It has been almost a decade since Congress passed the mental health parity law, with its promise to make mental health and substance abuse treatment as easy to obtain as any other condition. However, today, in the midst of the opiate epidemic and an increase in the suicide rate, patients still struggle to get treatment.
That's the conclusion of a report published Thursday by Milliman Inc., a national risk management and healthcare consulting company. The report was published by a coalition of mental health and addiction advocacy organizations.
Among the findings:
- In 2015, behavioral health care was four to six times more likely to be provided outside the network than medical or surgical care. That means that patients with mental health and substance abuse problems were more likely to face the high out-of-pocket costs that can make treatment unaffordable, even for those who have insurance.
- Insurers pay 20 percent more for primary care providers for the same types of care while they pay for addiction and for mental health care specialists, including psychiatrists. This may limit the willingness of these specialists to contract with insurers.
- State statistics vary widely. In California, 32 percent of office visits for behavioral health care were out-of-network. In Washington, DC, the figure was 63 percent.
The Milliman researchers examined two large national databases containing medical claim records from leading insurers of PPO organizations (preferred providers) that covered nearly 42 million Americans in the 50 states and the District of Columbia in 2013 to 2015.
"I was surprised it was that bad, as someone who has worked in parity for more than 10 years, I thought it would have been better," said Henry Harbin, former executive director of Magellan Health, a managed company of behavioral health care. "This is a wake-up call for employers, regulators and the very plans that do what they do, are making it difficult for consumers to receive treatment for all these diseases." They are failing miserably. "
In a statement issued with the report, the coalition of mental health groups, including Mental Health America, the National Association for Mental Illness and The Kennedy Forum, called on federal regulators, state agencies and employers must perform random audits of insurers to ensure they comply with the parity law.
Harbin, now consultant on issues parity, the report's finding that mental health service providers are paid less than primary care providers is a special surprise, in nine states, including New Hampshire, Minnesota, Vermont, Maine and Massachusetts, payments were 50 percent higher for primary care providers when they provided mental health care.  The result is an insurance plan with close behavioral health networks that do not include enough therapists and other caregivers to meet the demands of patients.
For years, insurers have maintained that they are making every effort to comply with the Mental Health Equity and Addiction Equity Act, aimed at equalizing mental health and other medical services coverage. conditions And previous research has found that they have come a long way towards eliminating obvious discrepancies in coverage. Most insurers, for example, have reduced the annual limits of the therapy visits they will cover. Higher copayments and mental health deductibles separately have become a minor problem.
California has been among the few states that apply laws that require patients with behavioral health problems to have fair and timely access to care. The California Department of Managed Health Care, for example, requires insurers under its supervision to show, at least on paper, that they are complying with the federal parity law.
But even with greater application, problems in the state continue. The Milliman report found that of the behavioral health care received in California in 2015, 28 percent of inpatient care was out-of-network and 48 percent of outpatient care was out-of-network.
Discrepancies seem to continue in the more subtle ways that insurers deliver benefits, including the size of provider networks.
Kate Berry, senior vice president of America's Health Insurance Plans, the industry's leading trade group, said the real problem is the shortage of behavioral health doctors.  "Health plans are working very hard to actively recruit providers" and offer telemedicine visits in areas with shortages, Berry said. "But some behavioral health specialists choose not to participate in contracts with providers simply because they prefer to see patients who can pay out of pocket and may not have the kind of serious needs that other patients have."
is a challenge that no participant in the healthcare infrastructure can solve. "
Carol McDaid, who heads the Parity Implementation Coalition, responded that insurers have been willing and able to address the shortage of providers in other fields When there was a shortage of gerontologists, for example, McDaid said, insurers simply increased rates and more doctors joined the networks. "Plans have the ability to do this; I just believe that the will has not been there until now, "he said.
The shortage of therapists who accept insurance creates a landscape of care that is difficult for some of the most vulnerable patients to navigate.
Ali Carlin, 28 He said he used to see his therapist in Richmond, Virginia, every week, paying a $ 25 copay per session, but in 2015, the therapist stopped accepting his insurance, and his rate increased to $ 110 per session.
] Carlin, who has borderline personality problems and addiction, said he called 10 other providers, but could not find someone who accepted his insurance and was taking new patients.
"It's a daunting experience for someone who has problems to keep your home and have a job and friendships, "Carlin said." It makes me feel like no one can help me, and I'm not good enough, and it's not an achievable goal. "
In Virginia, the Milliman report found that the 26th by cie The visits to the behavioral health office were outside of the network – more than seven times more than medical care.
Without alternative, Carlin stayed with her former therapist but must save between sessions. You have enough to cover one visit every few months.
"I earn $ 30,000 a year, I can not afford a therapist or a psychiatrist out of pocket," Carlin said. "I just can not pay it." I'm choosing food over a therapist. "
Angela Kimball, director of advocacy and public policy for the National Alliance for Mental Illness, said she is concerned that many patients like Carlin simply give up treatment altogether.
" One of The most common reasons people give for not receiving mental health treatment is the cost. The other can not find care, "he said." He is hurting people in every corner of this nation. "
This story was produced by Kaiser Health News, an independent editorial program of the Kaiser Family Foundation.