PolicyLab

Did you know that only about 20% of children with mental, emotional or behavioral disorders receive care from a specialized mental health care provider? Untreated mental illness in children can lead to costly outcomes such as dropping out of school, substance use and suicide, but it can be challenging for some families to get the mental health care services they need.

In particular, inadequate insurance coverage for behavioral health services is a major barrier to patients accessing evidence-based behavioral health treatment. Children and their families across the nation are often pushed out of their health insurance network for behavioral health care, meaning they will pay more out of pocket for these services. Federal legislation has attempted to curb this practice, but substantial discrepancies in coverage of behavioral health versus physical health services persist.

How States Can Improve Families’ Access to Behavioral Health Care

States have the opportunity to address these gaps through comprehensive state behavioral health parity legislation (C-SBHPL). This type of legislation mandates that health insurance companies provide the same level of coverage for all behavioral and physical health benefits (e.g., copayments, visit limits) with no discrepancy. C-SBHPL also is recommended by the Community Preventive Services Task Force, a group established by the U.S. Department of Health and Human Services to identify evidence-based population health interventions.

C-SBHPL can require insurers to cover all conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, a resource health care professionals commonly use, as well as specific treatments. These requirements are significant because federal behavioral health parity laws do not specify this information and consequently, many insurers and managed care organizations (MCOs) don’t cover certain conditions (e.g., autism) and treatment (e.g., medication-assisted treatment for opioid use disorder). Research has shown that C-SBHPL strengthens a patients’ use of behavioral health treatments, and an economic review found that this type of legislation does not increase insurance premium costs.

Yet, despite the fact that C-SBHPL is an effective and cost-neutral policy, only 19 states have implemented it. To increase uptake of C-SBHPL, we must improve how evidence on its effectiveness is disseminated to state legislators—the decision-makers with the exclusive authority to adopt the policy. However, until now little guidance has existed to inform how researchers, advocates and others can disseminate evidence about C-SBHPL, or behavioral health policies more broadly, to this crucial audience.

Factors Influencing Legislators’ Support for C-SBHPL

Dr. Jonathan Purtle, an assistant professor at Drexel University Department of Health Management and Policy, and myself, recently published a study in Milbank Quarterly journal in which we explored how those who help support the health of children and families can effectively disseminate C-SBHPL evidence to legislators and how fixed legislator characteristics (e.g., ideology), changeable legislator characteristics (e.g., beliefs about policy impact) and state-level contextual factors might influence legislator support for the policy. Of the nearly 425 U.S. state legislators we surveyed, we found that about 39% strongly supported C-SBHPL. We also learned that beliefs that C-SBHPL increases access to behavioral health treatment and does not increase insurance premium costs were the strongest predictors of whether a lawmaker would support this legislation. Legislators whose survey responses indicated possible stigma toward mental illness were less likely to support C-SBHPL. We also found that state-level contextual factors, such as a recent mass shooting and a large increase in the opioid overdose death rate, were not significantly association with support for C-SBHPL, indicating that legislators’ individual beliefs may have more influence on C-SBHPL support than what is happening in their community.

Where Do We Go from Here?

In conducting this study, we were excited to have uncovered some very tangible findings that could support a movement to help improve families’ access to behavioral health services. We learned that the dissemination of evidence about C-SBHPL to state legislators should target changeable characteristics—including beliefs about policy impact, behavioral health treatment effectiveness and mental illness stigma—because these factors strongly predict their support for policy adoption. Furthermore, when advocating for C-SBHPL policies, advocates should emphasize evidence demonstrating that these laws increase access to behavioral health services and do not increase insurance premium costs. It is my and my colleagues’ hope that targeted dissemination of this evidence will support additional C-SBHPL laws, helping more children and families access behavioral health care to improve their overall health and well-being.

Xi Wang, PhD, is a former research scientist at PolicyLab.