Running Head: DISPARITIES IN BEHAVIORAL HEALTHCARE

Disparities in the Behavioral Healthcare Community:

Focusing On Insurance Coverage and Policy

Jenna Peon
University of South Florida
Behavioral Health Systems Delivery
MHS 4002

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Abstract
This work addresses mental health disparities in terms of demographics and
access to healthcare, focusing on insurance coverage for behavioral health
services and policy regarding these issues. Using +ELEVEN+ sources to
identify relevant information, this paper explores the dynamic behavioral
health parity movement. Significant findings address how far-reaching and
impactful disparities among the behavioral healthcare community are, as
well as identify how well the financial and political needs of consumers are
being met. Upon research it was found that strides toward parity have been
significant in recent years, largely in part to the Mental Health Parity and
Addiction Equity Act (MHPAEA) and efforts towards a better healthcare
marketplace with comparable coverage for primary care and mental health
services. However, there are still significant barriers to ensuring parity and
adequate access to care for all mental health and substance use consumers
within the community that must be addressed and amended.
Keywords: Behavioral Healthcare, Disparities, Parity

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Introduction
Health disparities are differences or inequalities in access to care that
affect different groups of consumers. They can be systematically
implemented or unavoidable, and based on socioeconomic, geographic,
racial, gender, disability, or other determinants. They can reflect social
advantages or disadvantages among individuals, hinder access to proper
treatment, or affect overall health outcomes (Braveman, et al, 2011). The
focus of this work is to address the disparities that still exist between medical
health and mental health. Recent efforts towards parity including changes in
policy, improvements in the healthcare marketplace for consumers, and
properly addressing racial, ethnic, and social boundaries of access to care
have made significant enhancements to the behavioral healthcare system.
Remaining disparities must be promptly amended in order to continue
optimizing the mental health conditions among both individuals and the
community.
Complexity of Mental Health Diagnoses
Since the beginning of modern healthcare insurance in the first half of
the twentieth century, there was always a major focus on physical health
coverage as opposed to mental health coverage. As the fields of psychology,
psychiatry, behavioral health, and other related fields have expanded in
recent decades, programs and expenditures have developed dynamically as

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well (Garfield, 2011). In this process, obvious inequalities in mental health

coverage have surfaced and created significant obstacles for consumers.
Individuals who are diagnosed with a mental health issue are thrown into a
whirlwind system of services that is not always easy to navigate. Besides the
stigma of the disorder they are faced with, they must also deal with new
terminology that may be hard to understand due to educational or cultural
boundaries, medication names and side effects, different doctors and
treatment centers which are not optimally integrated, and on top of this all,
they have to figure out how to pay for these interventions and medications.
The possibility of lost wages and absence from work or school is daunting,
and the consumer often has difficulty determining the extent of coverage by
their insurance provider, if they even have coverage.
History of Policy
The Mental Health Parity Act was introduced 1996 and represented an
unequivocal stride in the direction of health equality in policy. This bill did not
require providers to include mental healthcare on all plans or significantly
alter the delivery of services or financial support through insurance. It simply
mandated that group health plan providers who offer both medical and
mental health coverage cannot impose yearly or lifetime monetary limits on
mental health benefits that are more restrictive than those placed on
medical or surgical benefits (Hennessy & Goldman, 2001).

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Although the changes in law did have a positive impact for some
consumers, the legislation severely limited the benefits to certain
populations. The new law only applied to workplaces of fifty or more
employees, and did not cover substance use treatment programs. Also,
although providers could not provide a dollar limit on services, they could get
around the policies by limiting the number of visits to certain types of
healthcare providers that would be covered (Hennessy & Goldman, 2001). A
report from SAMSHA following the MHPA found that less than 1/5 of
employers made any changes in their benefit packages due to the
legislation, but most introduced or modified the number of visits covered,
severely limiting access to care for mental health patients. More than 33
percent of all plans studied reported no changes to benefits and no
anticipated cost increases due to compliance with the new law (SAMHSA
Background Report, 1999). Similarly, a study in 2000 by the U.S. General
Accounting Office found that 87 percent of employers in compliance with the
MHPA still hold at least one feature of coverage that was more limiting to
mental health than medical health, for example, the same day and limit
visits discovered by SAMHSA (GAO: Mental Health Parity Act, 2000).
The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008
was a federal ruling that elaborated upon previous legislation, extending
parity even further into all of the states. Unique from previous laws, this bill

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placed restrictions on so-called non-quantitative treatment limits in managed

care programs that had previously inhibited consumers. Harsh utilization
reviews, abrasive standards for participation in a provider network, and
required authorizations for coverage were all techniques used by providers to
hinder the utilization of mental health and substance use services. However,
the MHPAEA once again required that these limitations be no more strenuous
than those placed on medical and surgical treatments (Busch, 2011).
Recent Policy Affecting Parity
The Affordable Care Act (ACA) of 2010 extended parity protections to
individuals covered by small-group policies which were previously exempt
under the MHPAEA, and offered coverage to millions of previously uninsured
consumers. The vision was to extend a universal healthcare marketplace to
the most possible Americans, and equalize care for all types of health
services. In 2011, an estimated 4 million consumers out of the 11 million on
the marketplace were not covered for mental health and substance use
benefits. Once the provisions of the act were phased in circa 2014, the
legislation placed limitations on out-of-pocket expenses, further limited
disparities between primary care services and behavioral health services,
and increased coverage on preventative services which can be crucial in
avoiding serious mental health issues. Access to care was significantly
improved by the provisions of the ACA which eliminated denial of coverage

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or unfair premiums due to preexisting conditions (Beronio, Glied, & Frank,

2014). The Patient Protection and Affordable Care Act also extended services
covered for those enrolled in Medicare Part D, optimizing positive impacts on
the older adult community experiencing mental illness. Among many
benefits aimed directly at psychiatric rehabilitation, increased access to
program such as supportive housing have had positive impacts in the
behavioral healthcare community (Cook & Mueser, 2016).
Social Determinants of Behavioral Health Disparities
Disparity can occur due to limits in policy or a lack of adequate
legislation, but can often presents itself along lines of different social,
economic, geographic, and ethnic or racial backgrounds. Significant
differences in access to care, service usage, and insurance coverage are
present among consumers of minority subpopulations. Blatant inequalities
are displayed regarding who has insurance benefits and adequate access to
care because of financial support from a coverage provider. Overall, one in
four American adults (ages 19-64) did not have health insurance during at
least one point in the year in 2011, most of them lacking coverage for one
year or more (Moonshinge, et al, 2013). A later report by the National Center
for Health Statistics in 2013 found that while only 10.6 percent of nonHispanic whites lacked health insurance, Hispanics were over 30 percent
likely to not carry coverage, followed by non-Hispanic Blacks at nearly 19

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percent, and non-Hispanic Asians at 13 percent (NCHS Data on Racial and

Ethnic Disparities, 2014). In a society that is so focused on equality among
groups and closing racially segregated gaps in all aspects, we still face an
obvious problem in one of the most basic needs of our populations: health
care.
Disparities also exist among genders. In 2013 the CDC found that 18.8
percent of females were uninsured, while 24 percent of males lacked
coverage (Moonsinghe, et al, 2013). Financial and economic instability also
lend themselves to differences in access to care. A 2004 survey of adults
over 50 by the AARP found that 40 percent of unfilled prescription
medications were due to the cost of the drug (Teague, 2016). As a wealthy,
developed nation, it seems implausible that our citizens cannot gain access
to necessary healthcare treatment and medication due to lack of funds.
Improving insurance coverage among all subpopulations and providing
financial support for those who may be unemployed or retired will lead to
higher utilization of health services.
Barriers to Coverage
Before the strides by parity legislation made to equalize coverage for
medical and mental health, one of the largest obstacles to receiving and
maintaining adequate mental health care was the use of limits on the
number of visits allowed to treatment facilities, and unfair differences in co-

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pays and benefit amounts for mental health services compared with primary
care services. Since the changes in law and federal parity requirements have
altered the system of service delivery, the gap in these differences has
begun to close. However, providers have found further ways to limit
coverage or make it difficult to obtain financial assistance in covering
behavioral healthcare costs, all while still remaining in compliance with
parity policy. One of the most barring restraints used by providers is the
vague use of medical necessity. It has become hard to put both
quantitative and non-quantitative limitations on the treatment of mental
health issues due to parity guidelines, however, there is judgment passed on
what is medically necessary and this can often rule out treatment for
individuals who truly need it. Even in 2013, definitions placed on medical
necessity were found to be stricter for mental health plans as opposed to
their somatic medical counterparts (Bartlett & Manderschied, 2016).
Addressing the need for uniform regulations on all aspects of coverage and
service delivery is clearly a broad issue to tackle. But, treating behavioral
health services in exactly the same manner as physical health care, including
congruent restrictions to policy, is inherent to the retention of parity for all
consumers.
Solutions and Implementations for Further Change

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Creating awareness and advocating for change on behalf of the better

interests of all consumers is the most crucial step towards resolving
disparities. Addressing issues with access to care will clearly close gaps in
availability and utilization of services. It is crucial that mental health and
substance use treatments are treated in the same manner as medical and
surgical procedures when it comes to insurance benefits and implementation
of policy. The MHPAEA combined with the ACA and other steps towards
maintaining an ideal healthcare marketplace for consumers have definitely
begun to level the playing field for behavioral health patients. Further
development of legislation and government programs that endorse health
parity among all Americans would ensure better health outcomes in both
individuals and populations.
Implications for Behavioral Health
There are obvious ethical concerns about the inability to access care
due to socioeconomic or related determinants. However, other positive
effects can be achieved when an effort towards parity is endorsed. One study
shows that improved Medicare Part D coverage implemented in 2003
lowered depressive symptoms in a group of older adults. Although the
average age of the sample does not necessarily represent the general
population, the findings are still significant. The Medicare Prescription Drug,
Improvement and Modernization Act applied substantial changes to

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prescription drug coverage for seniors that used Medicare as their provider
for health insurance. The study suggested that changes in Part D coverage
significantly decreased depressive symptoms among the patients studied
(Ayyagari & Shane, 2015). This leads to the postulation that healthcare
coverage and access to care have a direct positive impact on health
outcomes for affected consumers. While disparities in insurance policy
holding do exist in our current state, the evidence of positive results due to
closing this coverage gap cannot be denied.
Regardless of existing disparities, it is undeniable that individuals with
mental illness experience severely delayed treatment-seeking. The average
latency between onset of symptoms and first contact with a general doctor
regarding treatment is ten years. Even for those with the most serious
conditions, the gap is still five years (Wang, et al, 2004). Other studies have
shown that people with poor mental health are more likely to experience
poor physical health as well. Individuals who do not have coverage by
insurance are less likely to seek treatment upon its necessity, and more likely
to receive treatment through emergency services, often when it is already
too late (McLaughlin, 2004). The significant link between mental and physical
health suggests that upon gaining parity for all health care benefits, an
increase in the overall health outcomes of both the individual and society as
a whole would be improved. From a behavioral or public health perspective,

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this would have serious positive effects on the future within our
communities.
One study used a pre-post design to analyze the effects in a large, selfinsured employer following a policy change that removed limits on the
covered number of outpatient visits for mental health services. The results
found a 255 percent increase in service use by subscribers, and a 176
percent increase in use by their dependents (Grazier, et al, 2016). This
significant increase in the utilization of services following policy changes that
aim towards parity suggests that if equality was largely achieved for all
populations in the community, increasing access to care, more consumers
would properly utilize the services that their conditions necessitate. Thus,
parity legislation put in place by the federal government is expected to
increase participation in outpatient services by consumers who were
previously limited in their number of visits covered.
Another analysis of insurance coverage for individuals with mental
health issues found that 62 percent of those affected did not seek treatment
at all, and over 20 percent perceived unmet needs in their necessary
treatment. In this study, a strong link was displayed between having
insurance and seeking care. There was also a correlation between coverage
and a lower incidence of perceived unmet need. This recent study supports
opinion that inadequate care and low rates of treatment still persist within

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our communities and must be addressed by reducing structural and

attitudinal barriers (Walker, et al, 2015).
Conclusions
Parity across all health status determinants is the ideal outlook for the
health care field. Disparities in insurance coverage and medical care costs
have been amended by recent policy changes, particularly the Mental Health
Parity and Addiction Equity Act and Affordable Care Act in the last decade
(Walker, 2015). While policy and insurance initiatives have made moves in all
the right directions, some barriers to eliminating disparities still exist within
our communities. The most delicate issue at hand is the obvious racial,
ethnic, socioeconomic, and gender-based inequalities in insurance coverage
and the delivery of behavioral health services. Barriers exist on physical,
psychological, cultural, societal, and treatment biases. Increasing advocacy
and awareness within the communities is one of the most crucial ways to
implement change. Reducing stigma towards mental illness and improving
access to care for minorities and other disadvantaged populations will be the
key hurdles to overcome in the journey towards full parity among all
consumers (Conner, 2016). The integration of mental health and primary
care services will facilitate better outcomes for both individuals and the
community (Crowley & Kirschner, 2015). Implementing full parity for
insurance coverage of and access to mental health and substance use

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services will lead to improved health outcomes, a reduction in emergency

service usage, and overall positive changes in the field of behavioral health
care.

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