Mental health “parity” is officially a done deal. Congress passed a law back in 2008 requiring health insurers to treat mental health on a par with physical health, covering care for mental illness and addiction no less than they cover physical care. Many states have also passed their own mental health parity laws.
So why has former Congressman Patrick Kennedy of Rhode Island — lead sponsor of the 2008 bill together with his late father, Sen. Ted Kennedy — spent much of the last couple of years criss-crossing the country to advocate for mental health parity? Why did he feel the need to come to a Massachusetts Division of Insurance hearing this week to push parity yet again?
You could find the answer at the hearing itself.
It came from Benedetto Mitrano, who testified that his drug-addicted son, Michael, had been through several treatment programs, but died in August. "Insurance always refused to pay for one reason or another," Mitrano said. "He was never 'sick enough.' My son is dead. Is he sick enough for them now?"
He was never 'sick enough.' My son is dead. Is he sick enough for them now?"
And from Dr. Matthew Mostofi, a Tufts Medical Center emergency physician who compared two patients from his previous night's shift, one with appendicitis, who was treated quickly, and one who was suicidal, and had to wait many hours for care, held up by insurance requirements:
"Both have emergency medical conditions," he said. "If you look at these two patients, which is more life-threatening? The fact of the matter is, this depressed suicidal patient has a higher mortality [risk] than the patient with appendicitis, and yet this is the one that we delay and make wait, and I believe illustrates disparity."
And from Trudy Avery, who fought to get her insurance carrier to pay for her son's addiction treatment: "What is written on paper and what actually occurs are two different things," she said.
Therein lies the rub. Though mental health parity is the law of the land, the federal government has not yet issued its final regulations translating the law into practice, so it cannot be actively enforced. In the wake of the Newtown shooting, the Obama administration pledged to issue those final rules, but they are still not out.
Some can wait no longer. Class action lawsuits alleging violations of the parity law have been filed in California and, just this month, in New York. The New York State Psychiatric Association accuses insurer UnitedHealth Group of limiting actively suicidal patients to just one psychotherapy session a week, among other denials, Psychiatry News reports.
Meanwhile, around the country, many states have been moving forward to decide for themselves how to enforce parity — hence the Massachusetts hearing, and Kennedy's presence. (Listen to an excerpt of Kennedy speaking in the sound file at the bottom of this post.)Massachusetts is gathering public comment on proposed parity rules through April 5, and Kennedy says that given the state's leadership in health reform, what it decides will serve as an important bellwether for other states.
"You are where the rubber hits the road," Kennedy told the commissioners presiding at the hearing.
If Massachusetts is any indication, several points of contention on parity rules arise:
• Is there a problem? How can you know?
Talk to psychiatrists who deal daily with insurers, and they'll likely tell you that parity is a fiction. ("It's not even good fiction," notes Dr. Steve Schlozman, a psychiatrist at Massachusetts General Hospital. "Good fiction has an arc and a satisfying resolution. This is more like a lousy 70's sit com, over-using the same tired themes and hijinks. The problem is, we're powerless to change the station.")
But health insurers question whether there's a problem. Lora Pellegrini, president of the Massachusetts Association of Health Plans, said in a phone interview: "Our plans set a high priority on ensuring access to high quality and appropriate behavioral health care, and I think we demonstrate that through our national quality scores."
Patient satisfaction ratings are high as well, she said. The association also pointed to state statistics that show that mental health care visits have been rising for the last several years, and that the existing Office of Patient Protection gets few formal complaints about denials of mental health coverage.
Those mental health complaints, however, are the most common sort of complaint the patient-protection office receives, emphasized Matt Selig, executive director of Health Law Advocates, a non-profit law firm that helps low-income consumers denied access to health care.
We don’t want any more than physical health care, but we demand no less.
The proposed Massachusetts rules require health insurers to formally certify that they are complying with parity rules, or explain how they've fallen short and what improvements they plan. Pellegrini's group says that should be enough.
But advocates at the hearing, including Kennedy, say the health plans should be required to report publicly on how exactly they cover, say, cancer or diabetes, so that an "apples-to-apples comparison" with mental health coverage can be made.
"We want to be treated the same," Kennedy said. "We don't want any more than physical health care, but we demand no less."
• How easy is it for consumers to complain? And what happens once they do?
Kennedy and others argued that people with parity-based complaints need help making them official.
"People need to know the state is on their side," said Laurie Martinelli of the National Alliance on Mental Illness. "There needs to be a transparent and user-friendly complaint system," including an easy-to-use complaint form and time frames for how quickly a response must come.
Money must also be invested in publicizing the system, she said, because "people don't really know these channels exist."
Kennedy called for a requirement that when insurers deny coverage for mental health or addiction treatment, they must also notify the members who've been denied of their right to file a parity complaint with the state.
The Massachusetts Association of Health Plans is asking, rather, for a sort of intermediate step once a member complains, a chance to work out the coverage dispute before the state starts to investigate it.
• Is this complex? Or simple?
Speaking for the Massachusetts Association of Health Plans at the hearing, Sarah Gordon Chiaramida pointed out that insurers need more government guidance to address the complexities of the federal parity rules.
In response, Kennedy asked for a final word, emphatically delivered, including:
The law is very specific. It's...Do you do it for diabetes? Would you cover preventive care? Would you cover intermediate care? Would you cover acute care? Yes, yes, yes? Then do it for addiction and depression and other mental illnesses.
...Do you do it for rehab for stroke? Do you do inpatient, do you do outpatient? You do? Okay, then we've got to provide it for addiction and mental health. This is not complicated stuff, folks. And what we need you to do is force the insurers to publish what they do for diabetes, what they do for cancer, what they do for stroke... And if it compares up the same, then you're in compliance. You don't have to wonder if you're in compliance. You're in compliance. But if it doesn't marry up, guess what? You're out of compliance...
All we want is to be treated the same. That's the message of this legislation.
When Kennedy says "we," he's including himself very personally: He has been diagnosed with bipolar disorder, and "I have addiction and alcoholism in my story," he said in a phone interview.
But "because I was a member of Congress, I got my treatment paid for. The bottom line is that mental health benefits are really for the Fortune 100 and members of Congress, because everyone recognizes the important of mental health to high-functioning people. The Green Berets have the best mental health of any branch of the military. These are really strong people, the Green Berets, what do they need mental health for? They want to be their best. This isn't about weakness or strength, it's about, how do we reach our potential?"
Kennedy credited health insurers with significantly improving their mental health coverage over the last few years. "They know the world's going to change and they're scrambling," he said. "We may not think they're moving fast enough, but there are a lot more people who are getting health care that wouldn't otherwise be getting it, because the insurance companies know they're going to be held to this new standard."
Still, he said, "it’s really shocking, as you could hear from the testimony, the extent of the disparity in treatment." Part of the problem, he said, is that because of stigma, people with mental illness or addiction have not tended to speak up the way people with, say, breast cancer or AIDS have.
"When was the last time," he asked, "that you had someone with bipolar disorder or alcoholism get up and say, 'It's absolutely wrong, the way you're treating me, and I'm not going to stand for it'?"
Readers, responses? Click the orange play button on the sound file below to hear an excerpt of Patrick Kennedy's remarks.
More information on parity in Massachusetts: Health Law Advocates Parity Initiative
To submit a comment to the Division of Insurance, email firstname.lastname@example.org and refer to "Docket No. G2013-02" in the subject line.
This program aired on March 29, 2013. The audio for this program is not available.