(GA Recorder) — A little-known federal law passed when President George W. Bush occupied the White House requires insurers to give behavioral health care equal footing with medical benefits.

That means, if a person’s co-pay is $10 to have chest pains checked out by a medical doctor, then an insurer that offers mental health coverage cannot charge a higher co-pay for the same person to see a behavioral health specialist about anxiety or depression. The law applies to both mental health and substance use disorder treatment.

But advocates question whether that nearly 14-year-old federal law – the enforcement of which is partly left to the states – is being enforced in Georgia. A coalition of advocacy groups has pegged ramping up enforcement of the law in Georgia as its top priority this year.

“We have no idea if the state is following federal law,” Abdul Henderson, executive director of Mental Health America of Georgia, recently told a group of lawmakers. “Georgia has not done anything to determine if group health plans and insurers in the state are following the law. I have a saying regarding parity, and it goes, ‘In states where there is no enforcement, you will find non-compliance.’

“In Georgia, we are nowhere near knowing how bad the situation really is,” Henderson added.

Lawmakers appear interested in finding out, though. A yet-to-be-unveiled behavioral health proposal – including both legislative and funding measures – is expected to focus at least partly on parity. Other states, like Texas, have also ramped up enforcement of the federal parity law in recent years.

There is bipartisan and high-placed support building for the proposal – parity, in particular – and it happens as Georgia ranks near the bottom when it comes to access to mental health treatment.

“This is something we’re going to need to talk about. This is going to be a hollow effort if we don’t cover this issue right at the outset.”

– Speaker David Ralston said of parity

But that momentum going into the session doesn’t guarantee anything. Former U.S. Sen. David Perdue’s decision to challenge Gov. Brian Kemp in the GOP primary has created an uncertain political climate going into the session, and then there’s the insurance industry.

“Mental Health Parity has been the law of the land since 2008, and insurers are working every day to make sure our plan members have access to both behavioral and physical health services that meet their needs and which are affordable,” Jesse Weathington, president and CEO of Georgia Association of Health Plans, which represents health insurers at the state Capitol, said in a statement.

“The reality is Georgia has historically underinvested in mental health delivery and there is a severe provider shortage, which the pandemic has only worsened. That can’t be solved overnight by duplicative regulations targeting payors or without increasing the number of providers.”

Lawmakers added funding for mental health services in the 2021 session, but about $32 million of the cuts made early in the pandemic remain. The state’s behavioral health system has reported feeling strained during the pandemic, but its leaders submitted a flat budget at the governor’s request. Kemp is set to unveil his proposed spending plan this month.

‘A real linchpin’

A special commission formed in pre-pandemic times to review the state’s behavioral health system called parity in insurance coverage “central to all the issues being considered by the commission” in a report issued early last year.

A Carter Center report called parity “fundamental to the ability to access behavioral health treatment.” The report also found that greater enforcement would benefit taxpayers, with insurers paying for more treatment people are entitled to and potentially fewer people turning to costlier state services like hospitalization and crisis services down the road.

House Speaker David Ralston is a major driving force behind the bipartisan push to address mental health shortages in Georgia. Ross Williams/Georgia Recorder (2021 file photo)
House Speaker David Ralston, a Blue Ridge Republican, called parity “a real linchpin, as it were, for the rest of our agenda.”

“This is something we’re going to need to talk about,” Ralston said in a December interview. “This is going to be a hollow effort if we don’t cover this issue right at the outset.”

Proponents argue that enforcing parity requirements could vastly improve access to mental health and substance use disorder treatment across the state, as well as increase the likelihood of people receiving the care they need ahead of a crisis.

“This is one of those fundamental issues that underlies so many of the other challenges that we face,” said Helen Robinson, associate director of public policy with The Carter Center’s mental health program.

For example, enforcing parity could help plug the behavioral health workforce shortages in rural communities, Robinson said. If providers could count on adequate and fair reimbursement, there would be more of them – and more of them who accept insurance, she said.

“This impacts everyone and impacts people with public and private insurance, and it impacts people at all parts of the state, all demographics. So, it is truly one of those issues that the state could have great impact on Georgia families by prioritizing parity,” Robinson said.

Georgia residents can report suspected violations to the state today, but few have. That may say little about how widespread the problem is, though.

In 2017, Georgians were 4.2 times as likely to have to go out of network for an office visit for behavioral health services when compared to primary care, according to a Milliman report.

“I do think that a lot of people don’t know that there’s a federal law that entitles them to this type of coverage,” said Jeff Breedlove, chief of communications and policy at the Georgia Council on Substance Abuse.

“And I blame the insurance companies because they waste no amount of money on advertisements for things they want you to know about,” he said.

Consumers who are aware but are experiencing a behavioral health crisis also may not have the time, energy or resources to challenge a denial. They may give up rather than press their insurer or file a complaint, Robinson said.

“We really can’t leave it to the individual, the parent or the consumer to have to fight the insurance company,” Robinson said. “I would like people to know their rights, but I also would like the state to step in and to regulate and enforce parity on behalf of families.”

‘Good people policies’

The state Office of Insurance and Safety Fire Commissioner, which regulates health insurers in Georgia, pointed to the U.S. Centers for Medicare and Medicaid Services when asked why the state had not been enforcing the law.

“To answer your question, CMS is the federal agency with first authority for enforcing federal parity laws,” agency spokesman, Weston Burleson, said in a statement. “That being said, we are empowered to conduct investigations into Georgia-based insurers for violations of relevant law where evidence warrants it, but as of yet, we have only received five complaints since January 1, 2017.

“We are aware of legislation being introduced on this topic this upcoming session and have met with various stakeholders to provide our feedback. We look forward to working with all involved to ensure every Georgian has access to the care they need,” he said.

Burleson said Commissioner John King was unavailable for an interview. King, a Republican, was only recently elevated from the interim commissioner status he’s held for more than a year as an appointee of the governor. His elected predecessor, Jim Beck, reported to federal prison in Alabama last month to serve time for stealing from a former employer. King is running for a full term this year.

But King told a group of lawmakers in November – including his Democratic opponent next year, state Rep. Matthew Wilson, who raised the issue at the meeting – that he sees the need to address parity.

“I want to come up with a good, thoughtful and sustainable solution but working with, obviously, the industry,” King said at the time.

Burleson told lawmakers the agency was looking into requesting additional information from insurance companies on mental health using “existing authority.” He said there was also an effort to fund a data analyst position within the agency.

Wilson argues the agency could be doing more, saying the 2008 federal law has given King and commissioners before him broad powers to enforce parity.

“I think for too long we’ve had state leaders who haven’t viewed good people policies as being good for business,” the Brookhaven Democrat said.

Over at the state Department of Community Health, which oversees Medicaid, an agency spokeswoman said the agency is working with CMS to implement recommendations from the reform-minded behavioral health commission.

A bipartisan spark in hyper-partisan times

Advocates and some lawmakers have declared this year “the year for mental health.” And Ralston said he’s optimistic the bipartisan spark behind the issue will withstand any election-year shenanigans.

The speaker said the commission will release new legislative and funding proposals soon. He said he’s interested in changes that will bolster the workforce, make sure school systems have mental health professionals on campus and ensure law enforcement officers are trained to identify mental health issues.

“I think mental health is not a party issue. It’s a Georgians issue,” Ralston said in December. “I think it would be just a tragedy if we were to allow that issue to be sidetracked by the political gamesmanship. I know that’s going to be out there on other issues, but you know, mental health is too important, and so I don’t really think it will become a casualty of election-year politics.”

Breedlove with the Georgia Council on Substance Abuse isn’t worried so much about party politics.

“We have people in the Gold Dome that say, ‘I’m a conservative Republican,’ or ‘I’m a progressive Democrat,’” Breedlove said. “What I would say to them when the insurance lobby pushes back on this is the following: Conservatives that say they’re pro-family, this a pro-family issue. And progressives who say they’re pro-people, and therefore equity and inclusion, well, this has that issue too.

“The issue of parity means equality, it means fairness, it means that there won’t be discrimination, and logically, when it’s not being enforced in our state, that means there is,” he said.