Congress appears poised to work on a bipartisan mental health and substance misuse package this year, following a series of hearings this week stressing the need to boost the workforce, insurer benefits and telehealth access.
Legislators also seemed to support giving federal departments more power to force health insurers to comply with parity laws, following a report in late January finding widespread inequities between mental and medical benefits in the U.S. that sent physician groups up in arms.
The Senate committee on Health, Education, Labor and Pensions held a hearing on the U.S. mental health crisis on Tuesday, followed one day later by the House Ways and Means committee — that body's first hearing on mental health in more than a decade.
The renewed push comes as the pandemic continues to exacerbate already acute mental health and substance use disorder challenges in the U.S., including inequities in care access and a workforce stretched exceedingly thin. Over the past two years during COVID-19, rates of conditions like anxiety and depression have soared, and the country has seen record numbers of drug overdose deaths.
The lack of infrastructure coupled with the escalating overdose crisis and rising rates of depression, anxiety and suicidal ideation require immediate, systemwide action by Congress, witnesses said.
"If we're going to respond to the behavioral health issues the pandemic has made worse ... that will take legislative action," HELP Chairwoman Patty Murray, D-Wash., said.
Boosting the workforce
Accessing care for mental health and substance use disorders is an extremely difficult prospect. For SUD, barriers like a lack of trained workers, treatment programs relying solely on one type of intervention, emergency rooms not accepting patients unless they're detoxing due to low bed availability, and rampant stigma and discrimination all complicate receiving sometimes critical care, testified Michelle Durham, vice chair of education at Boston Medical School's psychiatry department, on Tuesday.
Additionally, the lack of behavioral health specialists is swamping psychiatric hospitals, said Mitch Prinstein, chief science officer at the American Psychological Association. Part of the problem is low Medicare and Medicaid reimbursement, resulting in few specialists accepting that insurance, Prinstein told the Senate on Tuesday.
Almost 130 million people live in areas designated by the federal government as mental health professional shortage areas, with that access particularly lacking in rural regions of the country.
Prinstein asked Congress to allow psychology trainees to be reimbursed under Medicare, something that's currently allowed for medical residents. That would allow the mobilization of "thousands of mental healthcare workers quickly," Prinstein said.
Other fixes would be to offer more student loan repayments to psychological residents, along with more funding for grants that allow community organizations to offer mental health programs, witnesses testified at both hearings.
A more systemic issue is treatment silos, which result in providers potentially only specializing or working in substance use disorders or mental health, ignoring the common overlap between the two fields.
"That adds complexity when people want to go for care and they have to go to many different providers to get the treatment they need," Durham said. "We need to stop siloing in healthcare."
Legislators agreed that bolstering the workforce was a top priority for addressing the nation's mental health obstacles.
"My hope is that we build out a package of focus on mental health and really key in on the workforce issues because I think we recognize that in all our states, we are sorely, sorely lacking," said Sen. Lisa Murkowski, R-Alaska.
Insurer barriers to care
Patchwork insurance coverage and administrative requirements can be another barrier to people and families getting the behavioral healthcare they need, witnesses told Congress.
In late January, HHS and the Labor and Treasury departments published a report finding health insurers were widely noncompliant with mental health coverage parity laws. Law requires that any financial or treatment requirements imposed by payers, such as copayments or prior authorization requirements, on mental health or SUD benefits aren't allowed to be more restrictive than those imposed on all other medical or surgical benefits.
No plans analyzed by the federal government were in compliance with the law. However, alerting the plans did lead to some increasing benefits, the report said, a fact Sen. Chris Murphy, D-Conn., called "both defeating and encouraging."
The report called for Congress to give the Labor Department more power to enforce parity laws. One enforcement measure on the table is giving regulators civil monetary penalties, allowing them to fine any plans with illegal barriers to mental health and SUD benefits.
The American Medical Association on Tuesday also urged Congress to do more to make plans comply with the mental health and substance use disorder parity law — including imposing fines. AMA also said it supported giving the Labor Department the power to go after the issuers of those plans that actually administer benefits, and usually design any limitations or coverage terms.
"Insurers will not change their behaviors without increased enforcement and accountability, and patients will continue to suffer until that happens," AMA CEO James Madara wrote in a letter to Senate HELP committee leaders.
Enforcement will be "almost impossible" without the ability to fine, APA's Prinstein said.
Some legislators spoke out in support of giving the Department of Labor that power, noting there's bipartisan support for increasing industry compliance with existing law.
"We just have to give the tools to the department so insurers comply," Sen. Murphy said.
Coverage in this area is extremely lacking, testified Deborah Steinberg, a health policy attorney at the Legal Action Center. Most Medicare beneficiaries have no access to SUD treatment, and coverage for mental health is "strikingly more limited" than commercial plans.
But even privately insured people are five times more likely to go out of network for mental health and SUD treatment compared to other medical care. Such out-of-network utilization is far higher for SUD services, research has shown.
But along with shoddy coverage, insurer practices like prior authorizations — touted by insurers as a way to reduce unnecessary costs — are creating additional barriers to care, according to witnesses.
"In the emergency room, for example, we have to get prior authorization before sending someone to an inpatient psychiatric facility," Durham said. That can take hours, delaying needed care and stressing the ER's resources — and even then, the request may not be approved.
Doctors should be spending their time providing care, not "at the beck and call, if you will, of those prior authorizations," Durham said.
Steinberg on Wednesday told the House Ways and Means Committee that removing prior authorization for opioid addiction treatment resulted in more patients receiving treatment and fewer hospital admissions down the line.
"Every single hour that we spend navigating prior authorization to get a patient the evidence based treatment they need is an hour that could be spent on something else … any way that we can cut down on the processes would be helpful so that we can just get the treatment that they need," Jennifer Lockman, CEO of the Centerstone Research Institute, said Tuesday.
Telemental health access
Since telehealth flexibilities were expanded in early 2020 to increase access to care during the pandemic, many patients, doctors and virtual care advocates have called on Congress to make the temporary allowances permanent. The Biden administration has expressed its support for expanded telehealth access after the COVID-19 national health emergency, and Congress is currently considering a number of bills that would permanently nix regulatory barriers to virtual care.
"We should make this even easier, permanently," said Rep. Kevin Brady, R.-Texas, on Wednesday, calling telehealth expansion a "silver lining" of the pandemic.
Specifically, to help with mental health access, telehealth advocates have pushed for removing restrictions they view as arbitrary, such as the requirement patients have an in-person visit with their provider before they can have a behavioral telehealth visit.
A bipartisan bill introduced in June, called the Telemental Health Care Access Act, would remove that requirement.
Boosting telemental care is important as the evidence suggests providing services via phone or video has roughly the same outcomes as providing them face to face, Centerstone's Lockman said. Lockman and other witnesses stressed how virtual care allowed physicians mobility and certainty during the pandemic, knowing they had a modality to stay in touch with even the most wary patients.
"I believe telehealth was really truly what saved the behavioral health delivery system," testified Deepa Avula, director of North Carolina health department's mental health and SUD division. "Where plans have pulled back there is evidence that people are disengaging ... if this flexibility is suddenly stopped, there will be a significant amount of Americans that will lose care."
"It's time for us to begin the important work of making virtual health permanent," Rep. Kevin Hern, R-Okla., said at Wednesday's hearing.