By Yen Duong
49 out of 100, or a solid F.
That’s the grade that North Carolina received on a report card in October on how well its laws support federal laws passed more than a decade ago calling for mental health to be treated on par with physical health.
“Our F rating, we believe, underscores the barriers to care and challenges that many people in North Carolina who are living with mental illness continue to face in our state,” said Michelle Laws, a policy expert from the National Alliance on Mental Illness-North Carolina. “Even though the report card really looked at state statutes […] there are there other issues that we still have to work on.
Mental health parity isn’t panning out for some patients and parents,
Mental Health providers struggle with disparities in the system,
Determining disparity in mental health treatment can be difficult,
Most states don’t do well with mental health parity, but others are setting an example for enforcement.
“It was disheartening to see but it’s just a reminder that there’s still quite a bit of work to do.”
The parity law, the Mental Health Parity and Addiction Equity Act, was passed in October 2008 to ensure that mental health care patients receive the same benefits as patients who have had a heart attack, for instance.
“You can’t be more stringent in the way that you treat a behavior or mental illness or substance abuse disorder than you do a medical condition,” explained Kathy Shortt, a deputy commissioner with the North Carolina Department of Insurance.
NC DOI is an NC Health News underwriter.
Shortt offered an example of a parity issue. If an insurance company requires weekly progress reports from hospitalized patients with a physical condition but requires daily reports from patients in mental health facilities, that company would violate the parity law. Similarly, a company that agreed to cover as many days in a hospital as medically necessary for an appendix surgery, but capped the number of days you could stay in the hospital for a mental health problem would also be in violation.
Adherence to the law has been inadequate, said former Congressman Patrick Kennedy, who sponsored the parity act.
“The last 10 years I’ve been fighting to get more enforcement of the law,” said Kennedy, who founded the Kennedy Forum and associated website Parity Track to measure disparities in coverage and access for mental health for inpatient and outpatient services both in and out of network. The site also covers differences in pharmacy and emergency benefits.
“The test of the parity law is how much more difficult is it for someone to seek care in any one of those settings for a mental illness than it is for them to seek care for diabetes, cardiovascular disease, [or] cancer, as examples,” he said.
The website gives each state a report on their statutes about parity. It also lists all state legislation and regulations related to parity. North Carolina received an “F”, and so did 32 other states. Illinois was the only state to receive an A with a score of 100 out of 100 for its statutes protecting parity.
Access out of reach
Nearly one in five North Carolinians experience a mental illness and more than one in seven of those mentally ill people lack health insurance, according to the report card.
Even for patients with health insurance through the Affordable Care Act, difficulties may still arise in accessing mental or behavioral health care, Laws said.
“In North Carolina, we have people who are not able to access mental health services within their provider network,” said Laws from NAMI-NC. “That creates another challenge and barrier to access to care and treatment.”
Despite the need, almost 60 percent of American adults with mental illness did not receive treatment for those illnesses in the past year, according to a NAMI handout.
The Parity Track site also included links to a 2017 report by Milliman, a consulting firm that does extensive work with government agencies, which analyzed millions of health insurance claim records to measure the disparity.
“Some of the medical services providers receive, according to the Milliman report, anywhere between 20 to 22 percent higher reimbursement rate for […] physical health conditions compared to what the behavioral health providers are receiving,” Laws said. “There’s inequity again, that creates again challenges for the consumer and the patient.”
Besides the failing grade from the Parity Track report and the statistics borne out in the Milliman report, Mental Health America, an advocacy organization promoting mental wellness, ranked North Carolina as 38th in the country in terms of access to care. Over 400,000 North Carolinians with disabilities couldn’t see a doctor because of the costs involved, according to that 2019 report.
“That’s a lot of money”
North Carolina government organizations and non-profits need to work together to offer more safe, affordable housing for people with mental illnesses, Laws said.
“Those continue to be issues that are barriers for persons living with mental illness to thrive and live and work in their community,” Laws said.
She added, “We still have people who are resorting to living in inappropriate placement like adult care homes because there are simply not enough affordable housing options available for that.”
Scott Leshin, whose company SJ Health Insurance Advocates helps patients write appeals to insurance companies, said that unaffordability of substance abuse treatment has led to even more inappropriate placement. Many drug rehabilitation programs in N.C. cost over $20,000 for a course of treatment, which patients must often pay upfront before asking for reimbursement from their insurers.
“That’s a lot of money when most people in the U.S. have $400 in their savings account,” Leshin said. “So those that can go to treatment are those who can afford it and have the cash. What happens to those that don’t? They go to jail.”
About 17 percent of the N.C. prison population has a mental illness, according to a 2018 report from a NC Legislature Task Force, which is about four times higher than in the general population.
New insurance plans designed to avoid parity
Parity faces another obstacle this year with the rise of short-term limited duration insurance plans, which are not required to cover mental health and can charge higher premiums for people with a history of mental illness.
If patients are unsure if their employer health plan is self-funded or not, they should reach out to their employer.
Health plans that must follow federal parity rules include:
- Group health insurance plans for employers with 51 or more employees.
- Most group health insurance plans for employers with 50 or fewer employees unless they have been “grandfathered” in
- The Federal Employees Health Benefits Program.
- Affordable Care Act health plans purchased through the Health Insurance Marketplaces
Health plans that do not have to follow federal parity rules include:
- Medicare
- “Grandfathered” individual and group plans from before March 23, 2010.
- Self-funded small private employer plans that have 50 or fewer employees.
- Self-funded non-Federal governmental plans that have 50 or fewer employees.
- Large self-funded non-Federal governmental plans that opt-out of the requirement.
Source: NC Department of Insurance website.]
In 2017 and 2018, these short-term plans were limited to only three months and could not be renewed. But federal rules changed in October 2018, allowing the plans to last one year, with up to two additional years of renewal.
Thirty-one states place restrictions on these plans, either limiting them in duration, number of renewals or banning them outright, according to independent health insurance website healthinsurance.org. North Carolina has no such additional restrictions listed on that site, and Ted Hamby, a deputy commissioner at the NC DOI, said that the state is currently following federal guidelines.
Along with other organizations, the national organization of NAMI filed a lawsuit against the federal government to invalidate the new rules, which they fear will lead to the disparate access common in the days before the Affordable Care Act.
“We’ve fought so hard to get parity, and the expansion was such a huge step forward, and now we feel like we’re going back in time,” said Jennifer Snow, director of public policy for the national office of NAMI.
Snow said that younger, healthier people may flock to the cheaper and less comprehensive short term limited duration plans. This leaves the elderly, those with mental illnesses, pregnant people and others with pre-existing conditions in a separate group, a situation that would drive up premiums for them.
“It really goes against the whole idea of the Affordable Care Act, that everyone is going to be covered so risk will be spread out more evenly,” Snow said. “By letting these plans expand, it’s going to create two pools, a younger, healthier market and an older, sicker market. We’re really concerned about the implications that has for people with mental health conditions.”
Two steps forward, one step back
Kennedy refers to the parity act as a “medical civil rights bill” to equalize treatment for mental health and addiction.
“[Mental health and addiction] never get reimbursed the same; there’s never the same professional esteem for those who are delivering the care for mental health and addiction,” Kennedy said. “There’s never the respect for the patients who are suffering from chronic illness and who need the same care as if they were suffering from diabetes but are denied that care simply out of old fashioned stigma and bigotry.”
Karen Rogers, executive director of the local Mental Health America chapter, said she thinks North Carolina will change after managed care organizations change Medicaid and send fewer severely mentally ill patients to local providers.
“After 10 years of the parity law, we’re definitely not there,” Rogers said. “But as we move toward [the Medicaid transformation] I think it will be a step in the right direction.”
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Thank you for bringing this crisis in front of many who are unaware. Our Non-Profit works locally to fight for individuals rights to treatment; would love to talk further with you!
Thank you for highlighting the health disparities in treatment between physical health and mental health. I was trained in the Integrated Care model while in grad school that I believe could be a way for health care organizations and providers to bridge the gap in North Carolina. The problem is awareness that this a bigger issue that most realize. I recently had an opportunity to attend a film and discussion with community providers in Alamance County NC. The film is called Resilience, The Biology of Stress and Science of Hope that highlights the importance of administering ACE score screenings to children and families combined with an integrative care approach to meet social disparities. Once I read this article, I thought it would be beneficial to share this film with you.
I work at a free clinic in Alamance County for the uninsured. I am a licensed clinical social worker and mental health outpatient therapist.
This issue is an extremely important one. I am among the families who was negatively impacted by the high costs of treatment of a son who ultimately ENDED UP GOING INTO THE PUBLIC SYSTEM after the narrowly allocated service dollars were used up through our private insurance. BUT THE OTHER WAY IN WHICH THERE IS NO PARITY in our state is the fact that too many people needing mental health services, even in acute need, have no insurance at all! The issues of this situation are not included in this article because this category of citizens were not included in the Parity legislation. So we need parity BEYOND what current law calls for! Thanks for letting me comment.