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988 Sustainability Depends on Healthcare Insurers Paying Their Fair Share

Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .​

A push for behavioral health parity, where insurance companies provide equal treatment for mental health and substance use services as physical ones, isn’t new. However, inequality between the two has increasingly garnered attention from federal and state leaders. Awareness that Arlene Stephenson, senior advisor at the National Association of State Mental Health Program Directors (NASMHPD), says likely grew because of rising behavioral health needs during the pandemic and implementing 988—the three-digit number for mental health, suicide, and substance use crises—and corresponding 988 crisis systems. 

Stephenson is drafting a playbook on behavioral health parity in the United States with co-author William J. Hudock, a former senior public health advisor at SAMHSA. She says states are extremely concerned about how they will finance their 988 crisis systems long term. “They know they can’t rely on grants and appropriations forever, and some states haven’t even been able to get appropriations.” The playbook will help state behavioral health agencies better understand parity laws, enforcement, and their role in helping foster it. 

Parity and 988 have been coupled since the idea of a nationwide three-digit number for mental health seemed a pipe dream in Utah, the brainchild of Republican state lawmakers Sen. Daniel Thatcher and Rep. Steve Eliason. They shared the concept with former U.S. Sen. Orrin G. Hatch, who took it to the U.S. Congress. The state legislators had been trying to create a statewide three-digit number but were met with resistance. “Growing up, when there was a difficult problem, my father would sarcastically say, ‘That’s going to take an act of Congress,’” laughed Eliason, “and that’s exactly what had to happen.” 

The National Suicide Hotline Designation Act of 2020 has the potential to put behavioral health emergencies on par with physical ones. However, state and county leaders are focused on sustainable funding that will allow for the development and longevity of robust 988 crisis systems, ensuring people have access to the level of care they need. That requires a parallel emergency system to 911—988 call center hubs, mobile crisis services, and crisis receiving and stabilization services. Without a 988 crisis system equal to the 911 crisis system, law enforcement and the emergency department (commonly called the emergency room) will remain the default responder and provider to behavioral health crises, thrusting people into the criminal legal system or high-cost care, financially and personally. 

Most often, law enforcement and the emergency department are not the correct responder and provider for a person in crisis. Ron Bruno, a retired Utah police officer and executive director at Crisis Intervention Team (CIT) International, has said that “mental healthcare shouldn’t come in a police car.” “It fell to us, but we aren’t the best solution or help to a person in an escalated state.” Crowding in the emergency department and insufficient access to community-based services and supports mean people might wait for hours, days, and even months in the emergency department for psychiatric care. It’s a public health crisis that preexisted but has been exacerbated by Covid. Emergency department use during the pandemic holds up a mirror to the healthcare system, revealing gaps, said Benjamin Druss, a psychiatrist and professor at Emory University’s public health school. “It’s been this huge stress test,” he said, “showing us how we use emergency rooms, both for medical and mental healthcare.”

Scaffolding a parallel and interconnected 988 crisis system allows people in a behavioral health crisis to get the level of care they need when they need it. However, Stephenson points out that a barrier to sustainable funding for 988 crisis systems is “insurers aren’t paying their fair share.” Disparities in insurance benefits continue to exist despite the U.S. Congress passing the Mental Health Parity and Addiction Equity Act in 2008 to prevent insurers from providing less favorable mental health or substance use disorder benefit limitations than those on medical ones. (The act built on the Mental Health Parity Act of 1996 prohibiting large health group plans from imposing a lifetime or annual limit on mental healthcare benefits disparate from those on medical.

The act initially applied to group health plans and insurance coverage, but the Affordable Care Act in 2010 amended it to also apply to individual health coverage and Medicaid Managed Care plans. In September, the U.S. House passed the Mental Health Matters Act, which, if enacted, would give the Department of Labor additional enforcement power over the Mental Health Parity and Addiction Equity Act, making it easier to enforce federal parity law. Without insurance parity enforcement, notes Stephenson, people needing crisis services will continue facing significant preauthorization barriers and financial burdens, and behavioral health providers will continue to receive less reimbursement than physical health providers for equal services.

The U.S. Department of Labor and the Treasury have jurisdiction over private group health plans, while public sector group health plans fall under the jurisdiction of the Department of Health and Human Services. State laws may strengthen but not weaken federal parity protection. 

Stephenson says some state legislators have taken 988 as an opportunity to establish their 988 crisis system and the sustainable funding needed to support it. For example, California’s new 988 legislation—the Miles Hall Lifeline and Suicide Prevention Act—explicitly links to the federal Mental Health Parity and Addiction Equity Act of 2008 and state parity law requirements as part of the state’s strategy to ensure the 988 crisis system is adequately funded. That includes reimbursement to 988 centers from healthcare service plans and disability insurers for “medically necessary behavioral health crisis services.” 

California’s 988 legislation ties behavioral health services to medical necessity, trying to unfasten the long-held notion that behavioral health needs are less valid than those related to physical health. This false and problematic belief has marginalized mental health and substance use disorder services, supports, benefits, and reimbursement. (Furthermore, many experts would argue that a person’s physical health can’t be addressed without addressing their mental health and vice versa.)

Coupling behavioral healthcare with medical necessity is gaining traction in the U.S. and other nations, such as the United Kingdom. For example, last December, editors at Scientific American wrote a piece titled “Expanding Mental Health Care Is a Medical Necessity.” They said the Covid pandemic and the corresponding tipping point in inequities and behavioral health needs have made parity more dire than ever. In the article, they included a quote from the Lancet’s Covid Commission Task Force stating that the disaster “offers a critical opportunity to invest in and strengthen mental health care systems to achieve a ‘parity of esteem,’ meaning that someone who is mentally ill should have equal access to evidence-based treatment as someone who is physically ill.” (Under the United Kingdom’s Health and Social Care Act 2012, “parity of esteem” is the principle that mental health must be given equal priority to physical health.)

Addressing parity, says Stephenson, also means defining and including behavioral health emergency services providers. For example, Washington State passed legislation in March to align its ​​Balance Billing Protection Act with the federal No Surprises Act. “Their parity law includes crisis stabilization facilities and mobile crisis teams as emergency services providers,” she says, “making an equivalent to ambulances, emergency departments, and emergent care centers.” The list of crisis stabilization facilities includes crisis stabilization units, evaluation and treatment facilities, triage facilities, and agencies certified by the department of health to provide outpatient crisis services or medically managed or monitored withdrawal management services. 

Congress and state leaders have an opportunity to remedy the disparity in care access with 988, but that’s not achievable without insurance benefit parity: equal coverage of behavioral and physical illness. Stephenson says it perplexes her why insurers treat behavioral health and physical health emergencies differently despite the existence of federal parity laws and that both are crises. For example, the window between people deciding to act and attempting suicide is short; for many, the time is between 5 to 10 minutes. According to a study published in Clinical Psychology and Psychotherapy, 73% of participants reported a period equal to or less than three hours between their decision and attempt. “Both behavioral and physical emergencies threaten life,” says Stephenson. “It’s time we get serious about enforcement.”


See the playbook authored by Stephenson and Hudock here: A Behavioral Health Parity Playbook: Strengthening State Laws and Partnerships.