Providers, patient advocates and key lawmakers are taking aim at health insurers as Congress drafts legislation to tackle the behavioral health crisis, arguing that low reimbursement rates and restrictions on coverage are limiting access to care.

Members of Congress are looking to toughen enforcement of mental health parity laws and address a reimbursement paradigm that providers say undervalues ??behavioral healthcare.

Data show Americans experience higher rates of depression, anxiety and suicidal ideation during the COVID-19 pandemic. Substance misuse and overdoses are also increasing. And more than one-third of US residents live in areas without enough psychiatrists, federal data show.

But 14 years after Congress passed the latest law mandating most insurers to cover behavioral health on par with medical and surgical care, millions still struggle to find treatment they can afford.

“Parity law is not the reality for many people with mental illness,” said Jennifer Snow, national director of government relations and policy at the National Alliance on Mental Illness. “There might be laws on the books, but health insurers are really falling short on providing equitable coverage.”

Health insurance companies and providers agree on one key problem: Increasingly fewer behavioral health professionals accept private or public insurance, so their patients must pay out of pocket. Providers cite low rates while insurers blame workforce shortages and increasing demand.

Payments and administrative burdens are driving mental health providers away from private insurance and government programs, said Stephen Gillaspy, senior director of health and healthcare financing for the American Psychological Association.

“More and more providers will say ‘I’m not going to be on panels for Medicare or Medicaid,’ or ‘I’m just going to go to cash-only,'” he said. “Then, the only people that can access mental and behavioral health services are those folks that have the income for it, so it’s a huge health equity issue.”

Between 2013 to 2017, patients were 5.7 times more likely to go out of network for outpatient behavioral healthcare than for outpatient medical or surgical services, according to a Milliman Research Report released in 2019. Patients seeking outpatient treatment for substance use disorder were 8.5 times more likely to use an out-of-network provider. This means higher costs for patients, and even more so for those with insurance that doesn’t include out-of- network benefits.

Dozens of trade groups, health systems, providers and patient advocates wrote the Senate Finance Committee asking for better access to mental health. Many recommend payment parity or at least higher rates.

Primary care reimbursements were 24% higher than behavioral health payments in 2017, according to a 2019 Milliman Research Report that analyzed preferred provider organization claims.

“I need to make sure that all of my psychiatrists come back into the system if they’ve opted out of it, and ensuring parity of payment is really important to that,” said Dr. Saul Levin, CEO and medical director of the American Psychiatric Association.

Insurers counter that providers have the market leverage and that Congress should avoid doing anything to tip the scales further. “There are some good ways to get more providers into our networks but you don’t do it by giving providers all the power,” said James Gelfand, executive vice president of public affairs for the ERISA Industry Committee, which represents large employers with self-funded health benefit plans.

“It’s about more than money. It’s about willingness to participate,” Gelfand said. Behavioral health providers themselves are choosing to not be in-network and to only take cash, he said. Instead of requiring payers to boost reimbursements, Congress should promote telehealth and build up the behavioral health workforce, he said.

Higher payments not only would encourage more behavioral health providers to accept insurance but would entice more students to enter the field, provider groups say.

“The core of those problems is we’re under-reimbursed and behavioral health cannot meet our costs,” said Dr. Sabina Lim, system vice president of health safety and quality for New York-based Mount Sinai Health System. “One of the best ways to actually demonstrate that we’re going to treat mental health in the same way as physical health is that we have to pay for it in the same way,” she said.

In 2019, about a quarter of adults with mental illness reported that they were unable to receive needed treatment, a share that has persisted since 2011, a according to Mental Health America report.

Data about 2020 and 2021 aren’t yet fully available but experts expect that higher demand led to more difficulties accessing care. A Census Bureau survey found that almost one-third of adults reported symptoms of anxiety or depressive disorders this January and February.

Key lawmakers such as Finance Committee Chair Ron Wyden (D-Ore.) have indicated that payment reform will be part of the pending legislation, which could be introduced this summer and possibly passed later in the year.

Sen. Michael Bennet (D-Colo.), the committee’s lead on parity, described behavioral health payments as “pitiful” and said reform should be a “cornerstone” of the legislation. Congress could boost Medicare rates and hope that spurs private health insures to follow suit, as they often do when the program raises or lowers payments.

Sen. Tina Smith (D-Minn.) has proposed hiking Medicaid reimbursements for these providers, as well. In 2019, only 35% of psychiatrists said they would accept new Medicaid patients compared to 71% of physicians overall, according to a study by the Robert Wood Johnson Foundation’s State Health Access Data Assistance Center.

Lawmakers are also looking at giving the Labor Department the power to issue civil monetary penalties against health plans that violate parity laws and to offer state insurance regulators grants to strengthen oversight. In a recent report to Congress, the department explained its ability to ensure compliance is limited without the authority to levy penalties.

The Mental Health Parity and Addiction Equity Act of 2008 doesn’t specify that behavioral health services must be reimbursed at the same rates as medical and surgical care. Payment disparities are only prohibited if the factors used to set rates are not comparable across services.

Providers also contend insurers are imposing tighter restrictions on behavioral healthcare, such as prior authorization requirements, that aren’t being applied as strictly to medical or surgical services, which would be a violation of parity laws.

In August, UnitedHealthcare settled with the Labor Department in in a lawsuit alleging the insurer unlawfully cut reimbursements for out-of-network mental health providers and flagged patients using mental health services for utilization reviews.