA implementation and enforcement activities, so MHPAEA compliance may be low on their priority list.”
The health policy brief, written by health policy consultant Sarah Goodell, cites several factors that could continue to cause problems with access to mental health and substance use services. It mentions a 2009 Health Affairs article that stated that two-thirds of primary care doctors reported being unable to access outpatient mental health services for patients who needed them. “Mental health professionals tend to be concentrated in high-population, high-income areas, and the lack of mental health care providers in rural areas as well as in pediatrics has been well documented,” the brief states.
Also, the insurance industry continues to wrestle with behavioral health treatments that don't have a direct equivalent service in general medicine and that therefore present a challenge when evaluating equivalent terms of coverage. The brief states, “As one health insurance executive noted, 'How to provide coverage for care levels and treatment venues that are unique to behavioral health, and aligning these with medical and surgical benefits, is a continuing discussion within health plans and between plans and regulators.'”
The policy brief also cited fragmented service delivery as a lingering obstacle to high-quality care, even with the presence of parity. Use of separate behavioral health carve-out companies that manage addiction and mental health benefits is partially to blame. “One challenge for group health plans is to integrate and coordinate mental health and substance use care with medical care despite using separate administrators,” the brief states.
And while the MHPAEA certainly took a more far-reaching approach than the federal parity law that preceded it, numerous plans remain not subject to its requirements, including self-insured companies of fewer than 50 employees and self-funded non-federal governmental plans. “It remains to be seen whether small employers will self-insure at a greater rate, possibly by purchasing stop-loss coverage to limit their liability, in order to be exempt from [essential health benefits] and therefore parity,” according to the policy brief.