While We Let Insurance Have Its Way, The Opioid Crisis Will Rage

The opioid crisis isn’t dominating headlines at a fever pitch as of late like it has in the past. But families across the country are still reeling from the epidemic that currently claims more than 130 lives a day from misuse and overdoses. Of course, it’s a multi-layered problem, but one of the most far-reaching and harmful facets is the lack of insurance parity.

As the National Alliance on Mental Illness (NAMI) describes it, insurance parity is “the equal treatment of mental health conditions and substance use disorders in insurance plans.” Throughout much of the America’s healthcare history, citizens have had limited access to mental health and addiction treatment thanks to a dearth of insurers covering these programs coupled with the government’s program scalebacks in the 70s and 80s.

In 1996, Congress tried to help by passing the Mental Health Parity Act (MHPA), which required mental health and addiction coverage be comparable to the general care that private companies of more than 50 employees offered their staff in health plans.

This wasn’t a fix-all solution, and many Americans yet faced coverage disparity. In 2003, the General Accounting Office reported that the 1996 Act’s success at implementation was disappointing. Most companies were acting in accordance with the legislation, “but substituted new restrictions and limitations on mental health benefits, thereby evading the spirit of the law,” such as limiting the number of covered outpatient visits and hospital days. Congress attempted to fill the gaps of the previous legislation by passing the joint Mental Health Parity and Addiction Equity Act in 2008. It sought to stop companies from creating those restrictions that helped them avoid the law and also included addiction issues in the insurance parity battle.

In other words, the bills attempted to ensure coverage for those with addiction and mental illness be comparable to coverage from other diseases, applying a wider scope of coverage. Moreover, companies could no longer charge higher deductibles and copays for mental health and addiction treatment.

But in a stroke of tragic irony, the second Parity Act also failed. Companies still found a way to snake around the law. How did they do that? The answer seems to lie with the insurance companies’ imposition of restrictive standards of “medical necessity” on mental health and addiction coverage to determine qualified coverage — something that is a clear violation of parity mandates.

That is, companies provide coverage to acute symptoms and stabilization of patients but restrict coverage of treatment for underlying causes of addiction and mental health conditions.

Consider a case from February 2019. Magistrate Judge Joseph Spero ruled in favor of the plaintiffs against United Behavioral Health, concluding that the guidelines for determining treatment coverage by insurance plans were not in accordance with “generally accepted standards of care” required by ERISA. In other words, the insurance company was able to implement strict guidelines for determination of coverage that favored restricting mental health and addiction coverage until the court ruled against the company. But other insurance companies throughout the country, by way of strict guidelines for qualifying for coverage, are able to avoid parity mandates.

This landmark case is significant, as it showed that courts can determine what entails (and what’s inconsistent with) generally accepted standards of care in insurance coverage. That is, the courts can provide a solution to disparate insurance policies and parity violations of the slightest kind. Of course, there could be various types of legislation drafted to ensure that parity is eventually achieved, but, for now, it seems that the best hope to ensure parity in addiction coverage may be seen through taking companies to court.

Indeed, this is an urgent call to action. In a 2018 report released by the Well Being Trust, 32 states received a failing grade for their parity statutes. And it’s not a surprise considering that, according to the Congressional Budget Office, insurance companies are paying 13 to 14 percent less for mental health care services than Medicare. Regarding addiction, fewer than 1 in 5 people with Opioid Use Disorder ever receive their medication for addiction treatment.

Given the number of overdoses has increased 250% between 2003 and 2015, the failure of these parity laws to achieve their goals is especially significant now.

We desperately want to curb addiction, overdoses, and death. There’s a clearing path to that end, and, for the sake of the suffering, we ought to take it. Let’s enforce our parity laws.