Biden’s Reconciliation Bill Aims to Strengthen Behavioral Health Parity, Access

After much haggling among Democrats in Congress, President Biden Thursday unveiled the latest framework of his reconciliation spending bill.

The new version of the Build Back Better Act is a $1.75 trillion bill that, pricewise, is a scaled down version of the spending agenda Biden has sought to enact as a capstone achievement of his first presidential term. Among various items included within the bill are those dealing with behavioral health concerns, particularly with a federal pledge to better enforce parity law.

The Mental Health Parity and Addiction Equity Act (MHPAEA) — otherwise known as the Parity Act — is a federal law that went into effect in 2008. Under the law, insurers are prohibited from offering coverage for behavioral services that is more restrictive than that for medical and surgical care. However, many within the behavioral health industry have long decried that insurers often do not practice parity to the letter of the law.

“Plans have gotten barely a slap on the wrist for violations that we know are occurring consistently,” National Association for Behavioral Healthcare (NABH) CEO Shawn Coughlin said Friday during an interview with Behavioral Health Business. “We really have been supportive of allowing a more serious enforcement mechanism.”

With the latest version of the reconciliation bill — which clocks in at 1,684 pages — authority for overseeing parity would move from the state to the federal level, which would be responsible for levying fines on health care plans that do not comply with guidelines. States were initially made responsible for executing parity law with the 2010 passage of the Affordable Care Act (ACA), which at the time applied to private health plans. MHPAEA would eventually be extended to Medicaid managed care plans in 2016.

Various research has shown reimbursement gaps still existing post-ACA, including a 2019 study conducted by health care management firm Milliman, which found that primary care reimbursement rates in 24 states were at least 30% higher than for behavioral care. The study also found that the disparity between out-of-network visits for substance use disorder (SUD) treatment and that of medical and surgical care more than doubled over a four-year period.

Mark Dunn, who is the director of public policy for the National Association of Addiction Treatment Providers (NAATP), believes that the new measure is a boost for parity law to be effectively discharged. He feels that parity operates at a nationwide disadvantage because there is no uniformity in how each of the 50 states enforces the law.

“That has been an ongoing issue for many years,” Dunn told BHB on Friday. “We have been pushing the federal government, saying, ‘It’s not working that great at the state level.’ This is a federal law, the federal government is ultimately responsible for enforcement.”

Dunn previously praised Biden’s approach to SUD in a July story with BHB, saying he believed the president was particularly sensitive to the issue given the past struggles of his son, Hunter, with addiction. Additionally, the Department of Labor — which has oversight on workplace benefit plans — is led by Marty Walsh, who previously battled alcoholism, and whose office has increased parity enforcement where it has authorization.

Dunn, on Friday, reaffirmed his belief that the Biden administration is serious about efforts to tackle SUD nationwide.

“This administration has an understanding that substance use disorder is a medical disease,” he said. “It’s not a moral failing, like some previous administrations have believed.”

Dunn feels the new parity rule regarding health plan oversight is one of the strongest signals in some time that the federal government is willing to take the lead on the issue. He believes officials in the Trump administration might have previously felt as though their hands were tied legally from fining insurers for parity violations, which is something the reconciliation bill seeks to change.

“That’s what we’re hoping will remain once this lengthy process is over,” Dunn said.

What lies ahead with the reconciliation bill fight

That “lengthy process” Dunn refers to is for the reconciliation bill, of which no timetable for a vote has been set as of Friday. Democrats — who control both the House and Senate on slim margins — have gone back and forth for months on the bill, which was originally budgeted at $3.5 trillion. The bill in its current iteration is to be funded by measures such as a 15% tax on profits of large corporations, as well as a surtax on the wealthiest 0.02% of individuals.

Coughlin also said that much can still change with the bill ahead of any scheduled vote, but is overall hopeful by what it could mean for the behavioral health industry. Besides parity, Coughlin praised the bill for addressing industry workforce concerns — such as $25 million allocated to community organizations to bring aboard peer recovery specialists, as well as $75 million for the recruitment of maternal mental health and SUD treatment personnel.

Additionally, Coughlin is encouraged that the bill called for covering 4 million more Americans under Medicaid, which is the nation’s largest payer of behavioral health services.

“The provisions on addressing the Medicaid coverage gap, which have the potential to cover an additional 4 million low-income or uninsured Americans, are positive as we look to improve access to people having some kind of health insurance,” he said.

Coughlin said that the reconciliation bill is not the biggest legislative statement that Congress has recently made in their commitment to behavioral health. He believes one better example of that has come from the Senate Finance Committee, in a bi-partisan effort, putting out a request for information to industry stakeholders on ways to improve behavioral health access. 

However, Coughlin feels measures in the bill regarding behavioral health are a step in the right direction, even if that step — in his opinion — could be bigger.

“It’s encouraging to see the focus put on this, but we know there’s a lot more work that needs to be done,” he said. “It is a solid recognition of the needs that are out there, but we are competing against the broader budget.”