The Obama administration last week delivered the final word on the Mental Health Parity and Addiction Equality Act (MHPAEA): Mental health and substance-abuse issues must be covered by health insurance in the same way as physical problems. Though the act was signed into existence in 2008, its provisions remained unclear and therefore had not yet been enforced by practitioners and insurance companies.
Under the new ruling, insurance companies must provide coverage for mental health issues and substance-abuse concerns at the same cost as physical ailments; people cannot be denied coverage based on mental health and addiction issues; and the allotted time for mental health- and rehab-related hospital stays must be no different than for a physical emergency such as a stroke or heart attack. The hope and intention of MHPAEA being enforced under the Affordable Care Act (ACA) is that people experiencing mental health conditions and addictions will no longer be discriminated against, charged higher out-of-pocket expenses, or turned away based on the nature of their symptoms.
GoodTherapy.org decided to check in with our Topic Experts and member contributors to examine the significance of mental health parity as it relates to professionals in the field of psychotherapy. The responses were mixed. Some are optimistic, believing parity to be a step in the right direction; others are wary of how it will impact their private practices, as well as how cooperative insurance companies will be in providing expanded coverage.
Applause Abounds for Increased Access to Care
Among those who see the extended coverage as beneficial is Allison Abrams, LCSW, who said, “I think this is an enormous step forward in the field of mental health, both for patients and providers. It is a success for mental health professionals, who all too often have to expend time and energy that could be spent elsewhere fighting with insurance companies for fair coverage for their clients. But, more importantly, it is an achievement for those suffering from any type of psychological stress, who otherwise may not have taken the steps to seek treatment.”
Abrams said the ruling sends an important message.
“Giving the same or ‘equal rights,’ as it were, to those seeking mental health treatment as to those seeking treatment for medical diseases makes a significant statement,” she said. “It is a step toward destigmatization of mental illness, and less stigma and less hurdles to jump over will hopefully mean that, in the long run, more and more people will reach out for the help they need.”
Abrams added, “This accomplishment further highlights what mental health professionals have known all along, which is that psychological or emotional health is as crucial to one’s overall well-being as physical health.”
Margaret Nichols, PhD, also is pleased with the ruling.
“I see this as an extremely positive law,” she said. “Besides the practical impact that the law will have, giving many more people access to mental health services, the law legitimizes mental health problems as ‘real’ medical problems. This can be very validating.”
Although Nichols notes that mental health parity has already been widely established in New Jersey, where her practice is based, Nichols foresees the “expanded numbers of people with health insurance” under the ACA having a positive impact on her business.
“In our private practice, we encounter many people who we must turn away because they have no insurance—weekly therapy is pretty expensive if you have to pay out of pocket. Now these people will be able to obtain insurance through Obamacare,” Nichols said. “In particular, I think younger people will be seeking therapy more. They already have more positive attitudes toward mental health services than their elders; now they will have the means to obtain this care.”
Carey Heller, PsyD, a psychologist in private practice in Bethesda, Maryland who works with children, teens, and young adults, expects demand for mental health services to increase.
“The cost of mental health care is often a deterrent to treatment, and I feel the new laws will help make mental health services more accessible and enticing to individuals who need it,” Heller said.
Similarly, Meri Levy, MA, believes the ruling will “empower” people to pursue the treatment they need.
“The final ruling on the Mental Health Parity and Addiction Equality Act reinforces the message that mental illness is as important as physical illness, and its treatment is as necessary,” she said. “Those suffering from depression, anxiety, obsessive compulsion, and the like are entitled to the same level of care they would receive for diabetes, heart disease, and asthma.”
The benefits go beyond making care more affordable and accessible for individuals experiencing serious mental health and substance-abuse issues. Angela DeCandia, MSW, LCSW, who specializes in couples and family therapy, describes mental health parity as a “milestone” for couples and families seeking therapeutic assistance in dealing with matters of relationship distress such as divorce, stepparenting, and infidelity.
“By ensuring that insurance carriers treat mental health and substance abuse in the same way they cover physical illness, the Mental Health Parity and Addiction Equality Act destigmatizes treatment, makes psychotherapy more accessible, and in doing so has the potential to create a relationship ‘ripple effect’ that may just save marriages, strengthen partnerships, and heal families,” DeCandia said.
Will Parity Help Eradicate Stigma?
The removal of stigma surrounding mental health concerns is a longstanding, ongoing effort, and it remains to be seen how effective the new legislation will be in achieving this goal. According to a report published on the National Institute of Mental Health website, “[M]any people who successfully manage their mental illness report that the stigma they face is in many ways more disabling than the illness itself.” Findings published in the National Alliance on Mental Illness-NYC Metro’s Mental Health Report 2013 seem to support this notion:
- Mental illness is ranked as the most stigmatized form of illness.
- The most common words to describe someone who has been diagnosed as mentally ill are “psycho,” “nuts,” and “crazy.”
- One in two people report being “frightened” by those with mental illness.
- Nine out of 10 feel it is inappropriate to reveal to coworkers that you have a mental health condition.
In light of statistics such as these, it follows that the subject of stigma appears so widely in the varied responses to mental health parity. Christopher L. Smith, LCAC, LMHC, LMFT, comments, “On one side, the effect of recent legislation should normalize mental illness and help it to be considered by people like other illnesses and conditions. On the other hand, the push for passage of this legislation has followed significant negative press that has strongly linked mental illness and perpetuating violence; this would tend to increase stigma and make people less likely to talk about mental health concerns. How these aspects will balance out remains to be seen.”
Speaking to the positive aspects of parity, Smith said, “What is clear, however, is that society is moving on this issue, and hopefully people will experience a better sense of peace and wholeness in their lives.”
Jonathan Bartlett, MA, MFT, added, “As the federal definitions of disease are clarified to include a wide range of ‘behavioral problems,’ consumers can now expect less stigma regarding the existence of past or present mental health diagnoses. Depression or an addiction problem will no longer rule you out when applying for a health-care plan.”
Bartlett’s optimism comes with a warning, however.
“Our tendency as a society to over-diagnose mental health issues is about to become equally transparent,” he said. “Learning that long-term treatment for [clinical] disorders is now covered in full by insurance will naturally tempt clients (and their therapists) to over-diagnose these problems. We are trained as a culture to hunt for a deal, are we not?”
Coverage Concerns Raised Among Practitioners
In spite of prevailing positivity, years of experience have taught many practitioners to proceed with caution wherever insurance companies and mental health laws are concerned. Thus, enthusiasm remains tempered in some circles.
“While the new regulations are exciting and a step in a positive direction for the role of mental health in our society, there still remains a long, uphill battle to overcome the stigma associated with mental health and substance-abuse services, and to truly be able to provide adequate care for those individuals who may benefit from our profession,” said Jeffrey Kaplan, MA, LMFT.
Kaplan, who has experience working in a substance-abuse facility in a suburb of New York City, isn’t convinced that insurance companies will actually authorize coverage for certain addiction services, such as inpatient care.
“A greater concern is in areas that this parity act has not addressed,” Kaplan said. “While benefits may now exist for mental health and addiction services, that is not to say they will be authorized by the insurance companies. Already this is an issue for inpatient care, as the determined ‘medical necessity’ that determines applicable care becomes an obstacle for many to receive appropriate services. … As a result, many patients are thus required to seek outpatient services based on their symptoms. These, too, are beginning to be restricted by insurance companies for similar reasons of ‘medical necessity,’ particularly intensive outpatient services for substance abuse.”
Kaplan also notes an important concern shared by licensed practitioners in fields that aren’t yet recognized by insurance companies.
“Some of the ‘newer’ licenses, such as creative arts therapists, mental health counselors, and licensed marriage and family therapists, are still prevented from being accepted by insurance providers, depending on the company,” he said. “As a result, those populations that these credentialed practitioners serve still may not be able to obtain services, despite the increased parity law.”
Although as a whole she expresses being “delighted that mental health has finally achieved parity with physical health,” Lynn Somerstein, PhD, RYT, who typically uses a sliding scale to accommodate her clients’ financial situations, also is unsure as to how extensive the new coverage will be.
“The law is still unclear as to who can provide services,” Somerstein said. “I’m a psychoanalyst and a yoga therapist, and I don’t know if these fields will be included.”
How Will Increased Coverage Impact Cash-Pay Providers?
Further concerns arise with the issue of out-of-pocket versus insurance payments. Andrew Mendonsa, PsyD, a clinical psychologist based in Beverly Hills, California, warns that the expanded coverage of mental health services may mean trouble for those in private practice who are accustomed to being paid out of pocket.
“I do believe the new health-care act will be the demise of cash-pay private practices,” he said. “In theory, everyone will have insurance, so why would someone pay out of pocket for services any longer?”
Mendonsa also is wary of how insurance companies will handle reimbursement fees, as they will now be “the primary pay source for private practices” and “there are plenty of providers willing to work for less just to have work.”
Taking Mendonsa’s concerns further, Deb Hirschhorn, PhD, notes, “I personally don’t take insurance at all, and many therapists are like me. So more insurance will not improve access to those of us who don’t.”
With millions of people gaining access to mental health care, are providers prepared to handle demand?
“I think people will seek out help with their new coverage,” Mendonsa said, “but my fear is people have been hanging on for so long, most will be in near-crisis levels when they are finally seen, thus increasing the demand for higher levels of care such as partial hospitalization, intensive outpatient (IOP), and locked inpatient. I am not sure these levels of care are ready for the potential flood that may result from the health-care reform.”
Though she is accustomed to treating people who pay out of pocket, Laura Reagan, LCSW-C, has a more optimistic perspective.
“Parity will ultimately contribute to consumers recognizing the importance of preventive care for their physical and mental health and wellness, as well as understanding the need to address acute mental health concerns as they would physical conditions,” Reagan said. “I do not participate with insurance, but I believe that as more individuals begin to consider therapy to be something normal, like getting a flu shot to prevent illness during the winter, increased numbers of people will seek therapy through my practice.”
- Kaiser Health News (KHN, 2013, November 8). Detailing long-awaited mental health parity law regulations. Retrieved from http://www.kaiserhealthnews.org/Stories/2013/November/08/health-on-the-hill-mental-health-parity-regulations.aspx
- National Alliance on Mental Illness-NYC Metro. NAMI New York City Metro: Mental Health Report 2013. Retrieved from http://www.naminycmetro.org/IWillListenStudyResults/tabid/166/Default.aspx
- National Institute of Mental Health. Teacher’s guide: Information about mental illness and the brain. The Science of Mental Illness. Retrieved from http://science.education.nih.gov/supplements/nih5/mental/guide/info-mental-a.htm
- United States Department of Labor. Mental health parity. Retrieved from http://www.dol.gov/ebsa/mentalhealthparity/
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