The need for mental health and substance use disorder services is substantial and growing. One in five adults in the United States, or 53 million people, had a mental illness in 2020, including 14 million adults who had serious mental illness; forty million adults had a substance use disorder. Mental health and substance use disorders became more prevalent during the COVID-19 pandemic; the percentage of adults reporting symptoms of anxiety or depression quadrupled from 2019 to 2021, drug overdose deaths reached an all-time high of 100,000 in the 12-month period ending April 2021, and mental health claims as a share of all medical claims for teens doubled between 2019 and 2020.

Policymakers Float Ideas to Improve Access to Mental Health Services

In response to these troubling trends, policymakers are seeking multi-pronged approaches to provide greater access to services that treat and manage mental health and substance use disorders (MH/SUD). The five Congressional committees with jurisdiction over health legislation have all held multiple hearings on behavioral health over the last year. Additionally, the Senate Finance committee released a comprehensive report that draws on input they’ve received in response to a Request for Information issued last fall. The report identifies a number of barriers to MH/SUD services, including provider shortages and inadequate networks. The report also announces the committee’s intent to pursue policy developed in bipartisan discussions to boost the behavioral health workforce, care integration, mental health parity, telehealth, and care for children and young people. And on May 11, a bill to reauthorize more than 30 federal programs to support MH/SUD services and require state and local government health plans to comply with the mental health parity law was advanced by the House Energy and Commerce Subcommittee on Health with a bipartisan vote.

Over in the executive branch, the President’s 2023 budget proposal would fund
MH/SUD workforce development, care integration, community-based mental health centers, and crisis services. For those with private insurance—a majority of people in the United States—President Biden’s budget proposes several policies to improve access to mental health and substance use disorder services.

• Mandating coverage: The budget proposal would require all insurers and employer-sponsored insurance to cover MH/SUD. (Currently, only insurers selling coverage in the individual and small group markets must cover those services as part of the essential health benefits requirement.)
• Patient-oriented standards: The President’s budget proposal mandates that insurers and employer-sponsored coverage use medical necessity standards that are consistent with the criteria developed by non-profit medical specialty associations and limit consideration of profit in medical necessity determinations. Some states require insurers to use expert-developed standards when considering whether to pay MH/SUD claims, but in most states and for the vast majority of employer plans that fall under federal jurisdiction, those standards can vary and be driven by financial considerations, not necessarily what is best for patients.
• Expanding provider networks: To increase access to MH/SUD services, the budget proposal authorizes federal regulation of network adequacy standards for MH/SUD providers and the development of reimbursement requirements to reduce disparities in payment between MH/SUD providers and medical providers.
• Improving enforcement of existing protections: The budget proposal would fund state-level enforcement of the Mental Health and Addiction Equity Act (MHPAEA), the federal law requiring coverage of MH/SUD services to be comparable to other medical services. Only 18 states reported to the Government Accountability Office that they conduct exams to assess insurers’ market practices and legal compliance on a regular basis, and only nine routinely review MH/SUD benefits for parity compliance. Previous federal funding has helped states expand their MHPAEA oversight and enforcement capacity.
• Expanding protections to more consumers: The proposal requires all plans covering state and local employees to comply with MHPAEA. Under current law, those plans can choose whether or not to comply and many have opted out.

Efforts to Improve Mental Health Parity Enforcement

These federal policy discussions and proposals are welcome in the face of a growing need for mental health and substance use disorder services. Another key part of a comprehensive approach to improving access to MH/SUD services is stronger enforcement of MHPAEA. MHPAEA regulations set standards for measuring whether MH/SUD services are comparable to other medical services. There are standards for financial requirements like copays and coinsurance, for treatment limits like caps on covered visits or hospital stays, and for “non-quantitative treatment limits” (NQTLs), such as prior authorization requirements. These limits may be harder to measure but can pose substantial barriers to accessing care. Federal regulations for NQTLs require parity in provider reimbursement rates and in the criteria used to consider whether MH/SUD care is medically necessary. Insurers and health plans that fail to meet these standards will fall short of ensuring patients can access in-network care with providers whose treatments are covered, no matter how successful policies may be in growing the workforce.

The Consolidated Appropriations Act (CAA), which took effect in 2021, requires insurers and employer-sponsored plans to conduct comparative analyses of NQTLs to ensure compliance with MHPAEA’s standards, and to share those analyses with federal and state regulators. The Biden Administration’s 2022 MHPAEA enforcement report—the first since the CAA’s NQTL requirements went into effect—details startling failures to comply with these requirements.

The report documents the enforcement actions of the Department of Labor, which has jurisdiction over employer-sponsored coverage, and the Centers for Medicare and Medicaid Services (CMS), which has jurisdiction over fully insured plans in three states (Texas, Missouri, and Wyoming) and state and local governmental plans. Of the comparative analyses that insurers and health plans submitted to DOL and CMS for review, none had sufficient information to demonstrate MHPAEA compliance. When insurers and health plans were asked to conduct, document, and submit those analyses, federal regulators identified multiple instances of MH/SUD coverage limits or restrictions being more stringent than that required for other medical services, including:

• Prior authorization requirements
• Provider network admission standards
• Concurrent reviews of continued care, such as additional hospital days or therapy sessions
• Out-of-network reimbursement rates
• Treatment plan requirements, and
• Coverage of autism services

These and other NQTL violations identified in the report demonstrate that patients had greater difficulty finding in-network MH/SUD care and getting that care approved and paid under their plan compared to other health care needs— the very problem MHPAEA sought to solve.

Takeaway

Recent and newly proposed policies from Congress and the Biden administration seek to increase access to MH/SUD services by expanding patient protections and strengthening enforcement of existing requirements. That’s a welcome response. The scope of the ongoing MH/SUD crisis requires tackling the problem on all fronts—expanding the workforce, improving care delivery, and strengthening coverage of MH/SUD services.