New rules needed to improve mental health, substance use care

To understand why the Biden Administration announced new rules last month to improve mental health care, look no further than ProPublica’s reporting on this issue in August.

Nearly all Americans have health insurance, but health insurers limit such care for millions of consumers by paying mental health providers too little, forcing providers to quit insurance networks, Maya Miller and Annie Waldman wrote for ProPublica. “Our reporting also documented how consequences can be fatal when patients can’t find therapists or mental health treatment,” they added.

Pay more or forego care

Miller and Waldman worked with two other ProPublica reporters, Duaa Eldeib and Max Blau, to interview more than 500 mental health therapists, including psychologists and psychiatrists, many of whom were driven out of the profession. The result: consumers with health insurance were forced to pay out of pocket or forego care, ProPublica reported in this article, “Why I Left the Network.” NPR published the same story on Aug. 25: “Finding a therapist who takes your insurance can be nearly impossible. Here’s why.”

The therapists told ProPublica they joined health insurers’ networks to reach patients needing mental health care who could not afford to pay out of pocket. But even in those networks, therapists confronted an insurance system set up to squeeze them out, the reporters wrote. While almost all Americans have health insurance, the therapists found that about half of those consumers with mental illness could not access treatment, ProPublica explained.

The new rules will make it easier to hold health insurers accountable for complying with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which expanded on the Mental Health Parity Act of 1996, according to this report from the Milbank Quarterly. Federal and state laws on mental health parity require insurers to provide the same access to mental health care that they provide to consumers needing medical care.

Despite such laws, health insurers often restrict coverage for mental health and delay or deny treatment, ProPublica explained. The reason: “These patients — whose disorders can be chronic and costly — are bad for business, industry insiders told ProPublica,” the reporters wrote.

Mental health stories to cover

For journalists covering mental health, the consumer and patient angles will be particularly important because so many Americans have trouble finding in-network therapists. A related story is whether health insurers say they have enough mental health providers to meet the demand for such care.

As ProPublica showed, insurers’ claims about having robust networks of providers are mostly false. The larger problem may be that the rates they pay therapists are too low and the barriers they put between therapists and patients are too high, ProPublica explained.

Another angle to pursue is that employers will complain that the new rules will drive up their health insurance costs, forcing them to drop mental health care, as Sara Hansard reported for Bloomberg Law in February.

Even before the Biden administration issued the new rules, the consulting firm PwC predicted in July that employers would pay as much as 8% more next year for medical care than they paid this year. The ERISA Industry Committee, a trade group for U.S. employers with large health plans, said the new rules could cause those costs to rise, as Amina Niasse reported for Reuters.

Rules will affect 175 million Americans

These stories are important because the new rules will affect employers that offer private health insurance and mental health care to the 150 million Americans who have insurance through their employers and the more than 250,000 Americans who have health insurance through the individual marketplace, according to the federal Department of Labor.Non-federal or state-government jobs, said Tim Clement, vice president of federal government affairs at Mental Health America, a nonprofit organization in Washington, D.C., that advocates for policy and legislation to improve MH care.

Given the high demand for mental health and substance use disorder services, health insurers need to boost payment rates to therapists, said Tim Clement, vice president of federal government affairs at Mental Health America, a nonprofit organization in Washington, D.C., that advocates for policy and legislation to improve MH care.

In an interview, Clement explained that the new rules will help federal health regulators assess insurers’ rates and their networks.

“Network composition is a big focus of the new rules,” he commented. In some areas, he said, there may be enough therapists, but they could be out of network because the in-network rates are too low.

Preventing limits on treatment

An important aspect of the new rules, Clement noted, is that they prohibit insurers from having more restrictive limits on mental health and substance use disorder than they have for medical and surgical care. The law defines such restrictions as non-quantitative treatment limitations that control the scope or duration of benefits, such as prior authorization requirements, step therapy and standards for adding in-network therapists, according to this statement from the three federal agencies implementing the new news, the departments of Health and Human Services, Labor, and Treasury.

When announcing the new rules, the White House cited research showing that in 2019 about 21% of adults over age 18 had mental illness, and 14.5% of individuals over age 11 had substance-use disorder. Yet, only 46.2% of those adults got mental health care and only 6.5% of those with substance-use disorder got treatment.

In addition, the White House said insured consumers were almost four times more likely to go out-of-network and pay more for mental health care than if they needed physical care, according to a study that RTI International published in April. “And the problem is getting worse: in recent years, the gap between usage of out-of-network care for mental health and substance use disorder benefits versus physical health benefits increased 85%,” the White House added.

Two years earlier, the federal Government Accountability Office reported similar problems in this report, “Mental Health Care: Access Challenges for Covered Consumers and Relevant Federal Efforts.” Consumers had trouble finding in-network therapists who accept new patients, the report said, adding that low payments to providers contributed to this problem and that some providers got paid more outside of plans’ networks.

Some of the rules will be effective on Jan. 1, 2025, Clement said, but most of the requirements will go into effect on Jan. 1, 2026.

Resources

• “Departments of Labor, Health and Human Services, Treasury Issue Final Rules Strengthening Access to Mental Health, Substance Use Disorder Benefits,” Sept. 9, 2024.
• “Leading Healthcare Stakeholders Respond to Administration Change to Mental Health Parity Act,” ERISA Industry Committee, Sept. 9, 2024.
• “I Don’t Want to Die”: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network,” ProPublica, Sept. 8, 2024.
• “Behavioral Health Parity – Pervasive Disparities in Access to In-Network Care Continue,” RTI International, April 17, 2024.
• “Factors Affecting State-Level Enforcement of the Federal Mental Health Parity and Addiction Equity Act: A Cross-Case Analysis of Four States,” Journal of Health Politics, Policy and Law, Feb. 1, 2023.
• “Narrow Networks Get Even Tighter When Shopping For Mental Health Specialists,” KFF Health News, Sept. 22, 2017
• “Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care,” JAMA Psychiatry, February 2014
• “A Political History of Federal Mental Health and Addiction Insurance Parity,” The Milbank Quarterly, September 2010.

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