Mental health refers to an individual’s condition in relation to his or her psychological, social, and emotional well-being. Mental health, according to the Centers for Disease Control and Prevention (CDC, 2021), has significant influences on how an individual feels, acts, and thinks. Furthermore, the condition of one’s mental health can determine how he or she will handle stressful conditions, make healthy life choices, and relate with others within a professional or private setting. The CDC (2021) reported that mental illnesses are some of the most common health conditions in the United States, with more than 50 percent of Americans expected to be diagnosed with a mental illness or disorder in their lifetime. Additionally, one in five Americans is projected to experience a mental illness every year, with one in five children being reported as having a seriously debilitating mental health condition (CDC, 2021). Finally, one in 15 Americans was reported by the CDC (2021) as living with a serious mental illness like major depression, schizophrenia, or bipolar disorder, among others. Despite the high prevalence of mental health illnesses in the United States, an article by Mental Health America (MHA, 2022) stated that at least 11 percent of Americans with mental health illnesses are not insured. Consequently, there have been concerted efforts at both state and federal government levels to improve access to mental health care through the introduction and enforcement of mental health parity laws and policies. The objective of this paper is to discuss the significance of mental health parity laws and policies and the impact of such laws on nursing, patient safety, and access to care.
Policy Issues Relating to Mental Health Parity Law
Mental health parity laws are designed to improve patient safety and access to care by expanding and protecting benefits provided by insurers in mental health care. According to the Centers for Medicare and Medicaid Services (CMS, 2021) and Mulvaney-Day et al. (2019), the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) was created to address some of the issues not addressed in the Mental Health Parity Act of 1996 (MHPA). For instance, MHPA stipulated that large group health plans were not allowed to impose lifetime or annual financial limits on mental health benefits that are less favorable than limits enforced on medical or surgical benefits (Block et al., 2020; Medicaid and CHIP Payment and Access Commission, 2021). While preserving the protections provided under MHPA, the Mental Health Parity and Addiction Equity Act (MHPAEA) introduced new protections for individuals seeking mental health insurance coverage. For instance, the protections provided for mental health insurance under MHPA were extended to include parity requirements for substance use disorders under MHPAEA.
The purpose of the Mental Health Parity Law is to ensure improved access to mental health care through the elimination of some of the financial and social barriers faced by individuals with mental health illnesses. For instance, the provisions that prohibit the limitation of benefits for people with mental health insurance coverage are crucial in reducing out-of-pocket spending, thus, increasing access to mental health services (Medicaid and CHIP Payment and Access Commission, 2021). By regulating the amount of money insurers can impose on individuals with mental illnesses, the Mental Health Parity Law guarantees continued access to care during inpatient and outpatient treatments. Therefore, the law on mental health parity is essential in protecting care coordination and continuum of care once an individual is discharged from a healthcare facility.
Nevertheless, with at least 11 percent of Americans with mental health illnesses being uninsured, there are several policy changes that can help to improve the state of mental health care in the country. First, Medicare and Medicaid services should be expanded to provide coverage for all people with mental health illnesses and substance use disorders regardless of their income level or age. To elaborate on the foregoing assertion, it is important for the federal government to identify the uninsured Americans, especially those with mental health illnesses, and provide them with insurance coverage regardless of whether they qualify as low-income citizens or senior citizens. Finally, Medicare and Medicaid services should be expanded to provide coverage for medical evaluations and diagnoses for people seeking to determine their mental health statuses. This is crucial in that it allows members of the public and clinicians to initiate timely interventions in providing medications and other therapeutic treatments to victims of mental health illnesses.
Significance to Nursing and Patient Care
Despite the positive steps taken in addressing mental health parity in the United States through Mental Health Parity Law, there are several shortcomings that threaten patient safety, quality of care, and access to providers. First, Mental Health Parity Law does not effectively provide guidelines on care coordination for patients with mental health illnesses following their discharge from specialist care providers (Block et al., 2020). Furthermore, it is important to note that while there are provisions or guidelines on annual or lifetime benefits for insurers, this provision only focuses on issues relating to medical expenses, as opposed to the continuation of care. To elaborate on the claim above, the process of transitioning care from mental health providers to family and other at-home caregivers is left to care providers and professional organizations to address. This omission leaves loopholes for organizations in the mental health care services to exploit where the quality of care for some groups in the community may be lower than in others. The assertion regarding potential discrimination in the quality of care emanates from the fact that reduced standardization of mental healthcare services from a legal perspective can cause vulnerable populations like ethnic/racial minorities, women, children, and members of the LGBTQ+ communities to be unfairly treated by healthcare professionals. As such, it is important that the current Mental Health Parity Law is amended to include the conduct of care providers in the continuity of care as opposed to focusing primarily on insurance coverage.
Furthermore, issues relating to lack of sufficient training among nurses and other clinicians in the mental healthcare services sector can increase the threat posed to patient safety, quality of care, and access to providers. Lack of cultural competence and sensitivity is one of the biggest barriers to quality and satisfactory care within any medical specialty. However, this issue is significantly highlighted in mental health care due to the fact that different cultures have diverse perceptions of mental health illnesses. Cultural competence in health care can be defined as an approach to care that respects patient diversity and cultural factors that can affect health and health care, like communication styles, behaviors, beliefs, language, and attitudes (Rice & Harris, 2021). Lack of cultural competence training in mental health nursing has the likelihood of increasing patient dissatisfaction, patient stigma, and willingness to seek medical services from specialists. However, Rice and Harris (2021) noted that providing cultural competence training to nursing students and specialists in mental healthcare would increase patient satisfaction leading to improved health outcomes for patient populations. Similarly, cultural competence in mental healthcare allows for positive community engagement where deleterious cultural beliefs and negative personal perceptions regarding mental illnesses can be addressed by medical professionals.
Mental health care has the potential of increased out-of-pocket spending due to the fact that some patients are uninsured or because of lack of coverage or reimbursement for patients who spend out of their pockets. Thus, due to extra financial costs like care coordination, outpatient care costs, and medication not being covered in some insurance plants, patients with mental health illnesses face the added risk of spending out of their pockets to cover such costs (Block et al., 2020). Hence, Mental Health Parity Law should be expanded to include Medicare and Medicaid coverage for prescription medication for patients with mental illnesses. Such coverage can be designed to supplement any potential shortcomings in private insurance coverage based on existing plans.
Finally, the most common social determinants of health affecting mental health parity include unemployment and income inequality, racial discrimination and social exclusion, and limited access to care providers. Unemployment and income inequality are some of the most common leading factors that contribute to unequal access to health care services. Lack of financial stability contributes to limited insurance coverage among the affected populations. The situation is exacerbated by the fact that mental healthcare is not perceived as part of primary care services but rather a specialist care service (Drake et al., 2019; Chapman et al., 2018). Thus, people in need of mental health insurance must incur extra expenses before enrolling in an insurance plan. Similarly, racial discrimination and social exclusion are equally important social determinants of mental health (Block et al., 2020). To expound on this claim, it is worth noting that ethnic minorities, women, and members of the LGBTQ+ communities experience disparities in access to health care in general. Furthermore, because of limited cultural competence and sensitivity within the health care sector, there is a shortage of specialists with the skills, knowledge, and expertise to effectively care for the affected communities. Failure to address racial discrimination and social isolation of minority groups in the health care sector worsens the affected communities’ ability and willingness to seek professional assistance when afflicted with a mental illness. Coupled with low income and unemployment within the affected minority communities, access to specialist care providers is further negatively impacted, resulting in higher cases of untreated or undiagnosed mental illnesses in minority groups.
Synthesis of Literature
Based on an analysis of current literature on Mental Health Parity Law in the United States, the three recurring themes identified were financial cost of care, access to specialist care, and social determinants of health.
Financial Cost of Care
Regulations on mental health care have undergone several changes throughout the history of the United States healthcare sector in relation to the financial cost of care. It is important to note that mental health is the only discipline associated with treatment limits, increased cost-sharing, and other organizational policies designed to reduce its use (Drake et al., 2019; Thomas et al., 2018). Therefore, the effects of parity are centered on specialty treatments with the objective of eliminating or reducing financial restrictions to mental healthcare. Initially, healthcare insurers were not required by law to provide mental health coverage as part of their plans (Peterson & Busch, 2018; Thalmayer et al., 2018). Moreover, even in cases where mental health coverage was part of an insurance plan, insurers were permitted to impose treatment limitations for people with mental health illnesses (Peterson & Busch, 2018). The cost of care was further worsened by the fact that companies with less than 50 employees were exempt from the law, with bigger employers having the allowance to apply for an exemption as long as complying with the law resulted in a cost increase of at least one percent (Peterson & Busch, 2018).
The introduction of the MHPA and the creation of state laws introduced variations regarding whether mental health coverage was mandated and the extent of such mandate (Peterson & Busch, 2018; Thalmayer et al., 2018). However, the introduction of MHPAEA sought to ensure that all treatment limitations for mental health disorders were comparable to limitations in medical and surgical benefits in employment-based plans (Peterson & Busch, 2018). The objective of this Mental Health Parity Law was to eliminate discrimination by employers and insurance companies towards employees and patients with mental health disorders.
Furthermore, legal and policy changes relating to mental health parity are crucial in eliminating financial barriers among individuals in low-income households and the unemployed. In an article by Thomas et al. (2018), the authors noted that the Affordable Care Act (ACA) was pivotal in expanding Medicaid to cover low-income individuals aged between 19 and 64 years. The ACA, therefore, affected people who were previously ineligible under previous laws to receive mental health insurance under Medicaid or private insurance coverage (Thomas et al., 2018; Peterson & Busch, 2018; Drake et al., 2019). Expanding mental health coverage by including individuals from low-income households and restricting limitations on benefits has the potential of reducing or eliminating some of the previously existing financial barriers to mental health services. Peterson and Busch (2018) further noted that both the ACA and the MHPAEA increased the number of Americans who could gain access to mental health coverage by affecting the insurance health benefits of more than 170 million people.
Furthermore, Mental Health Parity Law has positive impacts on reducing patient spending by expanding insurance products. Hodgkin et al. (2018) reported that following the implementation of MHPAEA and ACA, insurance products for mental illnesses expanded by 68 percent. This means that the number of mental health and behavioral disorders covered by insurance companies increased by at least 68 percent, thus, reducing the costs that patients incurred when seeking mental healthcare services. Parity in mental health law is further designed to reduce out-of-pocket spending from patients when paying for insurance coverage (Kingshill, 2021; Block et al., 2020). This is centered on the fact that while the number of products covered by insurers increased by 68 percent, there was concern that limitations on the length of treatments and continuum of care may have negative effects on patients’ financial effects and ability to achieve full recovery (Kingshill, 2021). Therefore, the ACA and MHPAEA sought to address such shortcomings by prohibiting potential limitations by insurers or care providers.
Access to Specialist Care
Mental Health Parity Law plays an important factor in improving access to insurance coverage and specialty care. Most Americans with limited access to mental health coverage can attribute such limitations to actions by insurance companies to impose limitations in ways that are more restrictive than in physical health services (Purtle et al., 2017; Harwood et al., 2017). One of the main benefits of ACA and MHPAEA is the fact that limitations on benefits are prohibited as well as prohibitions on existing condition exclusions (Campbell & Shore-Sheppard, 2020). Before the introduction of the parity law, insurers could exclude individuals with mental health illnesses from acquiring coverage or subject them to expensive plans that were financially costly and prohibitive (Campbell & Shore-Sheppard, 2020; Allabyrne et al., 2020; Peterson & Busch, 2018). The elimination of barriers to insurance or access to insurance services ensured that individuals with preexisting mental health illnesses were no longer denied access to specialist care of mental health services.
Similarly, expanding Medicaid to offer mental health coverage for low-income individuals also plays a crucial role in bridging the gap in access to care between low-income earners and people with financial stability. Similar changes are reflected in state legislations where limitations on mental health and substance use disorder benefits are prohibited (Purtle et al., 2017; Tran Smith et al., 2018; Chapman et al., 2018). With the eradication of limitations on mental health coverage, one can expect more people to seek mental healthcare services from specialists. Additionally, the expansion of Medicaid to include mental health coverage is crucial in ensuring that people from low-income households have access to quality care in the event of developing a mental health illness. Furthermore, Busch et al. (2017) and Harwood et al. (2017) noted that enactment of federal parity in mental health resulted in increased in-network services use, a potential indicator of insurers implementing measures to curb out-of-network use. While this approach may have some negative effects on patient health outcomes, it is worth noting that the overall impact is increased access to specialty care from in-network providers.
Social Determinants of Health
As earlier mentioned, some of the most common social determinants of health include unemployment and income inequalities, discrimination and social isolation, and limited access to care providers. Federal parity helps to address some of the social determinants of health contributing to lack of care equity by incorporating mental health coverage for individuals between 19 and 64 years and Medicaid (Harwood et al., 2017; Hodgkin et al., 2018). Furthermore, prohibiting limitations on benefits for people with mental health illnesses further enhances access to care for minority communities. Thus, mental health parity is crucial in improving access to mental health services for groups that were previously marginalized by restrictive insurance policies, such as low-income earners and people with preexisting conditions.
Failure to address issues relating to cultural competence and coordination of care in federal health parity law, however, has deleterious effects on health outcomes for affected populations. Since cultural beliefs, practices, and social stigma towards people with mental health continue to persist, the absence of legislative regulations on treating members of minority communities or educating communities on mental health can reduce willingness to seek medical services by patients (Rice & Harris, 2021; Hodgkin et al., 2018). Moreover, patients from minority groups such as LGBTQ+ and ethnic minorities may have unfavorable experiences when seeking medical health care services. Such experiences are likely to influence one’s willingness to attend future appointments or adhere to medical advice, resulting in poor health outcomes. Consequently, it is important to focus on culturally competent and patient-centered care when providing medical services to patients with mental health illnesses.
Recommendations on Improvements
It is important for all the stakeholders in the healthcare service sector to identify gaps in practice and find solutions to improve service delivery. The main stakeholders affected by mental health parity law include patients, family members, clinicians, insurance providers, and government regulators and policymakers. The first step towards improving parity in mental health includes the integration of mental health services into primary healthcare. Currently, mental health coverage and treatment is a specialty care, meaning that general hospitals are not required to have departments providing mental healthcare services (Chapman et al., 2018; Hodgkin et al., 2018). However, by integrating mental health services into primary healthcare services, general hospitals would be required to provide basic and specialty care to patients with mental health illnesses. The outcome of such policy would be increased access to care for patients with mental health illnesses since the number of care providers would be increased. Furthermore, the cost of insurance would be significantly reduced if mental health services are not addressed as specialty care services.
Finally, it is important that nursing schools, professional organizations, and other institutions of higher education in mental health services incorporate cultural competence in their education curriculum. Cultural competence programs and training should involve imparting nurses and caregivers with the skills and knowledge needed to navigate diverse patient cultural backgrounds (Rice & Harris, 2021). Furthermore, the utilization of cultural competence promotes patient-centered care and the involvement of community and family members in creating care coordination plans to ensure optimal patient outcomes. However, such measures can only be achieved through improved training and education on the part of professional healthcare providers.
Mental Health in Relation to IOM’s Future of Nursing Report and the Affordable Care Act
The Institute of Medicine (IOM) released a report in 2010 titled, The Future of Nursing: Leading Change, Advancing Health, which sought to provide recommendations on improving the nursing profession. The four main issues addressed in the report, according to Rekha (2020), included the recommendation that (1) nurses ought to practice to the full extent of their training and education, (2) nurses must achieve higher levels of training and education, (3) nurses should be full partners in the healthcare system with physicians and other health professionals, and (4) better data collection and information structure is required to ensure effective workforce planning and policymaking. Given the recommendations above, it is crucial that nurses take part in policymaking by acting as patient advocates and equal partners with health professionals and physicians. This recommendation is especially critical in mental health parity policies due to the fact that nurses are the frontline workers during patients’ hospital stay and the creation and implementation of care coordination plans. Thus, continuing education is important for nurses to acquire skills, knowledge, and abilities that will help them become more culturally competent and effective in driving policy change at organizational, state, and national levels.
Furthermore, participation in research to identify evidence-based practices (EBPs) in mental health care and translation of evidence to practice is crucial for nurses, according to IOM (Rekha, 2020). Translation of research into practice can, however, be effective if nurses have the power to practice to the full extent of their training and education, in addition to being treated as equal partners with physicians and other healthcare professionals. Failure to treat nurses as equal partners in the healthcare sector limits their ability to effect change within their organization and communities is limited. This can have negative effects on patient health outcomes since nurses are better positioned to identify challenges faced by the profession and patients during mental healthcare service delivery. Therefore, policy changes must be implemented to empower nurses as medical experts and community leaders in identifying social determinants of health and devising solutions to existing challenges to accessing quality care services.
Government Policy Response
The United States government, through MHPAEA and ACA, has implemented measures to improve parity in mental healthcare. Some of the aforementioned policy responses by the government include prohibiting limitations on benefits in mental health insurance under MHPAEA. Furthermore, the government has also expanded group health plans to include mental health and substance use disorder benefits on par with medical/surgical benefits (Chapman et al., 2018). On the other hand, by prohibiting exclusion from insurance due to preexisting conditions, the ACA expanded insurance coverage to more Americans with mental health illnesses. In cases where such individuals would have been denied care or restrictive terms imposed on them by insurers, the ACA guarantees that such barriers are eliminated. Finally, the expansion of Medicaid to cover insurance costs for low-income earners between 19 and 64 years as part of the ACA is a crucial component towards promoting equitable access to specialty care for all Americans. In a nutshell, both MHPAEA and ACA have played a significant role in promoting access to care without a significant rise in the cost of care for patients with mental health illnesses.
Conclusion
Mental health illnesses are some of the most common health conditions in the United States, with 50 percent of Americans expected to develop a mental health illness in their lifetime. Furthermore, at least 11 percent of American citizens with mental health illnesses are not insured. Some of the reasons for lack of insurance are related to social determinants of health like economic status, social status, and access to care. To alleviate the negative effects of restrictive policies by insurance towards people seeking mental health insurance coverage, the government has implemented parity laws such as the ACA and MHPAEA. The objective of federal health parity law is to promote access to specialty services without significantly increasing the cost of care for patient populations.
Nevertheless, mental health parity can be improved through the integration of mental health care into primary health care, where general hospitals are required to cater to patients with mental health illnesses. This would eliminate barriers to access to care services while controlling for the cost of insurance. Finally, it is important to incorporate cultural and traditional practices in providing mental healthcare services through community engagement. Nurses working with mentally ill patients can achieve this outcome if the recommendations of the IOM are implemented and nurses are allowed the opportunity to practice to the full extent of their education and training.
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