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By Mary Ann Swissler
This article was completed with the assistance of Fund for Investigative Journalism.

Janette has been very depressed and is considering psychotherapy. She went to therapy years ago but had to quit because her workplace insurance didn’t cover mental health treatment. Today, her desire for weekly talk therapy and maybe medication, are easy for her insurance plan to deliver in the good news/bad news world of mental health treatment reforms.

First, Janette went online to her state’s healthcare exchange and found out she’s lucky; not only did her state set up its own exchange it was one of 25 states to expand Medicaid. As with all plans—public and private—Medicaid now covers mental health in an unprecedented way: no strict visit limits, no copays higher than medical doctors, no lengthy prior authorizations, and a longer list of doctor choices.  Janette gladly returned to her old therapist because she knew her history. Getting to her office added an hour to her commute, and the $30 co-pay each week meant working overtime, but Janette felt it would all be worth it.  

But she quickly found a wrinkle that she had to iron out before re-embarking on medications, available for a low $5 co-pay—she couldn’t find a psychiatrist to prescribe pills who accepted Medicaid.

Undaunted, Janette put herself on the 6-month waiting list for a psychiatrist at her community health clinic, and obtained a temporary prescription for antidepressants from her primary physician.  Janette could have chosen a private plan but chose the much cheaper Medicaid; short-term inconvenience was a small price to pay. She might have a shorter wait; the Obama administration announced [] [[$50 million in funding]] to help Community Health Centers establish or expand services for people living with mental illness, and drug and alcohol problems.  

Janette’s also been trying to convince her widowed mother Ella to seek grief-counseling through Medicare. They’ve expanded coverage through the sweeping changes of Obamacare and a 2008 law, the Mental Health Parity and Addiction Equity Act, both requiring that both public and private insurers cover mental health and addiction treatments.

For Medicaid, this is only true if a state gets behind healthcare reform. And states will be responsible for enforcing mental health parity, according to a spokeswoman for the federal regulating agency, U.S. Health and Human Services (HHS).

Janette explained to her Mom that Medicare will now pay 80 percent of doctor fees, up from 50 percent, and cannot limit the number of doctor visits. Only the physician can decide what’s “medically necessary” and therefore eligible for insurance coverage. Janette’s concerned, however, because  Medicare announced they will end "protected class status" for psychiatric drugs beginning in 2015. This means that insurers will no longer be required to pay for the entire class of psychiatric and transplant drugs; other chronic disease medications for cancer and HIV/AIDS, for instance, will remain protected.  [Update 3/10: Medicare announced they're leaving "protected classes" in the Part D drug plan alone, as is.]

Moreover, more complex situations requiring hospitalizations, more intensive outpatient therapy and more medications still face discrimination by insurers, according to patients and attorneys interviewed. And 53 percent of 462 women surveyed who sought therapy from 2010-2013, called insurance “a barrier to care.”  The survey was conducted by Survey Monkey for this article.  

Interpretation of the law is the biggest obstacle, according to Los Angeles attorney Kathryn Trepinski:  “Patients and providers, not surprisingly, advocate a broad reading of the statute to include ‘all medically necessary treatment’ for mental illness. Health insurance companies, in contrast, argue for a narrow reading of the statute. They bristle at providing all medically necessary treatment, advocating instead for a discrete set of limited services such as diagnostic laboratory tests, physician services, inpatient hospitalization, and preventive health services.”  

Indeed, despite the new laws, a May 2012 report by the U.S. Government Accountability Office showed that health insurance plans have actually increased the number of exclusions for mental health and addiction treatments since the laws were enacted.  In 2010 and 2011, for example, 15 percent of the plans surveyed by the GAO were excluding residential mental health, a significant increase from 2008, the year Congress passed the law.

Insurers have repeatedly blamed this loose enforcement of the parity laws on the lack of guidelines from HHS. So a Hallejulah chorus went up among insurers and activists when the HHS guidelines came through in November 2013. But Trepinski, who is currently suing mega-insurer Anthem scoffed at the notion that regulations spell progress.   “California has had guidelines in place since 1999. Anthem has had plenty of time to get their act together and they haven’t,” she said.

According to legal documents filed by Trepinksi, “Despite these statutory mandates Anthem has persistently refused to authorize treatment to patients, through the use … of their guidelines. (Their) guidelines contain discriminatory treatment mandates that are not applicable to physical-only conditions.”

Sandra is another adult patient who wants therapy. She’s had an eating disorder off and on since age 14, a disease that kills more people than all other mental illnesses combined. Women make up 90 percent of those with eating disorders. Because of the new laws, she’s one of hundreds of litigants in lawsuits currently making their way through the justice system over the main bugaboo—medical necessity:  Her psychiatrist spelled out what she believed was “medically necessary” treatment, but then after an extensive Prior Authorization process, the insurer knocked her treatment instructions down like bowling pins.  

It’s the start of another trip on the insurance merry-go-round, Sandra thought to herself. Just as she gets her footing while in the hospital during the limited amount of time the insurer approves, the inpatient therapy ends, and she faces life on her own interrupted by the once weekly outpatient psychotherapy. The drugs take the edge off but don’t solve the problem. She tends to relapse and ends up back in her psychiatrist’s office asking for more hospital time. Or, more than once Sandra had to be taken by ambulance from her home or work.  

It’s a situation about 1 in 4 Americans find themselves in each day, the number of adults with a mental health issue, both minor enough to handle on an outpatient basis and the more serious diseases requiring periodic hospitalizations. Yet nearly half of the 11.4 million Americans suffering from a major mental disorder – schizophrenia, eating disorder, bipolar disorder – don’t receive treatment.

For women there’s the added layer of discrimination against the symptoms of traumatic life experiences which can mirror organic mental illnesses.  Problems normally restricted to women –eating disorders, domestic violence, stalking, sexual harassment and rape – are tougher for women to solve because of cultural barriers that persist in psychotherapy.

A woman might actually have someone stalking them, and not be clinically “paranoid,” for instance.  Or as Stassa Edwards wrote in the [] [[April 2013 Ms. Magazine]], “Certainly it seems that the twinning of sexuality and mental fitness is still a political tool deployed regularly to discredit women and their ability to make rational decisions.”  

Women aren’t overtly discriminated against in mental health treatment but women face a different world when it comes to mental health, said Kelly Anderson, executive director of Dane County, Wisconsin Rape Crisis Center.  Patients can be labeled with psychiatric diagnoses when they need different approaches, she said.  Anderson talked about “pathologizing feelings and behaviors” that arise from trauma, as an organic mental illness. In other words, victims are blamed.

It’s where the prevailing wisdom of the sexual assault healing community and traditional therapy part company. She calls for a holistic model for sexual violence counseling because “we can’t separate” the issues. “It’s not a denial of mental health problems” but of finding a balance, said Anderson.

Sexual assault victims in the military face a war with red tape in the Veterans Administration for [] [[PTSD counseling benefits]]. They are much less likely to be approved for disability status – needed to receive counseling – than if they complained of battleground mental trauma, according to Jacob Angel, executive director of the Military Mental Health Project.

Worse, Angel said, is a military culture that tells all vets they’re weak for having mental health issues at all. “They say, ‘It happened, deal with it, get over it’. That has to be overcome.”

[] [[A blue-ribbon panel]]  came to the same conclusion. “The military has produced dozens of programs aimed at preventing mental illness among troops during the wars in Iraq and Afghanistan, but there's little evidence that most of them work.”  

Angel pointed to the peace women vets who’ve been raped get when seeking mental health treatment. “They’ve had to search high and low for help but when they do they’re testaments that treatment works. There’s no cure but there are coping mechanisms.”

[] [[More homeless women]] than men with mental health issues wind up incarcerated,  according to a 2006 Justice Department study. “More than half of prisoners in the United States have a mental health problem. Among female inmates, almost three-quarters have a mental disorder.”  

So the long term answer to our question of the future of mental health insurance payments is yes, people living with mental health issues can emerge from the shadows of stigma and nonpayment by their insurers because of new rules and laws, including Obamacare, that require them to reimburse mental health and addiction treatment at the same rate as they do for medical care. On paper anyway, gone are the days when insurance companies can resort to trickery to avoid paying for hospitalizations or out-of-state treatment facilities or long-term outpatient care, usually under the catch-all phrase of not “medically necessary.”

But change will be slow. As one expert put it, “It’s not like this (law) passes and a [] [[spigot turns on]]  and benefits just start flowing. They have battalions of lawyers right now scurrying to figure out how they can get around this rule and they will try new techniques to limit access to care.”

The learning curve promises to be steep and the pace of change glacial, judging from the survey of 462 women taken in the Fall 2013 by Survey Monkey for this article.  They were asked about their experiences since 2010.

In the survey, 53 percent of the women called insurance “a barrier to care.” Those swimming in the glass half full will point to the 47 percent who called insurance “a helpful partner.”  When asked if insurance provided choice of therapists who understood their problems, only 46 percent said yes, insurance provided caregivers with relevant expertise.  Due to visit limits, 31 percent reported seeing her therapist for a shorter time than desired and 35 percent called co-pays “a barrier to care”.

Additional comments included: “It's not easy to find someone in your geographic area who’s covered”; “I didn't understand insurance practices and uses”; “When I was paying for my own individual plan it hardly covered any of my treatment”; “It was helpful for three appointments, then I could not afford the co-pay after that.”; “I was told to join a group but could not find one.”; “I paid out of pocket, because I was afraid of insurance discrimination in the future.”; “I could only see a handful of providers and they weren't nearby. Now I have no insurance and can't see anyone – I have been on a waiting list for over a year.”; “My health insurance didn't cover any therapy. I had to take out loans that amounted to tens of thousands of dollars to pay for treatment.”; “(Partially) it was a huge nightmare because I needed to be a full-time student to be covered and I needed to leave school for treatment several times so it was a huge ordeal trying to stay covered and also get treatment to save my health. It was like a catch 22.”; “I received several sessions free, but had to drive a minimum of an hour to get to appointment, and an hour to get home. The time involved itself caused as much anxiety. I just wanted to get the appointment over with so I could get home.”

The answer?  [] [[Patrick Kennedy]], co-sponsor of the landmark parity legislation, said enforcement will depend upon psychiatrists and administrators fighting alongside their patients for their rights.  “Consumers need to be vigilant,” and that’s part of the problem, added Los Angeles attorney Lisa Kantor. People seeking mental health treatment are vulnerable because of their condition and the stigma. “I think the insurance companies know this, and they prey on that fact…We need people to not take no for an answer.”

That’s going to be a new skill, according to the survey results. Over 84 percent reported not appealing a claim rejection. Among the women, 6 percent were rejected and 10 percent won their appeals. Only one person among 462 was suing. A first step is available through this [] [[free, step-by-step toolkit]] for appealing a denied claim.  

And, the current political climate will make enforcement by states tough, said Trepinski. Many state governments are fighting back against ObamaCare tooth and nail. “They don’t want to set up exchanges, they don’t even want patient navigators. Some states just want to squelch the act. Parity is going to get lost in the tussle.  It will be a state by state decision on who follows the parity act.”

But the real politics of mental health will come down to the assertiveness skills of the people receiving care. According to Trepinski, “Patients are going to really have to fight to get treatment.”

SIDEBAR:  Specifically, among a long list of [] [[new rights]] under MHPAEA and Obamacare mandate:
•    If a group plan offers mental health coverage, which 85 percent of employer-based plans do, they must provide completely equal mental health and addiction treatment. Individual coverage must comply by July 1, 2014.
•    That means no more higher co-pays, no more burying the insured in paperwork for strict prior authorization to treatment. Also, there’s no more lower reimbursement rates, no limits on hospital stays despite a physician’s decision that one is “medically necessary, and a transparent appeals process.

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