Years ago, I had a patient with a psychiatric condition that worsened because it went untreated, eventually leading to his incarceration. Like many individuals in the United States at the time, he had no insurance coverage for mental health services and was thus unable to access treatment.
Today, I often wonder: Could his life be any different now if we as a nation had prioritized parity policies equalizing medical and mental health services?
But accompanying this question is one that is far from retrospective and much more urgent: How many individuals can we save before it’s too late? Indeed, the consequences of the COVID-19 pandemic have underscored the importance of accessibility for mental health services. From January to September of 2020, 315,220 people and 534,784 people in the United States were screened for anxiety and depression respectively — conditions that lack full coverage by most insurance policies at the national level.
Preexisting California law, as well as current laws in other states, stipulate that insurance coverage is guaranteed for the diagnosis and medically necessary treatment of only severe mental illness, such as schizophrenia. These laws thus exclude mental conditions that are not considered severe or in need of medical mediation, allowing insurance companies to utilize these definitions to deny claims. The need for mental health services, however, continues to rise. In 2020, about 178,000 people in the United States reported thoughts of suicide, with higher rates among the youth.
Amid such alarming rates, universal coverage for all mental health services is an overdue conversation — it necessitates political action for new, equitable mental health parity laws.
Several mental health parity laws have taken effect in recent decades. The last federal attempt to establish an equitable parity law for mental health services was the Mental Health Parity and Addiction Equity Act signed by former president George W. Bush in 2008. However, substance use disorder and nonsevere mental conditions continued to lack full coverage in law until this year.
On Jan. 1, California’s parity law SB 855 went into effect, requiring health insurance companies to provide full coverage for all mental health conditions and substance use disorders. Such is the example that federal legislation should follow: A new parity law mandating full coverage for any mental health condition is crucial to reduce structural and attitudinal barriers to care in the United States.
It is no secret that insurance companies have denied services for years, even after the passage of the 2008 parity law. For example, Anthem Blue Cross faced $9.6 million in fines from California’s Department of Managed Health Care from 2014 to 2019 for denying claims inappropriately. Furthermore, insurance companies in the United States have also restricted access to mental health services through outdated or inadequate provider networks.
Equalizing coverage between medical and mental health services can potentially reduce the frequency of incarceration caused by untreated mental illness. Several studies suggest that individuals suffering from untreated mental illness and/or substance use disorder are disproportionately at a higher risk for incarceration. In fact, data from more than 100 studies reviewed in 2012 show that 1 in 7 prisoners have a psychosis or major depression diagnosis.
Individuals with mental illness are also less likely to have insurance coverage and receive treatment, and a significant correlation between incarceration and untreated mental illness and/or substance use disorder exists. According to a 2014 study from the American Journal of Public Health, about 26% of incarcerated individuals in the United States had preexisting mental illness, but more than half did not receive treatment while in prison. Furthermore, approximately 70% of incarcerated youth have a mental health condition, with a lack of access to mental health services being the reason for incarceration for that population.
Moreover, the high costs for substance use disorder treatment and the lack of insurance coverage for moderate mental illnesses are risk factors that often lead to homelessness. Although access to care might be possible through Medicaid, unhoused individuals may not be aware of available resources. Untreated mental illness is also a major risk factor for exacerbations and complications of coexisting medical conditions among the unhoused community. The prevalence of 30-day suicidal ideation and suicide attempt are extremely high among homeless individuals, with about 8% reporting suicide attempts in a recent Psychiatric Times study.
Opponents of SB 855, such as the California Chamber of Commerce and health insurance companies, have claimed that the bill will raise health care costs. Additionally, opponents argue that it might increase the rate of homelessness in California. Although there may be higher costs upfront, greater savings in the long run are possible. In fact, data from 2016 showing a $1.45 trillion cost in societal harm and economic loss annually (due mostly to lower productivity and high health care costs) also suggest that approximately $368 billion in savings is attainable with coverage for substance use disorder treatment among all users.
Given the great need for mental health services and the worsening of mental health disparities, it is imperative that a more equitable mental health parity law becomes a national policy. There are no sure outcomes at this time, but SB 855 is the first substantial effort in advocating for and prioritizing the most vulnerable in our society, and the passage of this bill into California law is a true step toward addressing mental health disparities that continue to plague the United States.