Mental Health Check IN: The United States of America

Every year since 1971, the United States conducts the National Survey on Drug Use and Health (NSUDH) through the government agency Substance Abuse and Mental Health Services Administration (SAMHSA), tracking the self-reported use of legal and illegal drugs as well as mental health disorders. The most recent 2018 data illustrates 7.8% (19.3 million) of Americans report having a substance use disorder, 19.1% (47.6 million) of Americans report having a mental illness, and 3.7% (9.2 million) of Americans report being dually diagnosed (NSUDH, 2018). Behavioral health disorders, which can encompass both mental health and substance abuse affect roughly 1 in 5 Americans (CDC, 2018). In 2018, there were 67,367 drug overdose deaths in the United States and the rates of overdose deaths from synthetic opioids increased by 10% from the previous year (CDC, 2018). In 2019, the National Safety Council reported that Americans were more likely to die from a drug overdose than a car accident. Americans have a serious mental health and drug problem, and it’s only getting worse. One out of every eight emergency room visits are directly related to mental health issues (CDC, 2018). Not only have mental health and addiction issues prevalence massively increased, but “60% of U.S. counties do not have a single practicing psychiatrist” (CDC, 2018). The problem is only getting larger and our ability to solve it is diminishing as time goes continues. Mental health care needs to be addressed now!

Dielman et al., in 2016 analyzed healthcare spending in the year of 2013, and the United States mental healthcare spending was ranked fourth out of fourteen aggregated condition categories, with cardiac disease being number one. $187.8 billion or 8% of all healthcare dollars were spent on treating mental health and substance use disorders (including pharmaceuticals) in the United States in 2013 (Dielman et al. 2016). FAIR Health, a national, independent nonprofit released a 2019 white paper report evaluating private insurance mental health claims from 2007 to 2017, “claim lines with behavioral health diagnoses increased 108%, rising from 1.3% to 2.7% of all medical claims” (Fair, 2019, p 2). The American mental health crisis is only getting worse, less than 3% of all claims are for mental health and sadly, managed care insurance companies severely restrict authorizations for mental health treatment.

The Mental Health Parity and Addiction Equity Act (MHPAEA) was officially signed into law in 2008 (Kennedy Forum, 2020). Webster defines parity as “the state or condition of being equal, especially regarding status or pay” (2020). The 2008 federal parity law requires insurers to cover illnesses of the brain, such as depression or addiction, no more restrictively than illnesses of the body, such as diabetes or cancer (Kennedy Forum, 2020). Unfortunately, even today, in 2020, many private insurance companies violate the law because of overly aggressive managed care tactics (frequent denials of care), as well as, no official governing or regulating body monitoring or even accurately tracking parity violations (Kennedy Forum, 2020). The Department of Labor is responsible for enforcing parity violations, it currently has one investigator for every 12,500 insurance plans (Kennedy Forum, 2020). The United States doesn’t fully realize how big the problem is, and insurance companies want it that way. Even if the department of labor found parity violations, there’s nothing they can really do which is why Secretary of Labor, Alex Acosta told president Trump’s opioid commission, “[I] need the ability to fine violators and to individually investigate insurers, not just employers” (Koons & Tozzi, 2019).

Insurance companies understand they are poorly regulated and continue to vagrantly and unethically deny mental health care on a daily and regular basis in the United States, and the more claims they deny, the higher the profits many of these publicly traded insurance companies make. It's a travesty and must change. Confused and overwhelmed with behavioral health treatment costs that insurance won’t adequately cover, many struggling individuals give up and suffer in silent pain severely exacerbating their mental health/substance abuse issues (Kennedy Forum, 2020). Certain private insurance companies are far worse than others. I believe parity law violation is inhumane and a large reason only 43.3% of U.S. adults with mental illness received treatment in 2018 in the United States (NAMI, 2020). To add injury to insult, a 2019 Milliman report also found that behavioral health providers specifically psychiatrists get on average 20% lower reimbursements than primary care medical doctors (Melek, 2019).

Assessment of Healthcare Policy

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the United States Department of Health and Human Services that is supposed to advance the behavioral health agenda for the nation, as well as, assesses the impact of substance abuse and mental health conditions have on everyday Americans lives. Samhsa’s mission is to reduce the impact of substance abuse and mental illness in American communities (SAMHSA, 2020). Unfortunately, despite Samhsa’s ability to define the mental health epidemic in America, the agency has been lackluster with mental health policy proposals. Based on an exhaustive literature search, the rest of this paper will discuss the assessment and analysis of the bill H.R. 2848 health policy proposals through the framework developed by prolific researcher Dr. Ruth Malone in 2005.  

What is the Problem?

Untreated substance abuse and mental health conditions are disrupting the quality of life for many American citizens. The problem persists because there is a lack of enforcement regarding mental health parity law. Major insurance companies vagrantly deny mental health care for unsubstantiated reasons and violate the federal law from 2008. Since 2008, when Congress passed the parity act, to 2016, the rate at which Americans died by suicide increased 16%. (Koons & Tozzi, 2019). The rate of fatal overdoses jumped 66% in the same period. “The health insurers are not following the federal law requiring parity in the reimbursement for mental health and addiction,” President Trump’s commission on the opioid crisis wrote in its report in November 2017. “They must be held responsible.” (Koons & Tozzi, 2019).

Where is the Process?

Prior to COVID-19 mental health parity had steadily been gaining public attention. In fact, it was even the topic of a hit Neflix special titled, “The Patriot Act” with host Hasan Minhaj in November 2019. The opioid epidemic caused society to realize how severe, large, and prevalent substance abuse and mental health disorders are. President Trump declared the opioid crisis a national emergency on May 4th, 2018, and in October of 2018, President Trump secured 6 billion dollars in new funding to combat opioid addiction. Currently, H.R. bill 2848 proposed in May of 2019 is sitting in the house committee on education and labor.

How Many Are Affected?

As previously reported roughly 1 in 5 Americans endorse a substance abuse or mental health concern (CDC, 2020). Roughly 60 million Americans.

What Possible Solution Could Be Purposed?

The bill H.R. 2848- Parity Enforcement Act was introduced to Congress on 5/20/19 by Donald Norcross. This bill fixes the loopholes caused in 2008 parity act via six proposals below suggested by the Kennedy Forum in 2019.

1) Requiring transparent health plan data reporting.

• Deep inequities currently exist in mental health treatment and insurance companies do not transparently report mental health/substance abuse denial rates, medical/surgical denial rates, utilization review practices, appeals, out-of-network usage and reimbursement. Without the data, how would we measure progress?

2) Giving department of labor the power to fine plans for parity violations and for costs associated with parity investigations.

• Currently, the department of labor lacks the ability to fine parity violations, let alone identify violations. This was a key recommendation by President Trump’s commission on the opioid crisis.

3) Creates a definition of medical necessity.

• Recent landmark federal class action lawsuit (Wit v. United Behavioral Health) determined insurers are not required to use medical necessity criteria that comply with general standards of behavioral health care. Congress should require that all health plans base coverage determinations on generally accepted standards of care and should mandate the use of medical necessity criteria developed by non-profit clinical specialty associations such as The ASAM Criteria and the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS).

4) Expands minimum coverage requirements.

• The Milliman report substantiates that more than 50% of inpatient and outpatient mental health services are provided by out-of-network facilities/clinicians. Insurers continue to deny and exclude intermediate levels of care for mental health and addiction treatment. Congress must make clear that insurers cover the full range of levels of care.

5) Allows for damages recovery related to past parity violations.

• Federal law does not currently give individuals who have been wrongly denied coverage for mental health or addiction care and have been harmed as a result the right to recover damages. Without private enforcement of the Parity Act that compensates for the harm illegal coverage denials cause, people’s rights will continue to hinge on inadequate state and federal regulator activities that fail to uncover or correct many violations.

6) Prohibits ‘discretionary’ clause under the ERISSA Act. The National Association of Insurance

• Commissioners has recommended that states prohibit “discretionary” clauses in insurance policies. If allowed, these clauses give insurers the right to interpret the meaning of their own policies.

What are the Ethical Arguments Involved?

Americans need to take a serious look at what inadequate mental health treatment is currently costing the nation: ER visits, crime, spread of communicable diseases, broken homes, misunderstanding, racism, gun violence, etc. Some ethical considerations when evaluating mental health parity law include cost, access to care, appropriate length/duration of care, and use of pharmaceuticals. Total spending for mental health services from 2013-2017 (excluding prescriptions drugs) and expressed as a percentage of total healthcare spending has remained consistent between 2.2-2.4% and spending for substance abuse treatment increased from 0.7% of total healthcare dollars in 2013 to 0.9% of total healthcare dollars in 2017 (Melek, 2019). Substance Abuse treatment sees less than 1% of healthcare dollars spent on direct patient care. This data highlights the profound lack of financial attention mental health has received. More than half of all mental healthcare spending in the United States is not even going to providers, it’s going to pharmaceutical companies. Regarding access to care, mental health has a unique situation in the United States, whereby an overwhelming majority of behavioral health services are performed by out-of-network providers. From 2013 to 2017 the disparity between how often behavioral health inpatient facilities are utilized vs out-of-network relative to medical/surgical inpatient facilities has increased from 2.8 times more likely to 5.2 times more likely or an 85% increase over 5 years (Melek, 2019). For outpatient facilities, utilization of out-of-network programs has increased 90% over 5 years (Melek, 2019). Why don’t insurance companies have more in-network providers? According to Koons and Tozzi, “Patient’s frequently complain of ‘ghost networks’- insurance directories full of clinicians listed as in-network, who in fact aren’t even contracted with the plan,” and in many cases not even alive (Koons & Tozzi, 2019). Behavioral health facilities also report major insurance companies taking more than a year to respond to their requests to contract and become an in-network providers. Is it possible insurance are intentionally sabotaging mental health treatment in the United States? Moreover, the disparities even amongst commercial carriers is noted. For example, Magellan and Aetna are both insurance companies that manage behavioral health benefits. Both claim to use the same criteria when determining length of stay and level of care; however, documented evidence has shown Magellan violates their own guidelines on parity law on a daily basis, Magellan frequently gives 25-35% of the length of care authorizations in comparison to other commercial payers. This goes on uncontested and largely out of the public’s eye on a daily basis in the United States. Finally, the last ethical consideration deals with the use of medication assisted treatment (MAT), where the goal is harm reduction. Does MAT help or hurt patients in substance abuse treatment? At the end of the day more research needs to be done; however, an ethical consideration would be the appropriate cost of MAT medications.

At What Level is the Problem Most effectively Addressed?

At the federal or national level.

Who is in the Position of Making Policy?

Currently, the committee on education and labor in the United States House of Representatives has the bill. The following are co-sponsors: Joe Courtney, Ann Kuster, Brian Fitzpatrick, Tim Ryan, Betty McCollum, Harley Rouda, Kendra Horn, Andy Kim, Katie Porter, and David Trone. Additional stakeholders regarding mental health parity include the president of the United States and the rest of congress.

What are the Obstacles to Policy Intervention?

Powerful and well-funded pseudo insurance lobbying groups that claim to fight for mental health parity and voting in the house of representatives and insurance companies refusing to make meaningful changes.

What Resources are Available?

In California, patients are able to report insurance companies to the Department of Managed Care; however, this often takes longer than 30 days for a decision to be rendered. The Kennedy Forum.

H.R. 2848 – Parity Enforcement Act of 2019

The bill was introduced in the House of Representatives 116th Congress by Representative Donald Norcross on 05/20/2019 and is currently sitting in the house committee on education and labor (Congress.gov, 2020).

Conclusion

The way behavioral health is treated by insurance companies needs to change. Clear identification of the problem, deep analysis and the prioritization of policies will change the way behavioral health: mental health and substance abuse treatment is administered in the United States of America. Based on the evidence a much-needed change needs to come, less thousands if not millions more Americans will continue to suffer.

References

Centers for Disease Control and Prevention. (2020).

Davenport, S., Gray, T., & Melek, S. (2019). Addiction and mental health vs. physical health: Widening disparities in network use and provider reimbursement. Milliman Research Report. The Bowman Family Foundation. Retrieved from https://millimancdn.azureedge.net//media/milliman/importedfiles/ektron/addictionandmentalhealthvsphysicalhealthwideningdisparitiesinnetworkuseandproviderreimbursement.ashx

Dieleman JL, Baral R, Birger M, et al. (2016). US Spending on Personal Health Care and Public Health, 1996-2013. JAMA. 2016;316(24):2627–2646. doi:10.1001/jama.2016.16885

Gilbert, N., & Terrell, P. (2014). Dimensions of social welfare policy. Essex: Pearson Education Limited.

Kennedy, P. (2020). Revolutionizing and Standardizing Mental Healthcare. Retrieved from https://www.thekennedyforum.org

Koons, C., & Tozzi, J. (2019). As Suicides Rise, Insurers Find Ways to Deny Mental Health Coverage. Retrieved from https://www.bloomberg.com/news/features/2019-05-16/insurance- covers-mental-health-but-good-luck-using-it

National Safety Council. (2018). Preventable Deaths. Odds of Dying. Injury Facts (Retrieved from https://injuryfacts.nsc.org/all-injuries/preventable-death-overview/odds-of-dying/data-details/)

Merriam-Webster. (n.d.). Parity. In Merriam-Webster.com dictionary. Retrieved May 9, 2020, from https://www.merriam-webster.com/dictionary/parity

U.S. Department of Health and Human Services, Substance Abuse and Mental HealthServices Administration, Center for Behavioral Health Statistics and Quality. (2018). National Survey on Drug Use and Health 2018. (Retrieved from https://datafiles.samhsa.gov/