This cover letter reflects the main idea and position of the research team regarding The Mental Health Parity and Addiction Equality Act. Studies have shown that the application of this Act was the most crucial step towards achieving equal opportunities in obtaining insurance services for mental health. Nevertheless, there are several assumptions in this law, which have been actively used by unscrupulous insurance companies, indirectly and implicitly restricting patient access to medical services. In this regard, a lobbying plan was prepared, determining the vector of struggle against such companies and offering solutions to the problem.
The researching group plans to use the Illinois statewide model as a perfect example and propose a government-supported program to increase the number of mental health providers and facilities. The intervention must occur at the federal level since only the authorities can eliminate the breach in the law. The literature examined below shows that cases of unfair use of this gap by insurance companies have become more frequent, and the problem has become especially aggravated against the backdrop of the pandemic. In this regard, it is needed to request a meeting with a representative to lobby for this plan involving interested parties.
Introduction
The Mental Health Parity and Addiction Equality Act (MHPAEA) of 2008 became an essential piece of legislation that aimed to establish equality between standard care and mental health. This document forced insurance companies to cover mental disorders such as substance abuse, treatment, and other illnesses related to a person’s psychological well-being equal to other conditions (Beronio et al., 2014). Before the law was introduced, mental health services were primarily out of pocket and were not covered by many insurance plans, often not designed for this purpose (Beronio et al., 2014). In addition, insurance companies not only had to provide a level playing field for these programs but also relieve them of any restrictions that provide less good service. This Act eradicated the historical situation in which mental health care was often not covered at the same level as medical care.
However, despite some progress, the implementation of MHPAEA 12 years after its introduction did not achieve the desired results and was largely sporadic. Davenport et al. (2019) report that between 2013 and 2017, the likelihood of providing services to patients outside the network increased by 85% compared to their medical and surgical counterparts. The difference between both types of visits increased 5-fold over the same period, and compensation for standard care versus mental health care increased 50% in 11 states and by 30-50% in 13 other states (Davenport et al., 2019). These trends are attributed to differences in federal and state interpretations of the law and a lack of mental health services. Progress has also been made against the backdrop of the government’s fight against drugs, but the result falls short of the original targets in the long term. Collectively, these problems allow unscrupulous insurance companies to avoid providing the services they need in various ways.
Description of Settings
The conditions on which lobbying efforts will focus include the public, health, and education. Choudhry et al. (2016) point out that public support is critical to lobbying efforts, and it is these dimensions reach the majority of people potentially interested in supporting an issue. In this case, attention can contribute to the promotion of the original ideas of the Act, which were supported at the state level from the very beginning. The public environment will include a variety of ways to seek support, including traditional advertising channels, social media, and the Internet. A healthcare facility includes hospitals and other facilities where staff can contact patients. Finally, educational institutions such as universities can influence students, among the most active political supporters. Such an integrated approach will attract the attention of all potentially interested parties due to the urgency of the problem.
The Act provides for work not only with individuals but also with group plans of insurance companies. In this regard, the interest of private labor groups is increasing, for which this aspect is vital in terms of working conditions and labor benefits. At the same time, the Ministry of Labor and the Treasury have jurisdiction in this matter. The plan has various loopholes for small groups that are indirectly regulated at the state level (Gertner et al., 2018). Opportunities for circumvention of the law open up for employers, insurance companies, and through compliance with the law: there are several restrictions on its application. For example, small groups and small self-insured employers or large, self-funded non-government government employers, however, must be exempt from this program (Gertner et al., 2018). This Act is intended to make mental health assistance available; therefore, it is needed to take the comprehensive approach described above to solve a complex problem.
Plan Objectives
The objectives of the plan are as follows:
- Provide a solid evidence-based foundation for the proposed legislative changes;
- Provide a plan of action for the promotion of goals lobbied for;
- Achieve the increase of mental health facilities in the chosen state over the next five years;
- Strengthen control over the implementation and implementation of fundamental changes introduced by the Act;
- Promote 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 prerequisites for the above problems are the appeal to out-of-network healthcare providers, the pandemic, and the financial side. Extensive research on this issue was compiled in a report by Milliman Davenport et al. (2017), presenting data from 37 million employees and independent practitioners from all 50 states. The main findings include disparities in out-of-network in patient services utilization, inequities in-office visits, reimbursement rates, and SUD facility utilization. Since 2013, people have been found to have used out-of-network in patient services 2.8 times more than on-net services (Davenport et al., 2017). Since then, this proportion has increased to 5.2 times in 2017, even more so during the COVID-19 pandemic, as many people have lost funds to support their insurance, thereby losing any legitimate use of network services (Davenport et al., 2017). Overall, despite the law, we currently have over 85% growth in the use of uninsured mental health services since 2013 (Davenport et al., 2017). This trend leads to a deterioration in the quality of patient care, as there is much less control over non-network facilities.
Office visits, an integral part of clinical practice and supervision, also strongly favor out-of-network services. The report states that the difference in the number of doctors visiting patients within the network was 5.0 times less in 2013 and 5.4 times less in 2017 (Davenport et al., 2017). Thus, patients are more than five times more likely to receive the services they need as part of a paid service than those covered by insurance. In general, the difference is more than 540%, which was further exacerbated during the epidemic with the corresponding restrictions, the burden on medical institutions, and a shortage of qualified personnel, medicines, and much more.
The report shows that providing mental health services at a reduced cost does not benefit organizations. Davenport et al. (2017) argue that in 23 states, reimbursement rates for mental health care were lower than for conventional health care services. The difference ranges from 30-50% for these 24 states, with 11 states of which the difference is 50% (Davenport et al., 2017). This practice forces healthcare providers not to sign agreements with insurance companies or join networks, preferring to have patients cover hospital costs themselves. Against the background of a significant decrease in the paying capacity of the population due to the loss of jobs or the suspension of the activities of many organizations, medical institutions are experiencing an acute shortage of funding. Considering that the USA allocates the most significant funds globally for medicine, the problem is acquiring a national scale.
Finally, the funds needed to support and treat patients with mental disorders adversely affects cash agreements. Between 2013 and 2017, the likelihood of patents being forced to use off-chain objects increased from 4.7 times to 10.1 times (Davenport et al., 2017). This trend shows that on-chain facilities are either too few and far apart or poorly equipped to meet patient needs. Likewise, many insurance companies still do not offer comprehensive mental health plans, despite the Act’s passage in 2008. There is no uniform system of fines for these insurance companies; as a result, the companies break the law with impunity. Intra-network institutions should be funded at the federal level since the problem requires a comprehensive and large-scale solution in order to qualitatively meet the entire demand for this kind of medical service in such a difficult time.
In connection with the pandemic, the very need for mental health care has increased, in connection with which the burden on the relevant institutions has increased. Identifying the main reasons for the loss of loved ones, forced and prolonged isolation, as well as loss of income, the researchers emphasize the two-sided nature of the problem: as a result, both medical institutions that have nothing to fund their activities and potential patients left without help are losing (Pfefferbaum & North, 2020). Against the background of problems, people are more likely to resort to psychotropic substances that worsen the state of mental health, which leads to insomnia and constant anxiety. In addition, COVID-19 itself can lead to stroke and other psychological complications. Patients with these illnesses are more prone to contracting a virus infection and more difficult to tolerate the consequences of the illness (Pfefferbaum & North, 2020). In this regard, now the critical moment for the government is to focus on this issue. The authorities remain the only source of essential activities and funding that could change the stalemate for healthcare facilities and potential patients.
Current Status of Actions Taken
Some of the actions taken following the premise of this law included progress in eliminating and reducing some of the apparent gaps in the approach. These pre-Law barriers included stricter restrictions on the visits quantity, including inpatient and outpatient care (Friedman et al., 2018). Other issues related to individual prior authorization requirements, individual deductibles, and copayments (Friedman et al., 2018). These problems create barriers between patients and health care providers and allow insurers to avoid providing these services. At the legislative level, an attempt was made to remove these barriers, which were associated with the use of psychoactive substances, but insurance companies found more subtle ways to circumvent the law.
A strong push to improve the status of the MHPAEA was given in 2010 with the adoption of the Affordable Care Act (ACA). Previously, the Mental Health Parity Act only extended to large employers and their health insurance plans, which was incredibly discriminatory and ineffective (Barry & Huskamp, 2011). Since 2010, this law has extended to both small group plans and individual plans. In addition, the ACA forced the providers of these plans to cover essential health benefits, including mental health problems and substance use disorders (Barry & Huskamp, 2011). The previous iteration of the MHPAEA did not mandate the inclusion of behavioral health plans, which made it imperfect and meaningless, and the ACA essentially established the Law as it was initially intended.
Other efforts to improve the Law and its effectiveness in the United States have included improved oversight, enforcement, and oversight of corporate practices. However, attempts to achieve this at a bipartisan level have either died or continued. For example, Florida Senate Bill 360 did not pass by the committee (Mulvaney-Day et al., 2019). A new bipartisan GOP bill is still in the works, and given the speed at which bills are considered and approved, it is unlikely to hit the web before 2023. Single Successful Government – Illinois has broad law enforcement that has provided a rigorous and robust framework for including mental health coverage at school, national and local levels (Mulvaney-Day et al., 2019). This legislation is why Illinois is the only state with a score above C in mental health coverage and accessibility (Davenport et al., 2017). However, there are still several problems that prevent the Act’s implementation by providing insurance assistance to all people who need it.
Firstly, insurance companies create preferential conditions, according to the Act, only for healthy people. Patients requiring immediate care face substantial medical costs (Brannan et al., 2019). Second, despite the law, the limits are set disproportionately to the expected and necessary assistance. Insurance companies can terminate insurance even in a difficult situation for a person. Finally, against the background of the pandemic, the use of psychotropic substances is increasing, which is why the situation is only getting worse with every day of inaction on the part of the authorities and medical institutions.
Evaluation of Effectiveness
As it is possible to see, the earlier engagements with the Act’s provisions at a legislative level worked very well. The ACA of 2010 managed to eliminate most of its significant 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 more minor and more subtle issues to improve. One of these significant issues includes the implementation of the Act at the state level.
One of the major problems that currently impede state-level legislation regarding oversight revolves around the fact that definitions of various terms in the Act are highly vague. It has been found that many states lack consistent definitions of 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 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.” It is a practice where insurers make up fake organizations and doctors to refer individuals (Shana, 2020). Alternatively, they place their networks too far outside the patient’s reach, making it 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 thinly 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 be seen that legislation that seeks to counter the apparent 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 of how to do it right – by acquiring extensive public support and providing a holistic solution to a problem. Their experience revolves around seeking to enhance access to mental health facilities for insurer companies to avoid responsibility for not providing the services required by the Act. It is necessary to focus primarily on ensuring patient access to networked medical organizations, which should not be too far away; must not be unqualified organizations created solely to comply with requirements.
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 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 insurance companies to create networks out of natural 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 and 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. Government intervention is proposed to improve the activities to which the Act should be directed. Despite the positive impact, many cases showed that the document requires significant revision, which should suppress the unethical activities of insurers, improve the percentage of receiving appropriate assistance to all those in need, and smooth out the increased burden on institutions due to the pandemic.
Resources Needed
Resources needed for the achievement of the plan include financial, lobbying, and professional assets. Instigating a statewide program for enhancing and providing access to better mental healthcare would require attracting professionals, building and staffing facilities, and encouraging businesses to contribute. It will require money, which could be received by applying for state or federal grants and 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 the proposed action before the public and the senators. Resources will be mobilized from the public by influencing educational and medical institutions to increase attention to the problem and ensure support and recognition of the need for action from the people.
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 precise 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. The importance of new institutions with control at the state level is precisely due to the assignment of network status to such institutions.
Measurable Outcomes
Measurable outcomes for the lobbied legislature can be borrowed from the Milliman report framework, which involved four 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, all of these parameters are currently 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 proposal’s success include the statistical dynamics of mental health facilities, their spread across individual counties, and the overall mental health state (Friedman et al., 2018). The Act and its statutes aim to improve the well-being 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 understands to which degree the solutions are offered to serve the public good.
Conclusions
The Mental Health Parity Act has become an important action to improve the mental health of the general population by proposing a legislative standard obliging insurers to create a level playing field for mental health and substance use disorders and related illnesses. At the same time, the law turned out to be imperfect, as insurance companies found ways to circumvent it. In 2010, ACA removed its most obvious glaring flaws, but the differences between state-to-state legislation left it in a vulnerable position. As it stands, only Illinois had passed a comprehensive set of state legislation to remove some of the significant blank spots in their mental health laws. Nevertheless, there is still much to do be done in order to insure absolute 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 proposed metrics to be utilized to evaluate the proposal’s effectiveness, should it be accepted, includes the four 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 approaches or surpasses Illinois in these parameters, the effort will 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 the insurers do not supplant its intended purposes.
References
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