States face extensive barriers to meeting federal regulations mandating a certain level of mental health services to people with private insurance, according to a study from Georgetown University released Thursday. 

The study analyzed how states are enforcing the Mental Health Parity and Addiction Equity Act (MHPAEA) during a growing behavioral healthcare crisis in the United States. 

The law enacted by Congress in 2008, aims to remove insurance-related obstacles to mental health and substance use disorder treatment. Specifically, it prohibits large employer group plans from imposing stricter limits on mental health and substance use disorder benefits than they do on other medical benefits. 

The study showed gaps in enforcement and oversight in the five states the study focused on – Arizona, Nebraska, Pennsylvania, Virginia, and Washington, which offers a window into what challenges other states may face as well. Effective review and oversight are time- and resource-intensive processes which pose significant challenges to regulators, the researchers found. Some states have difficulty obtaining the data needed to complete reviews of treatment limits. 

Federal and state regulators have found that enforcing the complex law is so challenging that a 2022 report by the U.S. Department of Labor found that none of the 30 plans and insurers evaluated could show that they were complying with key requirements of the law. 

One reason for this could be a lack of awareness about the law, which the researchers observed in several states studied. This “removes a tool that states rely on to flag potential violations,” the study said.

According to the researchers, funding from federal grants has been critical in state enforcement efforts, including educating providers, building in-house expertise, and developing procedures to review a broader range of treatment limits. 

In June, Congress voted on a bill to provide financial assistance to states for MHPAEA enforcement. 

However, researchers argue that states need additional resources to conduct necessary benefits reviews, and several states cite the need for additional federal guidance to strengthen their enforcement efforts. 

“Equal access to behavioral health services is critical since demand for care is at an all-time high,” said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, who funded the study. “State resource limitations and a lack of awareness are compromising the effectiveness of our federal parity law, and federal funding to states could help increase access at this time of crisis.”

Statistics show the increase in mental health issues facing teens and adults. In a UCSF study conducted in June and July of 2021, 48% of young adults aged 18 to 25 reported symptoms of anxiety, depression, or both. Nearly 53 million adults in the United States experienced mental illness in 2020, and more than 40 million people aged 12 and up had a substance use disorder, according to the U.S. Substance Abuse and Mental Health Services Administration. 

The researchers recommended requirements for more proactive steps that states need to create for insurers. That includes, requiring insurers to submit their comparative analyses and conducting targeted reviews, conducting baseline MHPAEA exams on all insurers in-state to ensure awareness of the law. The researchers also recommended using third-party data sources to conduct more narrowly focused and frequent exams of how the law is working. 

“The parity law holds out the promise that health plans’ coverage of behavioral health treatment will not be inferior to that of other medical care, but states need better tools and more resources to effectively enforce the law and deliver on that promise,” said JoAnn Volk, research professor at the Center on Health Insurance Reforms at Georgetown University. 

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