Mental health parity may finally become a reality

The Wellstone Act could bring better health care to millions of Americans

Mental health parity may finally become a reality
Andrew J. Nilsen

Katie Bird thumbs through a stack of opened envelopes, at least a hundred deep, on the coffee table in her lawyer's office.

"These weren't even all my denials," she explains. "Just the ones we saved."

Behind her are three accordion folders overflowing with more paper, the remains of two years of war with her insurance company.

Katie Bird, framed by files from the long fight with her insurance company
Mark N. Kartarik
Katie Bird, framed by files from the long fight with her insurance company
Paul Wellstone at a parity rally in summer 2002, while Pete Domenici speaks
Paul Wellstone at a parity rally in summer 2002, while Pete Domenici speaks

The files chronicle the nine appeals where she begged her provider to cover treatment for her eating disorder. Among the insurance reviewer's reasons for denying care: "There are also religious groups who fast and that is not psychopathology."

"Insurance companies create the rules and change them to suit their needs," says Bird's attorney, Elizabeth Wrobel. "Most patients simply give up and believe what the insurance company has told them, which is that they are not really sick or do not qualify for the benefits for which they have paid."

Bird's problems began at age seven, when she first thought she was fat. By age 13, her mother caught her with diet pills and sent her to the first of many treatment facilities. For the next 18 years, Bird cycled in and out of therapy.

In 2007, Bird had a daughter. Two years later, she was hospitalized for three weeks. She was 108 pounds and needed cardiac care. She knew she had to make a change.

"I was still working out in the hospital," Bird remembers. "I was going to bed at night afraid I wasn't going to wake up, and I didn't want my daughter to grow up thinking that was okay."

When Bird left the hospital, she entered treatment at the Emily Program. There, her team recommended residential care in order to break a lifetime of bad habits: 24-hour supervision onsite at the program. The Emily Program was a "preferred provider" in Bird's insurance company's network, and all four of her doctors agreed that the prescription was necessary based on how Bird's condition fit into the American Psychiatric Association's treatment guidelines.

But Bird's insurance company, United Behavioral Health — the behavioral care arm of Minnetonka-based giant United Health — wouldn't cover it.

Over the course of those nine appeals, UBH pulled out all the stops: Bird wasn't trying hard enough to get better, read one denial letter, and "needs to be taking responsibility for her own behavior." In another, Bird wasn't "actively psychotic, suicidal or homicidal," and so didn't need such a high level of care. Bird didn't meet UBH's own guidelines for care, went a third, though the company wouldn't clarify what those guidelines were.

"I find it so striking how differently my clients are treated in comparison to patients who require significant medical treatment," says Wrobel. "Imagine telling someone with breast cancer to try harder."

There's a federal law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, that is supposed to do exactly what Wrobel describes: make insurance companies cover treatment for mental illness and addictions "on par" with how they cover physical ailments, an idea known as mental health parity.

It should have helped Bird before she ever landed in court. But since Congress passed the act in 2008, insurance companies haven't had to listen to it.

"I'm frustrated," says Sen. Al Franken, the latest Minnesotan to lead the parity charge. "The real problem is that the interim regulations are unenforceable. We've made hundreds of phone calls, written letters, but on the question of whether or not the intent of the law has been carried out, the answer is comme ci comme ca." Kind of.

On January 16, President Barack Obama signed 23 executive orders on gun violence. Four of them talked about mental health, and one of them pledged to finalize what the rules would be for the Wellstone Act.

When Congress first passed the act, the legislation was a landmark 12 years in the making.

"My dad always called it a civil rights bill," says Paul Wellstone's son, Dave. "It was a big deal."

The bill would have given 113 million Americans increased access to mental health care, according to SAMHSA, the U.S. government's substance abuse and mental health branch. In Minnesota, it would have affected about 40 percent of those with health insurance. That's nearly two million people.

And those big jumps in coverage would have come at minimal cost, many studies indicated. Reports from both the Surgeon General and the U.S. Department of Health and Human Services showed that parity laws would result in a less than 1 percent increase in overall health care costs. In 1999, when President Clinton ordered parity for federal employees' health care plans, the switch actually saved the government money.

The Wellstone law was passed with all this in mind, putting in place temporary measures that were supposed to last until 2010, giving regulators time to put together a final set of rules. But then those rules never materialized.

"People don't realize that until a law has a rule, it's not worth the paper it's printed on," says Jim Ramstad, who championed the bill in the U.S. House during his nine terms representing Minnesota's third congressional district.

Instead, the temporary guidelines have meant that insurance companies can interpret the law as they see fit.

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I worked for Cigna for five years and saw all of this unfold on a daily basis.  Sometimes it was blatant, and other times it was a bit more confusing.  I completely agree that if a person has benefits and has not used them, then regardless of the level of care, especially if it is being recommended by an M.D., that person should be allowed to receive care for their issues.  If they have no insurance, that's another complicated matter.  

The one hang up, and I think this article pointed it out, is that when a person does not get the care needed, and they end up getting tossed around the system, getting "lower levels" of care, such as outpatient or intensive outpatient to save on cost, when the reality of it is that if they were simply allowed to receive a residential program from the beginning, maybe the years of hassle, other failed treatments, and expense could have been avoided.  Unfortunately, once you've maxed your benefits for the calendar year, forget it, your done!  And there is an abundance of elephant dung sized health care plans to see to it that you exhaust your benefits as fast as possible.  In other words, if your benefits renew calendar year starting in January, and your actively seeking help for you mental health or substance abuse  issues, you could conceivably max out by February, and spend the rest of the year without help or treatment, unless you keep paying out of pocket.  

This issue could easily be a 900 volume tome, and I could ramble on at great length, but I guess from the insurance perspective, they only do what is necessary to keep a human being alive and functioning (feed themselves, dress themselves, bathe)  at the bare minimum of expense, which I think is where the term "medical necessity" stems from.  And why the insurance companies have the power to determine this over the M.D. treating the patient, I will never know.  Mental health and substance abuse are not as easy a fix as mending a broken arm, or stitching up a wounded knee, they're much more long term, and progress can move very slowly.  If I may be allowed to be a bit of a hippie about it, my hope is that if we the human species have any hope of progressing further, and sustaining life on this planet, the cost, no matter what ridiculous financial figures they produce, would ultimately become a true non-issue.

...bit of rant I know, sorry, just wanted to get that out and add it to the discussion.  Thanks. 


There is an important technicality here that needs to be better explained.  Minnesota already has a mental health parity law so Minnesotans who buy health coverage from anything other than large employers were already covered by the parity law.

This new law was only for large employers who are exempt from all state mandates like mental health parity.  And, most important for these large employers, they don't actually buy insurance.  They are self insured so it isn't actually the insurance company issuing the denial, it's a third party administrator (many times an insurer who is running a TPA) that is implementing the coverages laid out by the employer.

So the complaints about the insurers not paying, should be more appropriately leveled at the employers who were not willing to pay.

Finally, there is a very important reason for claims denials.  It's to keep costs low.  While the call for better coverage is certainly worthy and nobody can deny it is very much needed, the problem is that it is extraordinarily expensive and most of these people want the treatment, but they want somebody else to pay for it.   The 'somebody elses' of the world would likely be more willing to pay for the care, if there was a way to make the care less expensive. 


You cannot get something for nothing. Insurance companies probably do not cover these mental maladies because they are difficult to define, diagnose, and successfully treat. Forcing insurance companies to do so at the point of a government gun is evil and will probably result in less coverage for the mentally ill and higher insurance costs for us all.

DonkeyHotay topcommenter

Mental Illness = America's BIGGEST Health Care problem


the lines between illness and health are very blurry, and political.  my own doctor has told me to lose 60 pounds.  I cannot find success-- despite spending thousands of my own money on various plans and groups.  I would like to try total immersion (similar to the article's subject, a residential treatement plan).  However just like the other ways I've tried, insurance won't cover a dime of it. 

My point is this:  I am basically sort of healthy, but my asthma, depression, and blood pressure are getting worse, and I would be more productive and happier if I could lose weight.  But, Big Insurance doesn't see this as a problem, and won't pay to try to get me "healthier". 

It's not the middle-health people like me who get care, it's the extremely low-health people who get care, just like government benefits--  the middle class pay pay pay their taxes, but the low-income receive the majority of benefits.


Great article.  I hope people will start paying more attention to the laws that protect our most vulnerable people.  



you replied to me "stop putting so much food in your mouth. Hope that helps."

Unfortunately, it doesn't help.  I have been faithfully on various low-calorie, low-carb, low-fat, etc diets, and none of them had any long-term success. 

What I need to be healthy will take more than "stop putting so much food in your mouth". 

Everything I've done with my own efforts has failed---that's why I need professional help. 

If a stomach-staple surgery would help lose the weight, reduce my asthma, blood pressure and depression/anxiety, then shouldn't I qualify for that?  But I don't weigh ENOUGH yet, so I don't qualify. 

It is really crazy how they restrict medical care only to the very sickest, or the very youngest, or the very poorest.  Those of us with jobs, sort of sick but not deathly sick, who are paying into Medicare & Medicaid, need medical care too, so we can keep paying for all the 47 percent who pay nothing.