The Behavioral Health Care Affordability Problem

Introduction and summary

For far too long, people—especially people of color, people with low incomes, and people with disabilities—have struggled to access behavioral health care services in the United States. Reports of individuals endlessly navigating inaccurate provider directories,1 insurance denials,2 and expensive treatment3 have proliferated in recent years.

The coronavirus pandemic has further highlighted and exacerbated the behavioral health crisis and barriers to access care.4 Self-reported anxiety and depression disorder symptoms have increased 400 percent during the pandemic.5 Moreover, the same historically oppressed communities that have faced the brunt of the COVID-19 crisis—Black, Native, and low-income communities, in particular—have also experienced heightened levels of mental health needs and have disproportionately struggled to access much-needed services.

Despite advancements toward mental health parity and state initiatives, mental health and substance use services remain inaccessible for millions of Americans who need them.

In recent decades, policymakers have created frameworks to improve behavioral health care affordability and access. While these guidelines are imperfect, they provide an important baseline on which policymakers can and should build. In particular, lawmakers and regulators should strengthen existing parity frameworks, leverage the Affordable Care Act’s (ACA) no cost sharing for preventive service provision for behavioral health, and develop enforcement mechanisms that operate without depending on consumer complaints.

The key framework: Mental health parity

Prior to 1996, there were no national laws in the United States to govern behavioral health coverage in the private insurance market. While there were regulations that mandated psychiatric coverage for federal employees in the 1960s and 1970s, behavioral health regulations were largely focused on mandated benefit laws, rather than parity, and these regulations were set by state legislatures.6

In 1996, Congress passed the Mental Health Parity Act (MHPA), which prohibited large-group employer-sponsored health plans that provided mental health benefits from imposing more restrictive annual or lifetime limits on mental health benefits than those imposed on medical or surgical benefits.7 While the MHPA was an important leap toward mental health parity, it contained many gaps by which insurers could evade compliance. For example, health plans could receive a waiver if they demonstrated that their costs increased as little as 1 percent as a result of compliance. Additionally, the law’s requirements were limited: It allowed treatment limits, insufficient numbers of covered facilities, differences in cost sharing, and restrictive medical management techniques to remain.8

During the next decade, several states implemented behavioral health parity policies with varying scopes in an attempt to close some of the remaining gaps of the MHPA. Then, in 2008, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA). In addition to reaffirming the MHPA requirements, the MHPAEA expanded these guidelines to apply to both substance use disorder and mental health services, while also instituting more comprehensive guidelines to promote behavioral health parity. Specifically, the MHPAEA extended the requirement that large-group health coverage for behavioral health services be no more restrictive than coverage for medical or surgical conditions to Medicare Advantage, Medicaid managed plans, and state Children’s Health Insurance Plans.9 The law also has more sweeping protections that prohibit treatment and visit limits, cost sharing, and network limitations from being more stringent than those for medical and surgical benefits.

The Affordable Care Act (ACA) was the first in this series of the parity laws to mandate behavioral health coverage, rather than require parity only if coverage is offered; it added mental health and substance use disorders (SUDs) to its list of essential health benefits (EHBs) required in small-group and individual market insurance plans.10 The ACA also extended parity regulations from group plans to the individual health insurance market, requiring parity for an additional 11 million individuals.

Read more on how the ACA has improved health care

Limitations of parity laws

Dr. Richard Frank, the Margaret T. Morris professor of health economics in the Department of Health Policy at Harvard Medical School, has noted that many of these policies constitute “parity in law” rather than “parity in principle.”11 Parity in principle extends beyond parity in law to mean that “people with mental illnesses and SUDs should have access to high-quality treatments for their illnesses and protection against the costs of care that meets their health care needs in the same way that any other health needs are addressed.”12

People with mental illnesses and SUDs should have access to high-quality treatments for their illnesses and protection against the costs of care that meets their health care needs in the same way that any other health needs are addressed. Dr. Richard Frank

For example, while insurers cannot charge patients more in cost sharing for behavioral health services or set annual limits on treatment, insurers often manage care or create networks in ways that prevent equal access to behavioral health services.

Generally, quantitative treatment limits (QTLs), such as annual and treatment limitations, are more straightforward to assess and enforce than nonquantitative treatment limits (NQTLs), such as network adequacy, prior authorization, and step-therapy.13 It is challenging to ensure compliance with NQTL parity; yet there are clear opportunities for policy intervention to enforce NQTL parity and ensure broader behavioral health access.

Network adequacy is included in the existing NQTL parity requirements—which means health plans must have a sufficient number of in-network primary care and specialty providers and included benefits to offer reasonable access to services. However, insurers often offer providers low payment rates, limiting willingness of an already insufficient workforce to join networks and impeding compliance with network adequacy standards.14 Insurers can also set treatment limits to manage care; these plans often do not offer as much treatment as a patient or provider may find beneficial or clinically significant. Moreover, insurance companies may require prior authorization or medical necessity forms that can slow or prevent access to care.

While these limitations impede parity in principle, they are often more challenging to enforce and may proceed undetected by regulating bodies.

Insufficient enforcement of parity

In addition to these gaps, few standards exist to adequately and regularly monitor potential violations of parity. Currently, state agencies, the U.S. Department of Labor (DOL), and the U.S. Department of Health and Human Services (HHS) share the responsibility of overseeing compliance with mental health and SUD parity requirements.15 A 2019 Government Accountability Office (GAO) report assessed oversight of the MHPAEA and other parity requirements, finding that while nearly all states reviewed group and individual insurance plans for parity before they were approved for sale to consumers, only 12 states reported conducting at least one targeted review of specific parity concerns in 2017 and 2018.16 The DOL and HHS conduct reviews only when they receive information, such as consumer complaints, about possible noncompliance with parity regulations. Yet because many beneficiaries who have trouble accessing behavioral health services are also experiencing behavioral health crises and struggling with a variety of social determinants of health, relying on consumer complaints places an undue burden on struggling beneficiaries and is bound to miss violations. Unlike state agencies, these federal agencies only conduct these reviews after the plans have been sold to consumers.

The GAO report identified some instances of noncompliance but was unable to determine the extent of noncompliance with parity requirements. It recommended that the assistant secretary of labor for the Employee Benefits Security Administration and the administrator of the Centers for Medicare and Medicaid Services (CMS) evaluate whether targeted oversight in response to information about possible noncompliance was sufficient. The Biden administration should direct these agencies to conduct these analyses expeditiously. And if they find that current practices pose significant risks, the GAO suggests that these agencies develop plans to more effectively enforce parity requirements and seek additional oversight authority as needed.

The current parity laws and state-level enforcement mechanisms do not adequately consider network adequacy standards appropriately as an inhibitor to parity. Even if parity were enforced such that a patient seeking in-network behavioral health care owed the same amount in cost sharing as for primary care, networks for behavioral health care providers are so restrictive that many patients would still struggle to find in-network providers. Equal coverage must therefore factor in the availability of providers that accept insurance and contract in network.

With proper oversight and enforcement, the existing parity laws could be used to expand coverage and access. However, due in part to the issues described above, many behavioral health care providers refuse to accept public or private insurance; insurers make it difficult for patients and providers to prove the medical necessity of the services; and a shortage of mental health providers leaves many people with no access to care.

Network adequacy remains a problem

A 2013 final rule intended to clarify implementation of the MHPAEA and extend consumer protections affirmed that parity laws apply to nonquantitative treatment limits—specifically naming geographic limits, facility type limits, and network adequacy. While parity laws do not adequately address dollar reimbursement to providers directly, low reimbursement rates to providers are tied to insufficient network adequacy.17 For example, a 2017 study that analyzed private insurance claims data for thousands of patients found major disparities in payment to psychiatrists and nonpsychiatrist medical doctors performing the same services: Psychiatrists were paid a median of 13 to 20 percent less than nonpsychiatrist medical doctors for the same in-network evaluation and management services, depending on severity of the diagnosis.18 However, for the same services out of network, psychiatrists were paid 28 percent and 6 percent more than nonpsychiatrist doctors for services for patients presenting problems of low to moderate and moderate to high severity, respectively.

These low in-network payments may discourage psychiatrists from joining networks, as the higher out-of-network payments incentivize providers not to contract with insurers, narrowing networks and reducing access for patients. Primary care physicians (PCPs) are already underpaid for their services, and mental health providers are paid even less—despite the legal mandate for parity compared with substantially all other medical and surgical services.19

With so much dependence on out-of-pocket costs, in many cases, mental health care may only be accessible for those with higher incomes.

According to an analysis by health care consulting company Milliman, for every $1 that insurance companies reimbursed primary care physicians in preferred provider organizations (PPOs) in 2017, they reimbursed behavioral health professionals only 76.2 cents.20 Milliman also found that primary care providers and medical and surgical specialists were paid 14.7 percent and 11.1 percent higher, respectively, than Medicare-allowed amounts, while behavioral providers were paid 5 percent less than Medicare-allowed amounts for in-network services.

Network adequacy: By the numbers

Low payment rates to behavioral health providers often inhibit the creation of adequate networks:

  • For every $1 reimbursed to primary care physicians in certain plans, behavioral health providers only made 76 cents.
  • For the same in-network services, behavioral health providers were paid 17 percent less than medical specialists and 14.5 percent less than surgical specialists.
  • In a study of the individual market, only 43 percent of psychiatrists and 19 percent of nonphysician mental health care providers participated in any network. These rates were 27 percent and 67 percent lower, respectively, than insurance participation among primary care providers.
  • In the same study, private insurers paid behavioral health providers between 164 and 178 percent more for out-out-network services than in-network services.

Given reimbursement rates that are lower than other specialties and have not increased in decades, as well as shortages in the mental health workforce, it is no surprise that network participation among behavioral health providers is low.21 In a 2017 study of more than 500 ACA marketplace networks, only 42.7 percent of psychiatrists and 19.3 percent of nonphysician mental health care providers were found to participate in any network, compared with 58.4 percent of PCPs.22 The study noted, “On average, plan networks included 24.3 percent of all primary care providers and 11.3 percent of all mental health care providers practicing in a given state-level market.”23 The authors suggested that given relatively recent standards of parity and behavioral health benefit inclusion, insurers have turned to other tactics, such as restricting networks to avoid paying for potentially costly behavioral health care needs.

Even a vigilant consumer who knows their behavioral health needs and makes a concerted effort to ensure in-network coverage may face additional barriers. In a 2015 study, researchers called 360 psychiatrists on Blue Cross Blue Shield’s in-network provider list in three large cities and were unable to make appointments with nearly three-fourths of the listed providers.24 The database listed wrong numbers and providers that refused to accept insurance or new patients. Yet these inaccuracies are not limited to behavioral health care or the private market: A 2016 CMS review found similar inaccuracies in nearly half of the entries reviewed in Medicare Advantage directories.25 Furthermore, the behavioral health provider industry can be volatile, with providers entering and leaving insurance networks often and those with time-limited coverage, such as short-term Medicaid and Medicaid pregnancy coverage, struggling to receive continuous care.26 These types of barriers to accessing in-network services reduce the likelihood that an insurer will pay for a beneficiary’s care.27

With a demand for behavioral health providers that greatly surpasses the supply, coupled with low reimbursement rates, many behavioral health providers can obtain a sufficient client base without accepting insurance. Indeed, insurance acceptance rates were about 30 percentage points lower among psychiatrists than among physicians with other specialties for private insurance, Medicare, and Medicaid. (see Table 1)

Table 1

While private insurers pay physicians and hospitals more than Medicare and Medicaid does for nearly all services, the landscape of behavioral health payments is a bit more complicated.28 In 2014, for in-network behavioral health services—which are difficult to access in many regions and on many plans—private insurers, including commercial and Medicare Advantage plans, actually paid 13 to 14 percent less than Medicare fee-for-service (FFS) rates for identical services.29 However, these lower reimbursement payments from private insurers did not reduce average cost sharing for patients, possibly because so many patients resorted to seeking out-of-network behavioral health services.30

6x

Additional likelihood that patients with commercial insurance used out-of-network services for mental health services versus other services

Comparatively, private insurers reimbursed beneficiaries at higher rates for out-of-network mental health needs than did FFS Medicare, but 1 in 3 out-of-network payments was paid completely out of pocket by the patient.31 Meanwhile, private insurers paid 43 to 53 percent more for out-of-network mental health services than did Medicare FFS.32 And out-of-network service use by patients with commercial insurance was six times more common for mental health services than for other services.33 Privately insured patients spent twice as much in cost sharing for out-of-network services than for in-network services.34

With so much dependence on out-of-pocket costs, in many cases, mental health care may only be accessible for those with higher incomes.

Mental health care is unaffordable and inaccessible without insurance

As the pandemic and related economic crisis continue, loss of employer-sponsored coverage and inability to afford insurance may drive more people to experience periods of uninsurance. Uninsured patients typically must bear the entire cost of behavioral health services, which can very quickly add up to thousands of dollars in treatment and make these services unattainable for many.

There are some limited programs at low or no cost, such as sliding-scale services at federally funded health centers, low-cost services with training graduate students at colleges and universities, and patient assistance programs for prescription drugs. In addition, reforms to expand affordable coverage—including Medicaid expansion and universal health care proposals as well as more providers being encouraged to practice in federally qualified health centers—would help people who are currently uninsured access behavioral health care. Likewise, permanently increasing marketplace subsidies across income ranges, as done temporarily by the American Rescue Plan Act until the end of 2022, would help more low-income people gain insurance.35

The true cost of mental health care

MNHealthScores, a website managed by the nonprofit organization MN Community Measurement, publishes average costs of various health services across payers in Minnesota.36 In this report, the Center for American Progress uses these data to estimate the out-of-pocket financial burden for patients responsible for some or all of the cost of services, including insured patients seeking in-network care before meeting their deductible, insured patients seeking out-of-network care with limited out-of-network coverage, and uninsured patients seeking care out of pocket.

Imagine an adult patient in Minnesota who exhibits symptoms of depression, as experienced by nearly 1 in 3 adults during the COVID-19 pandemic in 2021.37 The patient is insured but contacts the providers listed in network and finds that they are not taking new patients, no longer contract with their insurer, or have long wait times. Instead, the patient seeks care from an out-of-network psychologist for an initial intake visit, which costs $241 on average, and is diagnosed with major depressive disorder. A provider may suggest weekly cognitive behavioral therapy for 45 minutes weekly for 8 to 16 sessions.38 Yet the cost of a 45-minute psychotherapy session averages $160, which comes to an additional $480 for the first month, followed by $640 each month for the next one to three months. Assuming the patient needs 12 sessions, in addition to the diagnostic session, to see results, they might pay $2,161 out of pocket for all services with the psychologist before even considering longer-term maintenance treatment.

Over the course of psychotherapy, the therapist believes the patient may benefit from pharmacotherapy and refers the patient to a psychiatrist, who is also out of the patient’s insurance network. The initial diagnostic evaluation costs $346. Of course, treatment varies by a person’s diagnosis and situation, and rates differ by location and degree of provider. Assuming there are no additional evaluation and management services, this dual-pronged course of treatment for a depressive episode would cost $2,507, without accounting for the costs of prescription drugs.

Insurance limitations foster a crisis-response mental health system

Patients with insurance coverage often face restrictions and limitations that inhibit access to behavioral health care. Insurers may limit treatment and only cover services they deem medically necessary. Indeed, a National Alliance on Mental Illness (NAMI) online survey of people with mental illness who had private insurance, along with their families, found that respondents were more than twice as likely to be denied by their private insurer for mental health care on the basis of medical necessity, compared with other medical care.39 These kinds of designations may violate the nonquantitative treatment limits of the MHPAEA.

To qualify for medical necessity and service coverage, a patient must receive a mental illness or behavioral health diagnosis, even if their symptoms may not fit into the biomedical diagnosis categories. Furthermore, “medical necessity” remains undefined and unpinned to clinical standards. According to Meiram Bendat, founder of the mental health law firm Psych-Appeal, in a testimony before the U.S. House Subcommittee on Health, Employment, Labor, and Pensions, “Health plans are free to create and operationalize self-serving, overly restrictive medical necessity definitions that undermine access to essential health benefits, including mental health and substance use treatment.”40 If a patient bills to their insurer, the insurer can set treatment plans and limitations and determine how many sessions are needed to treat the diagnosis. While insurance companies claim to consider clinical guidance, medical necessity determinations, treatment plans, and limits on the duration of covered treatments are at the discretion of the insurer.

There is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions. Judge Joseph C. Spero

These limitations set by insurers foster a crisis-response behavioral health care system, rather than allowing for prevention and maintenance. For instance, a federal court judge in Northern California recently ruled that a unit of UnitedHealth Group had created internal policies to cut costs by effectively discriminating against patients with mental health and substance use disorders.41 U.S. Chief Magistrate Judge Joseph C. Spero, who decided the case, said, “There is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.”42 Patients reported denials for care as soon as they appeared stable.

When insurers deny coverage for treatment prematurely, patients can relapse or continue to struggle in between acute crises when treatment is inaccessible. Prevention and treatment for conditions is more efficient for payers and often more helpful for patients than treating an acute crisis. In primary care preventive appointments, for example, a person exhibiting symptoms of depression might have to self-identify these symptoms and bring them to a PCP’s attention. Just as a PCP might screen for signs of cancer, an infection, or a heart problem; act as the first line of defense; and refer out for conditions that may be beyond their scope of expertise, PCPs have the clinical capacity to screen for common mental health disorders and treat more basic cases.

However, PCPs should be careful not to overprescribe mental health medications as initial treatment and should ensure that they have the resources and capacity to follow up with referrals and treatments. Nonetheless, behavioral health care can be overlooked in primary care settings and, despite a recommendation from the U.S. Preventive Services Task Force in 2016, there is no standard obligation or requirement for PCPs to inquire about the behavioral health of their patients.43

Disparate experiences of behavioral health care

People experience challenges to accessing behavioral health access differently. In particular, low-income, uninsured, and underinsured individuals face heightened barriers to affording behavioral health services. Forms of marginalization and the lived experiences of intersecting identities contribute to additional challenges that may compound behavioral health issues. Indeed, stigmas toward behavioral health, combined with other forms of shame and discrimination imposed on people with marginalized identities, can affect treatment rates, access, and affordability of treatment.

Income disparities

Of the 11.8 million Americans who reported an unmet need for behavioral health care in 2016, 38 percent could not afford the cost of treatment.44 Furthermore, 2.5 million adults with serious mental illness (SMI) have incomes below the federal poverty line (FPL), and adults over the age of 26 with incomes below the FPL are more likely to experience SMI than those with incomes above it.45 In addition to the many challenges faced by lower-income individuals when searching for and seeking health care more generally, having lower incomes can make services with out-of-pocket costs or cost sharing inaccessible. Moreover, lack of transparency or confusion about insurance coverage for behavioral health services, as well as fears that insurers can limit care or determine medical necessity and threaten coverage, can make the process of initiating treatment even more daunting.

For these reasons, the experiences of having both a mental illness and a lower income can intersect in complicated ways and exacerbate both experiences.

Disparities among people involved in the justice system

Notably, people incarcerated in prisons and jails were three and five times more likely, respectively, to experience severe psychological distress than the general adult population in 2011 and 2012.46 The overutilization of 911 emergency services disproportionately harms communities of color, and people with serious mental illness are “16 times more likely than the general public to be killed during a police encounter.”47 Nearly 37 percent of those incarcerated in prisons and more than 44 percent of those incarcerated in jails have a history of mental health disorders.48

Importantly, these data do not indicate that people with mental illnesses are more likely to be violent or break the law; rather, they point to the criminalization of mental illness; the failure of courts, police, and incarceration facilities to direct people with mental health crises to the appropriate services; and the overall lack of access to these mental health services. Indeed, in a study of New York City jails, Black and Hispanic people were less likely to access mental health services than their peers but more likely to experience solitary confinement—which those with a mental health diagnosis are already 3.3 times more likely to experience than people without mental illness diagnoses.49 Overall, the experience of being incarcerated can significantly worsen mental health problems.

Furthermore, people with criminal records face additional challenges obtaining access to supports, highlighting the need to reduce barriers to eligibility.50

Disparities among unhoused people

Some criminalized activities stem from not having basic needs met. Poverty and homelessness are risk factors for both mental illness and incarceration. People in poverty are more likely to forgo mental health treatment due to high levels of stressors involved with meeting basic needs and having the financial stability to afford treatment options.51 Individuals who struggle with housing and financial insecurity also struggle to access mental health services: Nearly half of unhoused people in 2015 had a mental illness,52 and unhoused people have 10 times more contacts with the justice systems than does the general population.53

Access to quality, affordable, and affirming mental health services is necessary to address the disproportionate impact of unmet behavioral health needs for vulnerable populations. Additionally, policies and programs that address basic needs and the social determinants of health—including racism, housing, and neighborhood safety, as well as access to jobs and economic opportunity—are necessary to break the incarceration cycle and help individuals and communities live prosperous, healthy, and fulfilling lives.

Racial and ethnic disparities

Given the lack of culturally competent care and the shortage of providers able to treat unique issues such as displacement, racism, xenophobia, and culture loss, there are significant racial and ethnic disparities in behavioral illness treatment and access to that treatment.54 While more than 1 in 2 non-Hispanic white people with mental illness access treatment, only slightly more than 1 in 3 non-Hispanic Black or African American and Hispanic or Latino people with mental illness, as well as 1 in 5 non-Hispanic Asian people with mental illness, access treatment.55 Moreover, whereas mental health treatment rates increased among white and Hispanic people following implementation of the ACA’s major coverage provisions in 2014, no other racial or ethnic groups received significantly more mental health treatment than their same-minority-group counterparts pre-ACA implementation.56 However, in the same study, treatment rates for substance use disorder did not improve significantly for any racial or ethnic group after 2014.

Gender disparities

In 2020, women were more likely to access mental health treatment (51.2 percent) than men (37.4 percent).57 Yet these numbers do not reveal the full story: When race was factored in, Black women were half as likely to receive mental health treatment as white women.58 While up to 1 in 7 women experience postpartum depression, rates are significantly higher for new mothers of color—reaching nearly 38 percent.59 Despite their clear need for mental health services, women of color are less likely than white women to access mental health care during pregnancy and the postpartum period.60

There are a number of systemic reasons for this, including many mentioned above, such as lack of adequate insurance and high treatment costs. In addition, a study of low-income women—55 percent of whom were Black—found that the lack of affordable, accessible child care and transportation was a barrier to accessing mental health and SUD treatment.61 Many women of color face systemic and structural barriers to accessing mental health services beyond the postpartum period as well.62

LGBTQI+ disparities

Likewise, LGBT communities are at higher risk than non-LGBT communities of experiencing mental health problems, and severe mental illness may occur at higher rates among LGBT populations.63 Furthermore, transgender adults are nearly nine times and intersex youth are more than four times more likely than the overall U.S. population to have attempted suicide.64 Transgender youth and LGBQ teens, in particular, experience depression or depression symptoms at higher rates than their cisgender and heterosexual peers, respectively.65 Yet according to a nationally representative 2020 CAP survey, approximately 3 in 10 LGBTQ Americans reported cost barriers to accessing necessary medical care, including more than 1 in 2 transgender Americans and 60 percent of transgender individuals of color.66

It is important to note than disparities in mental illness rates reflect treatment accessibility, discrimination, and additional challenges faced by marginalized communities, rather than innate differences. Indeed, 84 percent of LGBTQ youth reported wanting mental health counseling, but 54 percent of those who wanted treatment did not receive it.67 High rates of mental health conditions may be part of a “minority stress model,” in which stigma, prejudice, and discrimination faced by minority communities create a hostile and stressful social environment that contributes to poorer health, often compounded by intersecting identities such as race and ethnicity.68

Disparities among disabled people

Disabled people, whose identities and experiences may also intersect with other disparate experiences described above, face particular mental health access challenges. One in 3 disabled adults experience frequent mental distress, nearly five times as often as nondisabled people.69 Yet many behavioral health provider offices remain inaccessible for people with physical disabilities.70 Few clinicians are able to identify unique risks faced by disabled people, including ulcers and other chronic conditions; consider ableism as a significant stressor; and avoid reinforcing ableism by dehumanizing disabled people as needing to be “fixed.”71

Even with the increased uptake of telemental health treatments, many disabled people still face communication barriers and, with disproportionally high rates of poverty among disabled people, access concerns such as lack of broadband.72 For example, in one 2012 study, only 17 percent of deaf patients received an interpreter for health care visits.73

Disparities in rural settings

A person’s location also affects their ability to access care. While there is a national shortage of behavioral health providers, rural community members struggle more greatly to access care. Indeed, nearly half of all nonmetropolitan U.S. counties lack a psychologist, and more than 65 percent lack a psychiatrist—more than double the rate in metropolitan counties.74 Additionally, in smaller, close-knit communities, stigma can be greater, as people seeking behavioral health care may fear being seen by someone they know at a treatment center.75 Together, limited access and fear of seeking treatment may drive behavioral health care to be a last resort to address an acute crisis, rather than preventive, ongoing care.76 The crisis-response approach is not limited to rural communities and reflects a larger cultural and clinical trend.

This report does not seek to provide recommendations that address the structural roots of these disparities, but rather proposes policy changes to increase access and affordability, which would benefit vulnerable populations to a greater extent. Further research that highlights and addresses these differential experiences would be a valuable addition to the discourse.

See also

Recommendations

State and federal policymakers have the tools at their disposal to improve behavioral health access and affordability. By leveraging and enforcing existing programs and legislation, policymakers can both ensure that people experiencing behavioral health struggles can access care and save lives.

Improve initial affordability

Policymakers should make initial behavioral health services more affordable to help patients get in the door and access care. The behavioral health care model prioritizes acute response to crisis and short-term solutions to complex behavioral health needs. Policymakers should incentivize prevention, early intervention, and maintenance of chronic behavioral health disorders. The Primary and Behavioral Health Care Act of 2021 (H.R. 3550), introduced by Rep. Lauren Underwood (D-IL), and President Joe Biden’s State of the Union mental health strategy would require health insurers offering individual or group plans to cover three behavioral health care visits with no cost sharing each year.77 Paired with network adequacy provisions to ensure that beneficiaries can find providers who accept their insurance, these provisions could greatly increase access to behavioral health care.

Primary care providers can conduct annual screenings for common behavioral health ailments. However, behavioral health specialists should also be able—with insurance coverage—to see patients in the early stages of complications that may precede diagnosis before the conditions become more complicated, decrease quality of life, and become more expensive to treat. In the same way that a patient can be screened for complications by their primary care provider—as well as specialists such as gynecologists, ophthalmologists, and cardiologists—patients should be able to see behavioral health providers for early treatment or maintenance of concerns or complications even if those sessions do not result in diagnoses. As required by the ACA, if these visits are redefined as preventive care, there should be no cost sharing. HHS has yet to codify this categorization with a rule.

According to existing parity requirements, maintenance treatment for behavioral health care after a patient is stabilized can be no more restrictive than for medical or surgical care. Following existing regulations, managing chronic behavioral health needs should be covered on par with managing a chronic illness such as diabetes. States and DOL and HHS regulatory agencies should monitor compliance of insurers with parity requirements for ongoing care. In addition, the Biden administration should issue an executive order to ensure federal agencies proceed with these reviews as a priority.

Limit patient cost sharing

Many people seeking behavioral health care must pay out of pocket until they reach their deductible. For plans offered in the federal marketplace for 2021, someone with a silver plan and no cost-sharing reductions has an average medical deductible of $4,500.78 In an analysis of deductibles in open enrollment on the federally facilitated marketplace, a person would have an average deductible of $2,825 after cost-sharing reductions.79 Meanwhile, the average deductible for an employer sponsored plan in 2021 was $1,434.

Two in 5 Americans are unable to afford an unexpected $1,000 expense.80 Therefore, many individuals faced with urgent behavioral health needs may forego care or accrue medical debt to do so. There are several ways to address cost-sharing requirements for behavioral health services that are too high for average Americans.

2 in 5

Share of Americans who can’t afford an unexpected $1,000 expense, while behavioral health treatment can cost thousands

One option is for states or the federal government to implement standard benefit plans that limit cost sharing in the ACA marketplaces. In the Notice of Benefits and Payment Parameters Final Rule of 2023, issuers offering non-standardized qualified health plans on the federal marketplace will be required to offer standardized plan options at every network type, metal tier (referring to plans categorized by the share of costs covered by a health plan), and service area in which they offer non-standardized plans.81

On the state level, Covered California, the state’s marketplace established under the ACA, initiated a standard benefit design for their marketplace plans that limits copays for primary care and specialist visits even when a deductible has not been met.82 For a standard silver plan in California, a primary care visit would cost $40 and a specialist visit would cost $80 out of pocket, rather than the full cost of treatment until the deductible has been met. For those with family incomes below 250 percent of the federal poverty level, rates decrease incrementally from $35 to $5 for a primary care visit and $75 to $8 for a specialist visit. Mental health care visits could be standardized to primary care levels, with reduced cost sharing for those with low incomes, although even an out-of-pocket limit at specialist rates would be a significant improvement. While the details of the federal standardized plans required by the 2023 final rule remain to be seen, this move could be an opportunity to improve mental health access, in alignment with the Biden administration’s other priorities.83

Another option is a separate, lower deductible for behavioral health care in ACA marketplace plans for those who have not yet met their deductible, modeled like separate prescription drug deductibles. Spending toward the behavioral health deductible would still count toward meeting the general medical deductible. The current parity regulations under the MHPAEA require equal or better coverage for behavioral health care; a lower threshold for insurers to begin covering behavioral health services would constitute better coverage and be permissible under the law.

Enforce network adequacy as parity

As an NQTL within the parity framework, network adequacy for behavioral health is often lacking and prevents insured patients from accessing care. The ACA requires insurers with plans on the individual marketplace to maintain networks that are sufficient in number and type of provider and do not lead to unreasonable wait times.84 The ACA, however, did little to define regulation and enforcement of these metrics, and in practice, patients often struggle to find an in-network provider for behavioral health care. While held to the same standards as all other medical and surgical specialties covered by ACA marketplace plans, behavioral health coverage is governed by additional consumer protections that have also largely evaded enforcement.

While held to the same standards as all other medical and surgical specialties covered by ACA marketplace plans, behavioral health coverage is governed by additional consumer protections that have also largely evaded enforcement.

On the federal level, legislators have proposed several bills to better enforce parity requirements. For example, the Parity Enforcement Act of 2021, introduced in the House of Representatives, would give the DOL authority “to enforce the parity requirements for group health plans with respect to the coverage of mental health and substance use disorder benefits.”85 Meanwhile, the Parity Implementation Assistance Act of 2021, introduced in the Senate, would provide states with grant funding to implement mental health and substance use disorder parity provisions.86

Many states have created more stringent requirements and accountability metrics for network adequacy, with some specifically in the context of behavioral health. For example, Illinois recently amended the Network Adequacy and Transparency Act of 2017, which required insurers to charge a beneficiary no more for out-of-network services than for in-network services if the beneficiary made a “good faith effort” to access in-network care, to account for “timely and proximate access to treatment” for behavioral health—a minimum standard state and federal governments should implement.87

Additionally, California, Tennessee, and Nebraska set travel time and distance standards for obtaining mental health services in order to promote network adequacy.88 New York, for its part, has created a behavioral health ombudsperson and its attorney general’s office has reached several settlements with carriers and created a hotline for consumer complaints.89 While indicators besides consumer reports would better inform parity, states should follow the lead of New York in creating pathways for consumers to report their struggles accessing care and make these channels easily accessible to consumers.

The MHPAEA parity regulations must be paired with robust enforcement of consumer protections. Regulators should investigate insurance plans that do not comply with the full scope of parity and penalize them where appropriate. This includes preventive care with no cost sharing, annual behavioral health checkups, adequate networks, and no difference between behavioral health and other health services in terms of nonquantitative and quantitative treatment limits.

The aforementioned GAO report questioned whether targeted parity reviews, in which the DOL and HHS only investigate plans for violations of parity if they receive a consumer complaint or other information, were sufficient in determining parity.90 An alternative approach would be for these agencies to set several standards and investigate insurance plans that do not meet these standards. For example, reviewers could monitor the ratio of out-of-network payments to in-network payments for behavioral health providers compared with those of other specialty providers. If the ratios differ beyond a certain threshold, an investigation into the parity of a plan would be warranted. Additionally, regulators could determine a band within which utilization rates should fall for behavioral health services. Utilization rates below the band would trigger an investigation into parity violations.

If an investigation triggered by failing to meet these standards found a plan in violation of parity, the plan would have to correct these parity violations and could face additional financial penalties. For example, the Pennsylvania Insurance Department found UnitedHealthcare to be in violation of several elements of the MHPAEA.91 As a result, it imposed $1 million in civil penalties and agreed to fund a $800,000 public outreach campaign. As a state government agency ramping up efforts to oversee and enforce the MHPAEA, the Pennsylvania Insurance Department should serve as a model for other state governments looking to hold insurers accountable.

Increase payments to providers

In theory, adequately enforcing parity regulations and network adequacy standards should drive insurers to more fairly calculate their provider payment rates to encourage providers to join networks. Medicare sets payment rates based on complexity, which disadvantages nonprocedural services, including many behavioral health services.92 Increased behavioral health payment rates for Medicare, Medicaid, and private payers are needed to incentivize network and workforce participation.

Increased behavioral health payment rates for Medicare, Medicaid, and private payers are needed to incentivize network and workforce participation.

States should increase their Medicaid rates to mental health providers. The ACA temporarily set primary care rates for Medicaid equal to those of Medicare. In recent years, states have begun to codify these changes in the long term and increase their Medicaid payment rates to providers for services that treat substance use disorders. A GAO report found that 80 percent of states increased payment rates for at least one SUD service from 2014 to 2019.93 State officials reported that these rate increases contributed to greater SUD provider participation in Medicaid.

For example, in 2017, Virginia increased its reimbursement rates for SUD services for Medicaid recipients to encourage providers to accept Medicaid for people affected by the opioid epidemic.94 This strategy was quite successful: There was a 69 percent increase in Medicaid recipients accessing opioid use disorder treatment and a 25 percent decrease in opioid-related emergency department visits.95 In fact, the program worked so well that the Virginia government decided to expand Medicaid reimbursement rate increases to 80 percent of Medicare rates for other services, such as primary and pediatric care.96

Conclusion

Despite advancements toward mental health parity and state initiatives, mental health and substance use services remain inaccessible for millions of Americans who need them.

Policymakers have key tools at their disposal to promote timely and accessible mental health treatment options. By creating pathways for affordable initial treatment, limiting patient cost sharing, enforcing network adequacy provisions, and increasing payments to providers, policymakers and regulating bodies can take steps toward ensuring behavioral health care access and affordability.

Acknowledgements

The author would like to thank Richard Frank, Maura Calsyn, Emily Gee, Jill Rosenthal, and Azza Altiraifi for their input and guidance, as well as the Criminal Justice Reform, Disability Justice Initiative, LGBTQI+ Research and Communications Project, Poverty to Prosperity, and Women’s Initiative teams at the Center for American Progress for their thoughtful feedback.

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