At Wit’s End: The Monkey Wrench in Mental Health Parity

“We want to see people get well,” declares Maureen Maguire, J.D., associate director of the American Psychiatric Association. She is pushing back against something that bedevils the crusade for full “parity” between mental and physical health services: the perception that some kinds of mental healthcare can go on for decades. Of course, the awkward truth is that they can.

A 1997 National Institutes of Health issue brief about “unresolved issues” regarding parity put the issue bluntly: “Especially troublesome to some employers,” it said, “is the possibility that parity legislation — insofar as it reduces financial barriers to treatment — may induce a large number of the ‘worried well’ to seek mental health services covered through their health insurance benefits. This group can be defined as those with relatively mild (if any) mental illness who simply do not have the urgency or severity of need exhibited by the seriously mentally ill.” The brief went on to cite filmmaker and actor Woody Allen and his many years in psychoanalysis.

There are two background issues here. One is the archaic but persistent view that there is something shameful about mental illness. Another is medicine’s relatively new emphasis not simply on battling disease but on ensuring optimal quality of life in the process. They intersect. Arguably, the image of Woody eternally on the couch,with an analyst’s bills that few of us could afford (even before the more controversial status he has acquired since 1997), is not the best antidote to the stubborn stigma. But it is now medicine’s charge not simply to extend our lives but to make them better. In that context, is there a gray area between “sick” and “well” in which psychotherapy helps essentially functional people function better? And if there is, must it be fully medicalized — and must we all pay for it with our premiums?

From 2015 to 2018, says the Centers for Disease Control and Prevention, 13.2% of American adults used prescribed antidepressant medications. Would they all be on society’s sick list without them? What about the fellow who regularly screws up at work because of an unresolved animus toward authority figures? People who keep gaining weight because food is some kind of substitute for love? The couple staying in a fundamentally dead marriage because life has taught them to fear taking risks? Or is it more accurate to say that with professional help such individuals can progress on a continuum toward deeper insight, better choices and richer fulfillment in life — with an indeterminate finish line?

Maybe once in a while we could all use a therapy session or two with a mental health professional, says Lynn Bufka, Ph.D., associate chief, practice transformation, of the American Psychological Association. While avowing that “therapy is not intended to be something you’re part of for the rest of your life,” she notes that many behavioral health issues come to light in visits to primary care doctors, who may not have the training, inclination or time to respond to them effectively. “There’s some powerful work demonstrating that a single session (with a mental health professional) can be very beneficial to individuals,” she says. “ ‘Tuneups’ around certain issues can really move people in the right
direction.”

For health plans, defining what treatments ought to be covered comes down to determinations of “medical necessity.” In the recent case of Wit v. United Behavioral Health, a managed care company was accused of using its own guidelines for what was needed instead of “professionally developed standards of care,” as Michelle L. Bedoya explains in a Health Affairs article published in May 2023. In 2019,a district court judge found for the plaintiffs because “in the name of cost saving, a major healthcare company ignored the legal standard of care in favor of arbitrary rules untethered to applicable professional norms undergirding plan coverage rules.”

Yet in 2022, a circuit court reversed the district court’s ruling, finding that the health plan’s interpretation of the rules was “not unreasonable.” Bedoya argues that the circuit court did not address the district court’s central analysis — the plaintiffs have filed a petition for rehearing — and she cites a report by the Departments of Labor, Treasury, and Health and Human Services contending that administration of the Mental Health Parity and Addiction Equity Act of 2008 gives health plans so much leeway in defining covered benefits that their “subjective determinations” result in “standards for parity that vary from plan to plan.”

Asked whether there is some portion of mental and emotional health treatment that ought to be considered elective self-improvement rather than strict medical necessity, Tim Clement, M.P.H., Maguire’s colleague at the American Psychiatric Association and the director of legislative development, acknowledges the possibility but quickly pivots.

"I don’t think we should trivialize any sort of mental healthcare. We don’t question people needing insulin on a regular basis. I caution against looking at mental healthcare and saying, ‘Because that’s been ongoing for a really long time, it’s not really medical care; it’s just something that someone’s doing for self-improvement.’ Although, on the other side of the coin, we certainly don’t want insurers to have to pay for treatments that aren’t helpful, that aren’t medically necessary, that aren’t useful.”