Abstract
I. INTRODUCTION: A NATIONAL CRISIS
Mental health is currently one of the most expensive health care issues. 1 The cost of treating mental illness's effects not only impacts the health care industry as a whole, but also imposes indirect costs on businesses through absenteeism, lower productivity, and reduced earnings. 2 Mental illness, and the effects of mental illness, costs the U.S. economy several billion dollars in losses every year, with predictions suggesting that these costs will only continue to rise in the next two decades. 3 Between 2006 and 2009 alone the costs of mental health care rose from approximately $57 billion to more than $150 billion. 4 These numbers will likely be exacerbated due to the mental health problems that are continuing to rise within the United States as teenagers and adolescents are experiencing mental illness at escalating rates. 5 Despite the rapid growth of mental illness, mental health coverage has not been expanding to meet the increasing demand for treatment. It is estimated that about 28% of the U.S. population has a diagnosable mental illness, even though only 8% actually seek treatment. 6 One of the foremost reasons that more people do not seek mental health treatment is due to concerns over the cost and coverage of mental health care. 7
Insurance companies have failed to properly address the obvious increasing costs and demands for better access to mental health treatments by treating mental health claims unequally when compared to other medical issues. 8 Employers and other health insurance providers are sending a message that mental health is not a priority through the lack of adequate financial assistance and by further propagating the difficulties that those who need treatment face. 9 This results in less coverage of mental illness, despite numerous parity laws that require insurance policies to treat mental health and physical health claims similarly. 10 The problem with the current legal parity framework is in enforcement of current legal protections and in the distribution of health care resources hindering patients' access to mental health treatment.
The disparate treatment of mental health and medical claims by insurance providers has a long, and mostly unsuccessful, history. 11 Furthermore, the topic is not unfamiliar to Congress. 12 In 1996, the first federal attempt at bridging the gap between mental health coverage and traditional medical coverage was enacted; this act became known as the Mental Health Parity Act (“MHPA”). 13 The MHPA was the first of many steps to be taken by the federal government in reducing the discrepancies in coverage of mental health treatments by insurance providers. 14 However, despite the good intentions of the lawmakers, the law itself fell short of providing the needed parity between mental health and medical coverage. 15
Following the 1996 federal law, many states began to expand on the MHPA's regulations by requiring greater parity in the plans provided on a state level. 16 Then, in 2008, Congress decided to re-address mental health parity with the Paul Wellstone-Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”). 17 This law expanded the parity requirements greatly. 18 It provided better access to treatment for those suffering from substance abuse and addiction, as well as depriving insurance companies of the many employer-friendly loopholes that had been expressly left in the MHPA. 19 These federal laws made great strides in addressing the preliminary issues, but ultimately neither were able to fix the problems that continued to plague mental health treatment and coverage. 20
Following the enactment of the Addiction Equity Act was the historic election of President Barack Obama. One of the main goals of the Obama Administration was the reformation of the American health care system. President Obama's efforts resulted in one of the most significant major pieces of legislation in reforming insurance coverage of mental health treatment, known as the Patient Protection and Affordable Care Act. 21 Commonly referred to as the “ACA” or “Obamacare,” this act massively overhauled the health insurance marketplace in the United States. 22 Under the ACA, federal law requires that insurance companies provide coverage for “essential health benefits.” 23 This category of essential benefits includes mental health, thereby requiring providers to cover mental health, instead of giving providers the choice to cover mental health treatments. 24
While the entirety of the ACA will not be fully phased into daily coverage until 2019, the mandates for mental health coverage have already been phased in. 25 There were high hopes for the new law and the impact it would have on mental health care, but the reality of coverage is anything but equal. 26 As consumers and advocates alike are finding, providers of insurance are using subtle ways to undercut the requirement for mental health care parity. 27 This problem proves to be a persistent one especially when combined with the recent opioid epidemic strangling many parts of the country. In response to the opioid crisis, Congress recently made a fourth attempt at amending the remaining complications in mental health coverage. 28 The 21st Century Cures Act (“Cures Act”), enacted at the end of 2016, was meant to address some of the persisting problems in mental health parity. 29 Many people were excited for the implementation of the new law, but its success depends heavily on whether or not the new initiatives will continue to be funded by Congress. 30
Courts are also being pulled in to address mental health parity issues that have risen in response to the implementation and interpretation of the new laws. 31 As consumers and other groups attempt to bring challenges against insurance providers for their unequal coverage of mental health care, the courts are in the process of trying to define what exactly parity looks like under the new laws and what enforcement of the laws should look like. 32 How the courts are interpreting what is considered equal treatment of coverage or not will have lasting impacts as the fight for parity continues.
Moreover, one of the consequences of the 2016 presidential election is the proposed repeal and replacement of the ACA by Donald Trump and the Republican-controlled congress. 33 During the weeks after winning the Electoral College, Donald Trump stated that he would keep some parts of the ACA but has since attacked the ACA repeatedly. 34 Since taking office, the Republican-controlled Congress has attempted to tear down the ACA numerous times and has succeeded in eliminating the individual mandate through their recent tax overhaul. 35 What will remain of the ACA and what will be repealed presents a new challenge to mental health parity and the coverage of mental health care in the wake of a presidential administration and Congress that is hostile to the ACA.
This Note addresses the history of mental health parity more in depth to provide a roadmap and framework to better understand the problems that are currently plaguing the coverage of mental health care. This Note proposes policy solutions to improve access to mental health care for a nation in crisis. In Part II, this Note will cover the MHPA, MHPAEA, and their roles in modern mental health insurance. In Part III, this Note will discuss how the ACA has contributed to the distinct landscape of modern mental health coverage. This Note will also address the problems currently being faced by consumers of mental health care and how courts are ruling on the topic in Part III. This Note will discuss the recently passed legislation known as the Cures Act, the plans of the presidential administration and the current Congress regarding health care, and how those may ultimately impact coverage of mental health care in Part IV. The conclusion will cover the implementation of legal and policy initiatives meant to more effectively deal with America's mental health crisis. There are two main problem areas with current mental health parity laws, which are providing patients access to mental health treatment and enforcement of current parity laws. This Note will outline the problems that have persisted through the decades and advance four policy initiatives meant to address modern hindrances to parity and mental health treatment.
II. A FEDERAL PUSH TOWARD PARITY THAT FELL SHORT
A. The Mental Health Parity Act of 1996
The history of mental health parity begins in the court system. 36 Consumers brought lawsuits against insurance providers that discriminated against insurance claims based on whether the treatment patients received was mental or physical. 37 However, courts in different districts diverged on the issue of what was considered adequate coverage of mental health treatments. 38 Courts would employ a variety of techniques when reviewing these claims, and the variety of methods led to inconsistent legal rules, which confused consumers and insurance providers. 39 This inconsistency is what inspired the federal government to step in to provide better and more consistent health care coverage for consumers. 40
In 1996, Congress passed the first version of the MHPA. The purpose of the Act was to stop “discrimination against mental health services and against people who need [mental health] services.” 41 The original version of the Act was quite extensive. It was unanimously passed in the Senate but was “heavily compromised” when it reached the House due to concerns about the real cost of mental health parity. 42 The resulting Act did little to advance the goals of those who proposed it but created the first federal step forward in mental health parity. 43
The MHPA was a small improvement for what consumers were facing in the marketplace. 44 It did make one significant contribution; it prohibited insurers from imposing disparate annual and lifetime limits for mental health treatments as opposed to physical care and surgical limits. 45 Another benefit of the MHPA was the relative ease and small cost in which insurers were able to implement the requirements of the MHPA. 46 This began to create a shift in people's perceptions of the feasibility of mental parity. 47 The initial act demonstrated that mental health parity could potentially be achieved without resulting in high costs to consumers and providers. 48
Notwithstanding the improvements to the marketplace, there were many problems ignored by the final version of the law. 49 The MHPA was an improvement compared to no legal parity, however, the law left open some very large employer loopholes. 50 Employers were not required to cover mental health in their insurance plans; it was only when insurers chose to cover mental health claims that parity was required between annual and lifetime limits for coverage. 51 Additionally, the law “expressly” allowed for employers to set the requirements for what was considered medically necessary, permitting different limits for cost sharing, hospital visits, and days of coverage. 52 The law itself did not address treatment limitations, limitations on types of facilities, differences in cost sharing, or the application of managed care techniques. 53 As a result, when insurers chose to provide mental health benefits, they still imposed discriminatory limitations on coverage that were not expressly barred by the MHPA. 54 Additionally, as soon as the Act became law, employers and insurance providers began reducing annual and lifetime limits for physical medical issues, thereby reducing the limits for mental health care as well. 55 As such, the MHPA resulted in minor improvements at best.
Shortly after the implementation of the MHPA, congressional investigators found that thousands of employers were violating the new federal requirements for mental health parity, despite the leniency of the law. 56 In a survey conducted by the General Accounting Office (known currently as the Government Accountability Office), it was found that 14% of employers in 26 states were found to be noncompliant. 57 The investigators found that even some companies that appeared to be in compliance had discovered ways to skirt the laws and federal requirements. 58 The General Accounting Office further found that employees and their dependents saw only minor changes in their health benefits, which did little to improve their access to mental health care overall. 59 This resulted in the MHPA being largely ineffective at providing increased access to mental health services. 60
Before the MHPA, only five states in the union had mental health parity laws. 61 However, after the passage of the federal Act many states began to implement and design their own mental health parity statutes. 62 This was due in part to the American public pushing to achieve greater mental health parity and in part to cover some of the holes left by the federal statute. 63 Most states implemented mental health parity laws that were more stringent than the federal one. 64 Despite the attempts of states to more greatly regulate mental health care, many providers and employers were exempted from the state laws for a variety of reasons. 65 The two most prominent reasons were that state laws varied greatly in scope between another and many states still left out employers who self-insured. 66 Therefore, notwithstanding the gains made in mental health coverage due to the federal Act and the state statutes, little improvement in terms of a tangible increase in access to mental health care had been made during this time.
B. The Mental Health Parity and Addiction Equity Act of 2008
In 2008, Congress tried to confront mental health parity again, with the passage of the MHPAEA. 67 Congress passed the MHPAEA in conjunction with the controversial bailout funds that were meant to stimulate the economy during the Great Recession. 68 The MHPAEA was added as an amendment to the preexisting Employee Retirement Income Security Act of 1974 (“ERISA”). 69 However, in order to provide employers with reasonable time to become compliant under the new mental health parity requirements, the law did not go into full effect until two years later, in January 2010. 70 The MHPAEA, like its predecessor, did not preempt state parity laws in an attempt to encourage states to create stricter versions. 71
At the time of the law's passage, employers did not appear to be concerned with the new requirements; in fact many thought that their plans already met the new federal requirements. 72 However, the MHPAEA required significant changes in many areas of mental health coverage, including demanding parity to extend to deductibles, co-payments, out-of-pocket expenses, coinsurance, covered hospital days, and covered outpatient visits, which even the most generous insurance policies did not usually provide. 73 The MHPAEA required parity to extend to all financial requirements and for mental health benefits and disorders to be more broadly defined. 74 Additionally, the law set up a governmental task force to advance the goals of the parity legislation through consumer information. 75 The most notable change in the MHPAEA from the original MHPA, though, was that employers were now required to cover certain treatments for substance abuse and addictions if they provide mental health coverage in their policies. 76
Congress passed the MHPAEA in order to close some of the employer-friendly gaps and loopholes left open through the MHPA of 1996. 77 The MHPAEA was a sweeping act of inclusion, but just like its predecessor it also had gaping holes that insurers took advantage of. 78 Providers were still not required to provide mental health benefits; the law only required that when an employer provided mental health coverage that that coverage must be equivalent to physical or surgical coverage. 79 Additionally, the MHPAEA requirements only applied to employers with 50 or more employees enrolled in a group plan. 80 All employers with fewer than 50 employees were exempt from the law and were subject only to state parity laws, which still varied significantly. 81 The law also left the option to employers to create definitions for mental health and substance abuse disorders in their plan. 82 Moreover, even though coverage of mental health treatment appeared equal on the plans, the pattern of denials for mental health treatment claims demonstrated the lack of parity that existed in practice. 83 Almost one third of patients were denied coverage for mental health care, versus only 14% being denied coverage for traditional medical care. 84
States stepped up again in response to the newer federal legislation on mental health parity. 85 In many states, the parity laws enacted were actually more expansive and comprehensive than the new federal counterpart. 86 This is in part due to the increasing public support for mental health parity and the growing need for better legislation. 87 One of the major problems with state sponsored mental health parity legislation, however, was still the inconsistency across state borders. 88
States tended to diverge on four key factors when creating mental health parity laws: 1) the definition of mental illness; 2) the type of mandate chosen; 3) the regulations of the terms and conditions used in insurance policies; and 4) the scope of coverage exceptions. 89 How states define and utilize each of these factors varied considerably. 90 Moreover, even when the language appeared similar in the statutes, state legislatures and courts interpreted them differently than other states. 91 This state-by-state irregularity still results in gaps of coverage. 92
III. THE PATIENT PROTECTION AND AFFORDABLE CARE ACT AND COURT RULINGS
In 2010, Congress passed one of the most comprehensive and sweeping health care reforms since Medicare: the ACA. 93 Along with the Health Care and Education Affordability Reconciliation Act of 2010, the ACA increased access to health care for millions of people, and mandated the coverage of certain “essential health benefits.” 94 Mental health, substance abuse, and behavioral health services are considered essential health benefits under the ACA and are therefore mandatory for insurance providers to cover. 95 There are limited exceptions to the new mental health coverage requirement, but overall coverage of mental health treatment is obligatory. 96
Additionally, because the ACA mandates that all citizens have access to, and have, an insurance plan, access to mental health coverage is easier than ever to acquire. 97 Through a similar mechanism, the ACA expanded mental health coverage for all children under their parents' plans until the age of 26. 98 The ACA also eliminated Medicare's discriminatory copayments for mental and physical health, extending mental health parity to public forms of insurance. 99
One of the major goals of the ACA was disease prevention. 100 The main objective was to ensure that Americans have access to mental health treatment early on to treat mental illnesses before they become more serious. 101 As was demonstrated by Massachusetts's health care model, which was used as a guide to create the ACA, when citizens have access to mental health care coverage, they seek mental treatment that will hopefully in turn prevent more serious issues, such as substance abuse, down the line. 102 This enables mental health professionals to treat mental illnesses earlier and potentially curb prolonged mental illness to the benefit of the patients and the system as a whole. 103 Additionally, because the ACA, coupled with the MHPAEA, increased broad access to substance abuse treatment and coverage, these acts may actually be helping to reduce crime rates while providing addicts a legal and healthier form of treatment versus self-medicating. 104 Finally, the ACA set up its own mental health parity task force, with the goal of expanding access of coverage and parity protections through producing guidelines and encouraging enforcement of the ACA. 105
Although the ACA has broadly increased access to mental health coverage, problems with mental health parity are still prevalent. The ACA allowed certain insurance plans to be “grandfathered” into the new framework, without requiring said plans to cover the essential health benefits. 106 This means that those who receive their health insurance through a grandfathered plan may not receive mental health care coverage. 107 Additionally, the ACA imposes lifetime limits on inpatient admissions to psychiatric units, which greatly impacts those who are diagnosed with chronic and serious psychiatric illnesses that require long-term treatment. 108 This type of limitation is not present for other types of illnesses or treatments. 109
However, the greatest legal challenges that are being faced by consumers is how insurance companies are skirting the federal requirements for coverage in subtle ways that reduce coverage and access to mental health treatments. 110 Insurance companies have continued to reject patient claims for mental health coverage more often than for physical coverage. 111 They do this by arguing nuances in the laws and challenging the plain language interpretations of the various mental health parity statutes. 112 Additionally, insurance companies have made it very difficult for mental health providers to get paid, thereby restricting access to a mental health professional even for those that have mental health coverage under their insurance plan. 113 The most serious legal problem with mental health parity appears to be with the enforcement and interpretation of the mental health parity laws that are currently in place.
One of the reasons that enforcement of mental health parity laws is challenging is because litigants may lack a sufficient cause of action to bring a claim in the first place. 114 The difficulty in bringing a cause of action is partially due to the scattered framework of mental health parity laws and how they overlap between the ACA and ERISA. 115 In order to bring a sufficient cause of action under the ACA and ERISA, plaintiffs must assert a constitutionally sufficient injury resulting from a breach of statutory duty and must identify a “statutory endorsement” of the cause of action. 116 Additionally, in order to bring a suit asserting mental health parity violations, plaintiffs must demonstrate that they are a participant, beneficiary, or fiduciary relating to the violation. 117 Otherwise, the plaintiffs lack standing to bring a claim for a violation of mental health parity laws. 118 Third parties who are not considered participants, beneficiaries, or fiduciaries of individuals injured by violations of mental health parity laws are not allowed to bring suits on behalf of those who are injured. 119 This makes enforcement of mental health parity laws difficult, because the average individual does not have the resources to challenge a major insurance provider. This has resulted in some class action suits against violators of mental health parity laws. 120 Even if a plaintiff can bring a sufficient cause of action and afford to challenge the insurance companies, courts are facing issues of statutory interpretation. 121
After the initial passing of the ACA requirements for mental health parity, courts were forced to interpret the laws based on interim rules. 122 The ACA regulations regarding mental health were implemented immediately, and the MHPAEA regulations were enacted around the same time as the ACA regulations, resulting in a sudden shift in the structure of mental health coverage. Agencies created interim rules that providers had to follow, while the final rules were going through the traditional notice and comment period before being enacted. 123 The final rules under the MHPAEA defined the standard of care insurance providers were required to provide under the ACA and were finalized in July 2014. 124
Over the course of the rulemaking process, it appears that the courts have been following a plain text interpretation when reviewing the statutory language and statutory requirements of the ACA and MHPAEA. 125 This has not prevented providers from trying to skirt the plain text meaning of the statutes though, and has resulted in court battles in several states. 126 For example, recently a class action in the United States District Court for the District of Northern California, was brought against Applied Materials, Inc., because, despite the plain text of the MHPAEA and the final rules, the insurance provider imposed an age-based exclusion of, and visit limitations on, treatment the plaintiff's son required. 127
Additionally, a class action suit was recently brought against United HealthCare in the United States District Court for the Western District of Washington, because United HealthCare had violated the plain text of the MHPAEA. 128 The plaintiff brought a complaint against United HealthCare for administering claims for mental health treatment in a discriminatory manner. 129 United HealthCare acted in a discriminatory manner by putting a cap on outpatient visits, in-network mental health office visits, and a 50% reduction on reimbursements for visits 21 through 40, when no such limitations applied to physical and surgical services. 130 Defendant insurance providers have even gone so far as to argue that claims brought against them for violating the MHPAEA should be dismissed because there is no legal remedy available. 131 This further demonstrates the inherent lack of enforcement.
In a 2015 class action suit, defendant UnitedHealth Group tried to make the argument that the appeals court should affirm the dismissal of the complaint because the plaintiffs did not have adequate remedy under the law. 132 The appellate court dismissed that argument by demonstrating that within the statutory framework of the mental health parity laws and ERISA, there was a “catchall provision” that acted as a safety net for plaintiffs seeking legal remedy. 133
Recently, Congress passed a law in an attempt to help clarify what the federal laws mean and require from insurance providers. 134 However, even with this new law, and previous laws, bringing challenges against providers for violating mental health parity laws remains difficult. 135 Many cases need to be brought through class action suits, and many of the cases are settled out of court. 136 This results in a reduced ability for courts to interpret the regulations and fix issues of enforcement.
Moreover, another challenge that litigants are facing is that when there is no plain text for a court to directly rely on courts can and have dismissed the case entirely. 137 When dismissing and/or ruling for summary judgment on cases that pertain to issues that may not be directly addressed by statutes, the courts have relied on interim rules to decide the cases. 138 Additionally, those courts that are dismissing the cases tend to rely on the interim rules after the final rules were established. 139 Thus creating inconsistency in viewpoints among the courts. 140
Initially, violations of the mental health parity laws within the ACA were not being prosecuted heavily. 141 Presumably, this was to allow insurance companies time to comply with the new laws. Nevertheless, recently state attorney generals and others have been challenging mental health parity violations more vigorously. 142 One common method that insurance providers are using to undercut mental health services, thereby violating the federal mental health parity laws, is to use “cost saving” initiatives that decrease access to mental health treatment. 143 Insurance providers like Cigna, are using “otherwise legitimate mechanism[s]” used to monitor compliance with insurance policies and regulations for boosting the company's bottom line. 144 They are rescinding previous payments and or denying pending payments to mental health services, thereby limiting a patient's access to treatment. 145
A potentially interesting interpretation of ERISA and the MHPAEA is that the MHPAEA may impose a fiduciary duty on certain individuals. 146 The MHPAEA does not directly impose a fiduciary duty on insurance providers or the like, however, the Court of Appeals for the Second Circuit found that the MHPAEA may impose an indirect fiduciary duty. 147 No other cases have cited this specific finding, and the opinion does not discuss the concept in depth, but it may still be something to watch for in future litigation. 148 In sum, despite the advances made by the ACA, there is a lot still to be desired and to provide clearer guidelines for courts to clear up the chaos.
IV. THE NEXT BIG HOPE FOR ACHIEVING PARITY: THE 21st CENTURY CURES ACT
The newest federal legislation to attempt to fix the holes in mental health parity is the Cures Act. 149 This is a massive act that includes huge amounts of federal funding not only for mental health initiatives but also for cancer research and for dealing with the current opioid problem in America. 150 The Cures Act was signed into law on December 13, 2016. 151 NPR has called this piece of legislation, which took its mental health parity reform measures from Senator Chris Murphy's mental illness proposal, “the most significant piece of mental health legislation since the 2008 law.” 152
There were several goals that Senator Murphy wanted the new legislation to address when he and his team were crafting and pushing for the mental health portions of the bill. 153 Of particular importance were the mental health parity components. 154 Senator Murphy also wanted to improve the existing framework and focus more on preventative measures when drafting the bill. 155 As such, improving the parity framework and improving prevention efforts were major goals of the Act. 156 To meet these goals the Cures Act put forth a number of new and enhanced federal requirements for health care providers. 157 The new law authorizes the spending of $1 billion over the next two years to help various physical and mental issues. 158 States have received funding from this bill, 10% of which is required to be used by the states for mental health grants to provide early intervention for psychosis. 159 This treatment program has been hailed as “one of the most promising mental health developments in decades.” 160 The Cures Act also uses $5 million to establish a grant program to provide assertive community treatment for those who have serious mental illnesses such as schizophrenia. 161 This program was expected to be extremely successful and provide those with severe mental illnesses access to a mental health provider 24 hours a day. 162
Moreover, the Cures Act has attempted to resolve one of the most significant problems in mental health coverage: physical access to mental health providers. 163 The new legislation includes grants to increase the number of mental health providers, like psychologists and psychiatrists, who are in short supply across the nation. 164 The law also provides additional funding for the research and development of new mental health treatments by building on Federal Drug Administration programs. 165 The Cures Act also provides states with some discretionary funding for uses such as better training for police officers when dealing with mentally ill individuals and other measures to help the mentally ill who are often funneled into the criminal justice system. 166 Many mental health experts and advocates are celebrating the passage of the Cures Act, and are looking forward to seeing the long-term results of the legislation. 167
However, there are concerns over the new legislation. The Cures Act authorizes the spending of $1 billion, but not everyone is convinced that that money is being spent wisely. 168 One critique of the Cures Act is that it is funneling more money into large pharmaceutical companies, rather than addressing the critical shortage areas. 169 Senator Murphy responded to those critics saying that there “are two sides to this story … The drug industry will be making a little bit more money, but patients will get drugs faster and it will save lives.” 170 Critics also say that this legislation is expensive, despite advocates saying that it is more expensive to ignore mental illness. 171 One major area of concern with the Cures Act is that despite having been allotted $1 billion in funds to be used for the next two years, it still requires future Congressional approval of funding the Act. 172 Thus, a future Congress can impede the new legislation merely by cutting off its funding. This is highly likely given the numerous funding battles that have gripped the nation's capital. 173 Additionally, the Cures Act only allots funding for two years, which may not provide enough funding or enough time to address the long-term effects of mental illnesses. Advocates say this should not be a large concern given that the measure passed both the House and Senate with substantial bipartisan support. 174
Other critics say that the legislation, although a great step forward, did not go far enough. 175 The current Cures Act is a significantly scaled back version of the original bill put forward. 176 One of the problems left largely untouched by the Cures Act is information sharing, which would allow mental health providers to share important care information with the loved ones of those suffering from mental illness. 177 While the law has directed the Department of Health and Human Services to issue guidance clarifying patient information disclosures with the goal of encouraging mental health providers to share important health information with loved ones, 178 many mental health providers are unwilling to share that type of information for fear of violating the Health Insurance Portability and Accountability Act. 179 Additionally, the original bill put forward more protections for outpatient services, which are still lacking with mental health treatment. 180
The future of mental health appears to be in limbo with the new presidential administration. During the presidential campaign, Trump ran on a platform of complete repeal of the ACA and “free market reforms.” 181 Additionally, his campaign website laid out detailed ideas about how to restructure the American health care system but said next to nothing about mental health care. 182 As the last idea mentioned on his webpage detailing where he stood on health care reform, then-candidate Trump merely stated, “There are promising reforms being developed in Congress that should receive bipartisan support.” 183
In an interview, Donald Trump discussed ideas for providing veterans better access to mental health care by saying that he and his administration will create a “mental health division” under Veteran's Affairs. 184 However, Donald Trump went on to say that the problems with mental health care, specifically with veterans, are wait time and inability to see a doctor. 185 While this approach is relatively accurate, it does not deal with the fact that many Americans – veterans or not – are facing those same issues, which he did not address in the interview. 186 More recently, however Donald Trump has back stepped and stated that he would keep parts of the ACA. 187 The parts he mentioned that he would keep do not pertain to mental health care though.
Recently, Donald Trump provided a broad outline of what he wishes to do in response to the opioid crisis. 188 This outline included expanded research into less-addictive painkillers and efforts to reduce the over-prescribing of opioids, as well as a “crackdown” on drug traffickers. 189 While Donald Trump himself has not gone farther in depth about his current or future plans regarding mental health coverage, the Republican members of the House have been very outspoken about their desire to “repeal and replace” the ACA. 190 Within months of the new administration taking office congressional Republicans attempted to get rid of the essential health benefits requirement, 191 and attempted to pass several repeal and replace bills in 2017 alone. 192
On March 6, 2017, Republicans introduced their first attempt to repeal and replace the ACA with the American Health Care Act (“AHCA”), which was a compilation of budget resolution bills in the House. 193 However, none of these bills would actually repeal the ACA because they were being put forth as budget reconciliation bills, which only require 52 votes in the Senate. 194 Any bill that attempts to make substantive changes or attempts to repeal the ACA would require 60 votes in the Senate. 195 While some lawmakers like House Speaker Ryan were excited for the potential of the budget resolutions to de-fund the ACA, many in the mental health community were speaking out against the attacks on the ACA. 196
The AHCA would have done a number of things including eliminating all tax penalties for those who do not have health insurance, allowing insurers to charge higher premiums to those who do not have continuous health care coverage, phasing out the Medicaid expansion under the ACA, 197 removing the ACA's actuarial value requirements thereby allowing insurers to charge higher premiums to older people, 198 and would no longer require state Medicaid plans to cover essential health benefits. 199
Mental health advocates said that the AHCA would strip away essential mental health coverage 200 and devastate current efforts to address national mental health issues. 201 Advocates believed that this bill would have rolled back needed mental health and substance abuse coverage while the nation is in the middle of an opiate crisis. 202 This is especially true because of the proposed cuts to Medicaid under the AHCA. 203 Medicaid programs provide vital mental health funding to states and the AHCA would have significantly cut the funding that would have been available for states. 204 Medicaid is the single largest payer of mental health and addiction treatment services in the nation, 205 and cuts to Medicaid would significantly impact lower income families 206 and those with mental illnesses. 207
Advocates were very concerned over the proposed Medicaid cuts and believed that the AHCA would significantly harm progress made in mental health treatment coverage. 208 Especially because in addition to cuts to Medicaid, the AHCA would not require state plans to cover mental health care. Without being forced to provide coverage for mental health in addition to reduced Medicaid funding, states would struggle to provide mental health coverage if they could afford to at all. 209 Currently, even under the ACA states are struggling to afford mental health treatments, the AHCA would have only made this task more challenging as states would have to choose between funding mental health care or funding other needed health services. 210 Thus, mental health advocates were worried about mentally ill individuals becoming homeless, put in jail, or dying as a result of the AHCA. 211
Even the American Psychological Association (“APA”) released a statement expressing disdain for the AHCA. 212 The APA's president came out saying that any health care reform legislation should be increasing, not decreasing access to affordable mental health care coverage. 213 The statement chastised congressional leaders claiming that removing the essential health benefits requirement for state Medicaid plans would result in the loss of coverage for life-saving treatments for millions and challenge the health of the nation. 214
The AHCA was withdrawn before the House could cast a vote on it, due to many Republican representatives defecting, 215 but many of the ideals encompassed by the AHCA are still major themes being advanced by the Republican Party in health care reform measures. Throughout the summer of 2017, the Republican-controlled Congress attempted several health care reform measures. 216 The bills were incredibly unpopular 217 and many constituents rallied against their congressional leaders in favor of the ACA. 218 These measures put forth during the summer of 2017 contained many of the same provisions that were introduced in the AHCA. Therefore, even though the AHCA never came to a vote, we could still see new bills in the near future attempting to bring about the same changes that AHCA endeavored to pass.
At the end of 2017, the Republican-controlled Congress passed a tax bill, which contained within it a measure to defeat the individual mandate. 219 As a result, the penalty for not having insurance is now a tax fine of $0. 220 This action will likely result in fewer people being incentivized to buy health insurance, 221 effectively causing premiums to go up and forcing others out of the health insurance market as well. 222 Moreover, the presidential administration recently announced that it would allow states to require individuals on Medicaid to “work or get ready for jobs” in order to keep their Medicaid benefits. 223 This and other impacts of the new Medicaid policy shift will result in thousands of individuals being forced off of the health care program. 224 With fewer people choosing to buy in and or being able to buy into the health insurance market and others being forced out of their current health care plans, fewer people will have access to much needed mental health care coverage under the current administration and Congress.
V. CONCLUSION: ADDRESSING THE MODERN PROBLEMS PREVENTING MENTAL HEALTH PARITY
There is no doubt that there are many problems that currently plague mental health coverage. However, what is debatable is whether or not mental health parity laws are actually the cure for the problems America is experiencing. Is federal funding going to the wrong places? Do parity laws positively impact rates of mental illness and mental health treatments? Is it worth the legal efforts to enact mental health parity legislation?
Since the enactment of the MHPA in 1996, mandatory mental health parity laws have sprung up all over the nation. 225 However, when Sara Markowitz, a Professor of Economics at Emory University, and Jonathan Klick, a Professor of Law at University of Pennsylvania, studied the impact of mandatory mental health parity laws, they found that there was no effect. 226 Markowitz and Klick used suicide numbers as their measurement of impact, and found that there was no statistically significant decrease in suicides after mandatory mental health parity legislation was passed. 227 Their study is not entirely conclusive about the impact of current mental health parity legislation however, because the authors only studied adult suicide rates from 1981 through 2000. 228 Most mental health parity legislation was enacted after 2000, therefore their study is outdated, but it does raise an important question of the effectiveness of parity legislation. Mental health is a bipartisan issue in most areas, especially due to the opiate crisis. However, if mental health parity legislation is ineffective lawmakers and advocates could be wasting valuable resources.
Moreover, even though mental health is a bipartisan issue, many critique how the various pieces of legislation address mental health problems and resource allocation. For example, critics of the Cures Act state that while the funding mechanism of the act appear to benefit those suffering from mental illnesses, the funding really benefits the pharmaceutical industry by providing companies with a large pay out. 229 Additionally, health law organizations criticize the current mental health parity laws for lack of enforcement and oversight. 230 What is the point of having strict mental health parity laws if the laws are not adequately enforced?
Previous mental health parity laws have addressed a number of problems. As aforementioned, the MHPA, the MHPAEA, and the ACA have addressed a number of problems that previously hindered mental health treatment. These statutes have improved access and quality of mental health coverage for millions of Americans in a relatively short amount of time. The Cures Act is addressing some of the subsequent issues such as funding for treatment research and facilities, as well as training initiatives for local law enforcement and personnel. Despite the advances, there are four persistent issues that new policy initiatives should address in order to achieve greater parity.
First, many areas of the United States do not have physical access to a mental health provider. There is a critical shortage for qualified mental health practitioners in many places throughout the nation, a crisis that gets worse by the day. 231 Ninety-six percent of counties in the United States are experiencing a shortage of psychiatrists who prescribe medications for individuals with mental illnesses. 232 One in five counties are experiencing shortages of non-prescribing mental health professionals such as psychologists, psychiatric nurses, social workers, and therapists. 233 Only 2% of mental health patients have access to effective therapeutic approaches. 234 Without qualified individuals to treat those with a mental illness, advances in mental health parity are null.
The second problem is that even in areas without shortages, individuals still do not have access to affordable mental health treatment. One of the means in which insurance providers discriminate between physical and mental health claims is in how they pay the health care professionals. Insurance providers do not always pay or reimburse mental health professionals the way they do physical health professionals for services rendered to clients. 235 Due to the payment disparities between mental and physical health claims, many mental health providers are forced to opt out of insurance networks in order to sustain their practices. 236 This results in patients also being forced to seek qualified professionals through costly out-of-network care. 237 For those who can find in-network mental health treatment, it can still be costly. Care is expensive, even for those who are covered by insurance. 238 As such individuals face many barriers to even getting in the room with a qualified mental health professional.
Third, an issue often ignored by legislation, is also how physical and mental health treatments differ. 239 Legislation works hard to create equality between physical and mental coverage, however the two are vastly different in their needs and practice. Coverage that works for physical treatments will not work as well with mental health treatments. Some are advocating for increased individualization in mental health parity legislation. 240 Equality between physical and mental health coverage should not be the goal, but equity should be. The two areas of coverage are inherently different, and legislation should start reflecting that. Legislators must continue to discourage disparate coverage by insurance providers but cannot simply tell insurance providers to supplant physical coverage for mental coverage and expect that to fix the nation's dilemmas. Mental health treatments and coverage should be more individualized to fit the specific disorders a person is facing. The push for more equitable treatment has already begun in the Ninth Circuit, 241 and should be expanded.
The final problem with the current legal parity framework is the lack of enforcement of existing legal protections and in the distribution of health care resources. Federal and state agencies need to hold health providers more accountable for potential prejudice in denying claims and subtle techniques being used to undercut parity between physical and mental health treatments. Enforcement and implementation of mental health parity laws is currently a challenge due to the subtle ways insurers are undercutting parity between physical/surgical and mental health claims. However, for parity to be achieved and for mental health to be properly addressed, agencies and governments need to clearly and effectively enforce the current legal framework.
The good news is that the mental health crisis and discrimination among mental health claims is not one going ignored by lawmakers. Congress recently held committee hearings in both the House and Senate to review the implementation of the Cures Act and address what areas are still in need of improvement. 242 Additionally, the proposed legislation by Senator Elizabeth Warren and Representative Joseph Kennedy III from Massachusetts to build on the Cures Act and further improve mental health parity also exemplify this. 243 Moreover, the parity task forces established by the MHPAEA and the ACA have been producing recommendations and analyzing data to perpetuate parity and improve mental health coverage overall which recognizes the four aforementioned issues. 244 As such, there are three main areas in need of improvement, all of which lawmakers are aware of and in the process of amending; enforcement of parity legislation, access to mental health treatment and legislation based on equity not equality.
The laws are already there, but the enforcement is not. As it stands, consumers have the burden of complaining to federal agencies and demonstrating discrimination between claims. 245 The burden should be placed on insurance companies to prove that they comply, not on the consumer. Additionally, governmental entities should conduct random audits of insurance providers to ensure compliance. Lack of proper and swift enforcement encouraging insurers to provide fair and reasonable coverage of mental health treatments is only adding to the mental health crises the nation is facing. As established at the beginning of this Note, mental health issues are extremely costly and are on the rise. More than ever, enforcement of mental health parity is needed. This also means that clear and consistent rules for courts to follow should be issued in order to create a consistent framework of enforcement.
Moreover, improvements in accessibility of mental health treatment should be made. Providing insurance coverage alone is a very shortsighted view of providing citizens with mental health care. The two main issues impacting access to a mental health care professional are affordability and physical availability. Many federal laws, such as the MHPA, the MHPAEA, and the ACA fail to address problems of why mental health providers are not physically available to many who now have insurance coverage. However, the Cures Act does attempt to address the issue of physical access to treatment. Should Congress continue to fund the Cures Act, it could be a major step in improving mental health treatment. While the Cures Act is attempting to address the physical availability concern, enforcement of current legislation and future laws must reflect the inherent differences that exist between mental health care and physical treatment. Individuals have trouble affording treatment even when a provider is available due to insurance companies treating mental health providers poorly and because of the current structure of coverage.
Despite the potential success of the Cures Act to provide more general access to physical treatment locations, one big area of improvement in terms of access to mental health treatment is to alter the current legislative framework to create more unique rules that increase the equity between physical and mental coverage instead of equality between them. The next step is to encourage legislative protections for mental health providers that subsidize movement to underrepresented areas that need mental health providers as well as creating insurance coverage that reflects the long-term needs of those with a mental illness. The federal government appears happy to pay out millions to pharmaceutical companies to encourage the creation of better treatments and therapies for mental illness, however, they fail to subsidize the most important people in the mental health treatment process: the provider of mental treatment and those who need the treatment.
While the current presidential administration has been hostile toward the ACA and other recent health care reforms, mental health reform has large bipartisan support in Congress and is a major concern among the general public due to recent epidemics like the opioid crisis. This is a prime opportunity for major mental health parity and treatment reform that could help millions of Americans now and in the future. Improvements toward greater access to mental health treatment as well as enforcement of current parity laws will provide the needed fixes to provide relief for millions of individuals during an era of increased mental illnesses.
Footnotes
1
See Lucy Larner, In 2013, US Spent More on Mental Disorders Than on Any Other Medical Condition, H
].
2
Sara Markowitz, Mental Health and Public Policy (2005) (Research Summary) (Nat'l Bureau of Econ. Research), http://www.nber.org/reporter/spring05/markowitz.html [].
3
See Thomas Insel, Post by Former NIMH Director Thomas Insel: The Global Cost of Mental Illness, N].
4
Id.; see Katharine R. Levit et al., Federal Spending on Behavioral Health Accelerated During Recession as Individuals Lost Employer Insurance, 32(4) H].
5
See Susanna Schrobsdorff, The Kids Are Not All Right, T
6
Markowitz, supra note 2.
7
See Issue Brief: Parity, M].
8
See generally Keith Nelson, Legislative and Judicial Solutions for Mental Health Parity: S. 543, Reasonable Accommodation, and an Individualized Remedy Under Title I of the ADA, 51 A
9
See Issue Brief: Parity, supra note 7.
10
See generally Barrett, supra note 8; see also Kessler, supra note 8.
11
Aviv Shamash, A Piecemeal, Step-By-Step Approach Toward Mental Health Parity, 7 J. H
12
Id.
13
Id.
14
See id. at 280-300.
15
Shamash, supra note 11, at 280-300.
16
Dana L. Kaplan, Can Legislation Alone Solve American's Mental Health Dilemma? Current State Legislative Schemes Cannot Achieve Mental Health Parity, 8 Q
17
Richard A. Garcia, Equity For All?, 31 J. L
18
Shamash, supra note 11, at 284-85.
19
Id.; see also Garcia, supra note 17, at 142-43.
20
Shamash, supra note 11, at 286; Garcia, supra note 17, at 143.
21
Shamash, supra note 11, at 293.
22
Id.
23
See Kathleen G. Noonan & Stephen J. Boraske, Enforcing Mental Health Parity Through the Affordable Care Act's Essential Health Benefit Mandate, 24 A
24
See Noonan, supra note 23, at 254-55; see also Shamash, supra note 11, at 296.
25
Shamash, supra note 11, at 293.
26
See id. at 294-309.
27
Policy Brief, Health Affairs, Health Policy Brief: Enforcing Mental Health (Nov. 13, 2015), http://healthaffairs.org/blog/2015/11/13/health-policy-brief-enforcing-mental-health-parity/ []; see also Shamash, supra note 11, at 286.
28
See Ana Radelat, Senate Approves Murphy Mental Health Bill, CT M].
29
See Radelat, supra note 28; see also Szabo, supra note 28.
30
See Radelat, supra note 28; see also Szabo, supra note 28.
31
See generally Am. Psychiatric Ass'n v. Anthem Health Plans, Inc., 821 F.3d 352 (2d Cir. 2016); see also New York State Psychiatric Ass'n, Inc. v. UnitedHealth Group, 798 F.3d 125 (2d Cir. 2015); see also Wilson v. Anthem Health Plans of Kentucky, Inc., 2017 WL 56064 (W.D. Ky. 2017); see also Danny P. v. Catholic Health Initiatives, 2016 WL 3551972 (W.D. WA, 2016); see also Natalie V. v. Health Care Serv. Corp., 2016 U.S. Dist. LEXIS 123783 (N.D. Ill. 2016); see also Smith v. U.S. Office of Pers. Mgmt., 80 F. Supp.3d 575 (E.D. Penn. 2014); see also Coal. for Parity, Inc. v. Sebelius, 709 F. Supp. 2d 10 (D.D.C. 2010).
32
See generally Am. Psychiatric Ass'n, Inc., 821 F.3d 352; see also N.Y. State Psychiatric Ass'n, Inc., 798 F.3d 125; see also Wilson, 2017 WL 56064; see also Danny P., 2016 WL 3551972; see also Natalie V., 2016 U.S. Dist. LEXIS 123783; see also Smith, 80 F. Supp.3d 575; see also Coal. for Parity, Inc., 709 F. Supp.2d 10.
33
35
See Robert Pear, Without the Insurance Mandate, Health Care's Future May Be in Doubt, N.Y. T
36
Shamash, supra note 11, at 279.
37
Id.
38
Id.
39
Id.
40
See id.
42
Shamash, supra note 11, at 280. During the initial stages of working to pass and enact laws providing mental health parity, many were concerned about the cost of it. There were concerns that requiring parity would significantly increase the cost of health insurance for consumers and companies.
43
Id. at 281.
44
Id.
45
Id.
46
Id. at 282-84; see Kaplan, supra note 16, at 330-32.
47
See Kaplan, supra note 16, at 330-33.
48
See id.
49
See Shamash, supra note 11, at 280-83.
50
J
51
Id.
52
Id.
53
Shamash, supra note 11, at 282.
54
Id.
55
Pear, supra note 41.
56
57
Id.
58
Id.
59
Id.
60
Id.
61
Kaplan, supra note 17, at 344-46.
62
Id.
63
Id.
64
Id.
65
Id.
66
Issue Brief: Parity, supra note 9; Kaplan, supra note 17, at 345-46.
67
J
68
See M
69
Coal. for Parity, Inc., 709 F. Supp. 2d at *12-14.
70
M
71
See Policy Brief, supra note 27.
72
See M
73
Id.
74
Id.
75
P].
76
See B
77
Id.
78
Shamash, supra note 11, at 284-87.
79
M
80
Id.
81
Id.
82
Shamash, supra note 11, at 286.
83
Policy Brief, supra note 27.
84
Id.
85
Shamash, supra note 11, at 287.
86
Id.
87
See id. at 287-8.
88
See id. at 288-9.
89
Id.
90
See id. at 288-92.
91
See id.
92
Id. at 291.
93
Id. at 286
94
Id.
95
Shamash, supra note 11, at 286.
96
Id.
97
Id. at 294.
98
Samantha M. Behbahani et al., The Patient Protection and Affordable Care Act: Will Parity for Mental Health Care Truly be Achieved in the 21
99
Issue Brief: Parity, supra note 9.
100
Behbahani, supra note 98, at 165.
101
Id.
102
Id. at 161.
103
See id. at 161-62.
104
Id. at 166-69.
105
T].
106
Shamash, supra note 11, at 297.
107
Id.
108
Behbahani, supra note 98, at 175-77.
109
Id.
110
Policy Brief, Health Affairs, supra note 27.
111
See Bruce Japsen, ‘60 Minutes’ Shows Insurers Deny Mental Health Treatment Despite ACA Rules, F].
112
See generally Am. Psychiatric Ass'n, Inc., 821 F.3d 352; see also N.Y State Psychiatric Ass'n, Inc., 798 F.3d 125; see also Wilson, 2017 WL 56064; see also Danny P., 2016 WL 3551972; see also Natalie V., 2016 U.S. Dist. LEXIS 123783; see also Smith, 80 F. Supp. 3d 575; see also Coal. for Parity, Inc., 709 F. Supp. 2d 10.
113
See Kimberly Leonard, Patients with Mental Illness No Better Off Under Obamacare, U.S. N].
114
See Am. Psychiatric Ass'n, 821 F.3d at 359-62.
115
See id. at 358; see also Wilson, 2017 WL 56064 at *2.
116
Am. Psychiatric Ass'n, 821 F.3d at 359.
117
Id. at 360.
118
Id.
119
Id.
120
See generally Wilson, 2017 WL 56064.
121
See generally Coal. for Parity, Inc., 709 F. Supp.2d.
122
See id. at 17-19; see also Danny P., 2016 WL 3551972 at *2.
123
See Issue Brief: Parity, supra note 9.
124
See B.D. v. Blue Cross Blue Shield of Ga., 2018 U.S. Dist. LEXIS 16993, *4-9 (N.D. Utah Jan. 2018).
125
See Smith, 80 F. Supp. 3d at 582-834; see also Wilson, 2017 WL 56064 at *2.
126
See generally Maria Stewart v. Applied Materials, Inc., Welfare Plan, No. 3:15-cv-026320JST (N.D. C.A. filed Sept. 30, 2016).
127
See id. at 8-9.
128
See generally Alexandra Carr v. United Healthcare Services, Inc., No. 2:15-cv-1105 JLR, (W.D. Wash. filed Jan. 24, 2017).
129
See Alexandra Carr, No. 2:15-cv-1105 JLR at 4.
130
See id. at 4-5.
131
N.Y. State Psychiatric Ass'n, 798 F.3d at 134.
132
Id. at 133-34.
133
Id.
134
Nathaniel Counts et al., What's Confusing Us About Mental Health Parity, H].
135
Id.
136
See generally Alexandra Carr, No. 2:15-cv-1105 JLR; see also Maria Stewart, No. 3:15-cv-026320JST.
137
See Natalie V., 2016 U.S. Dist. LEXIS 123783, at *21 (N.D. Ill. 2016); see also Danny P., 2016 U.S. Dist. LEXIS 85654 at *4-7.
138
See Natalie V., 2016 U.S. Dist. LEXIS 123783, at *25.
139
See id. at *25-26.
140
Compare generally id., with Danny P., 2016 U.S. Dist. LEXIS 85654.
141
Lloyd Sederer, Trump's Recipe for More Addiction, U.S. N].
142
See Sederer, supra note 140; see also Rebekah Mintzer, Fed Step Up Audits of Mental Health Benefits Parity, D]; see also M
143
See Sunrise Detox III, LLC v. Cigna Behavioral Health, Inc., No. 0:17-cv-60170-BB (S.D. Fla. filed Jan. 23, 2017).
144
See id. at 6.
145
See id. at 8.
146
N.Y. State Psychiatric Ass'n, 798 F.3d at133.
147
Id.
148
See id.
149
Radelat, supra note 28.
150
Id.
151
21st Century Cures Act, Pub. L. No. 114-255.
152
Szabo, supra note 28.
153
Telephone Interview with Caitlin Peruccio, Legislative Aide, Office of Senator Chris Murphy (Jan. 26, 2018).
154
Id.
155
Id.
156
Id.
157
Szabo, supra note 28.
158
Radelat, supra note 28.
159
Id.
160
Szabo, supra note 28.
161
Radelat, supra note 28.
162
Szabo, supra note 28.
163
Id.
164
Id.
165
Radelat, supra note 28.
166
See id.
167
Szabo, supra note 28.
168
Radelat, supra note 28.
169
Id.
170
Id.
171
Szabo, supra note 28.
172
Id.
173
See Kelsey Snell, Spending Bill Caught in Partisan Fight Ahead of Friday Deadline, NPR (Mar. 20, 2018 12:46 PM), https://www.npr.org/2018/03/20/595197537/spending-bill-caught-in-partisan-fight-ahead-of-friday-deadline [https://perma.cc/QKS9-3KYW]; see also Richard Cowan, Congress Struggles to Meet Deadline for Government Funding Bill, R].
174
Szabo, supra note 28.
175
See id.
176
Id.
177
Id.
178
Dena Feldman, Twenty-First Century Cures Act Includes HIPAA Provisions, C]. The main thrust of the Cures Act initiatives relating to the Health Insurance Portability and Accountability Act have been to direct the Department of Health and Human Services to study whether and what regulations should be revised or clarified.
179
Szabo, supra note 28. Many mental health providers fear violating the Health Insurance Portability and Accountability Act even though experts say that that idea is just one of a number of serious misconceptions that exist relating to privacy laws and mental health information.
180
Id.
181
Healthcare Reform, T].
182
Id.
183
Id.
184
President Donald Trump: The White House Interview (ABC television broadcast Jan. 25, 2017).
185
Id.
186
Id.
187
188
See Scott Horsley, President Trump Vows to ‘Liberate’ U.S. From Opioid Crisis, NPR (Mar. 19, 2018), https://www.npr.org/2018/03/19/594999711/president-trump-vows-to-liberate-u-s-from-opioid-crisis [].
189
Id.
190
See Carl Hulse, ‘Repeal and Replace’: Words Still Hanging Over G.O.P's Health Care Strategy, N.Y. T.
191
See Ian Spatz & Michael Kolber, The Future of Essential Health Benefits, H].
192
Burgess Everett, Senate GOP Tries One Last Time to Repeal Obamacare, P].
193
Timothy Jost, Examining the House Republican ACA Repeal and Replace Legislation, H].
194
See id.
195
See Burgess Everett & Jennifer Haberkorn, Trump's Obamacare Repeal Concessions Likely Can't Pass Senate, P].
196
See generally Jost, supra 193; see also D'Angelo Gore et al., Q&A: The Facts on the Republican Health Care Bill, USA T].
197
Jost, supra note 193; Gore et al., supra note 196.
198
Jost, supra note 193.
199
Id.; Gore et al., supra note 196.
200
Zezima & Ingraham, supra note 196.
201
Fox, supra note 196.
202
Zezima & Ingraham, supra note 196.
203
Id.
204
Id.
205
Fox, supra note 196.
206
See Zezima & Ingraham, supra note 196 (claiming lower income families tend to have higher incidences of mental illness and substance abuse).
207
See id.; see also Fox, supra note 196.
208
See id.
209
See id.
210
Id.
211
Id.
212
Press Release, supra note 196.
213
Id.
214
Id.
215
Stephen Collinson et al., House Republicans Pull Health Care Bill, CNN (Mar. 25, 2017), http://www.cnn.com/2017/03/24/politics/house-health-care-vote/index.html [https://perma.cc/2G4M-QWTU]; Phillip Elliott, 9 Strategic Mistakes President Trump and Republicans Made on Health Care, T]; Robert Pear et al., G.O.P. Revolt Sinks Bid to Void Health Law, N.Y. T
216
See Everett, supra note 192; see also Riotta, supra note 192; see also Roubein, supra note 192.
217
Emily Guskin & Scott Clement, Republicans' Obamacare Repeal Was Never Really That Popular, T.
218
See Steven Shepard, Poll: Voters Oppose Straight Obamacare Repeal, Politico (July 25, 2017), https://www.politico.com/story/2017/07/25/poll-obamacare-repeal-no-replace-240937 [].
219
See Robert Pear, Without the Insurance Mandate, Health Care's Future May Be in Doubt, N.Y. T
220
Id.
221
See id.
222
Amy Goldstein, Kentucky Becomes the First State Allowed to Impose Medicaid Work Requirement, T].
223
Goldstein, supra note 222.
224
Pradhan, supra note 222
225
Markowitz, supra note 2.
226
Id.
227
Id.
228
Id.
229
Radelat, supra note 29.
230
Issue Brief: Parity, supra note 7.
231
21].
232
Id.
233
I].
234
Id. at 45.
235
Id. at 15-16; Second Analysis of Insurance Data Confirms Lack of Access to Mental Health and Addiction Treatment for Millions of Americans, P].
236
Second Analysis of Insurance Data, supra note 235.
237
Id.
238
Brianna Ehley, Obamacare and Mental Health: An Unfinished Story, P].
239
Megan Lagreca, Treating A Chronic Case of Discrimination: The Ninth Circuit's Prescription for Mental Health Patients' Rights in Harlick v. Blue Shield, 58 V
240
Id.
241
Lagreca, supra note 230.
242
Jim Greenwood, Celebrating 21st Century Cures One Year Later, BIO].
243
Press Release, Congressman Joe Kennedy III, Kennedy, Warren Intro Bill to Strengthen Mental Health Parity Laws (Jan. 11, 2017), https://kennedy.house.gov/media/press-releases/kennedy-warren-intro-bill-to-strengthen-mental-health-parity-laws [].
244
T]; Second Analysis of Insurance Data, supra note 235.
245
U.S. Dep't of Health and Human Servs., Legal Action Center, Opinion Letter by Ellen M. Weber (July 26, 2017), https://www.hhs.gov/programs/topic-sites/mental-health-parity/achieving-parity/cures-act-parity-listening-session/comments/patients-and-advocates/legal-action-center/index.html [].