Despite ongoing efforts to achieve parity in health care, Americans still face significant financial and accessibility challenges when seeking behavioral health services. A recent study from Ohio State University, published in JAMA Network Open, reveals that individuals requiring behavioral health treatment are more likely to go out of network and pay higher out-of-pocket costs compared to those seeking care for chronic physical conditions such as diabetes and congestive heart failure.
These findings shed light on the persistent roadblocks many Americans encounter in accessing behavioral health services, as well as the difficulties providers face in offering them. Although legislative strides have been made to bridge the gap between behavioral and physical health care, disparities continue to exist, highlighting systemic issues that need urgent attention.
A Deep Dive Into the Research
The Ohio State University researchers conducted a comprehensive analysis using claims data from approximately 3.2 million people with mental health conditions, over 321,000 individuals with drug use disorders, and more than 294,000 individuals with alcohol use disorders. These claims were then compared to data from patients with diabetes and congestive heart failure—chronic conditions that are typically well-supported within insurance networks.
The study revealed that people suffering from substance use disorders and mental health conditions frequently had to seek care from out-of-network providers, resulting in significantly higher personal expenses. This disparity suggests that behavioral health services are not as readily available within insurance networks as other medical services.
The Cost Disparity: Behavioral Health Patients Pay More
The research highlights that individuals with behavioral health conditions consistently paid more for out-of-network care than those with chronic physical conditions:
- Patients with drug use disorders and alcohol use disorders paid an average of $1,242 and $1,138 more per year, respectively, for out-of-network care compared to those with diabetes.
- Individuals with mental health conditions spent, on average, $341 more annually on cost-sharing payments for out-of-network care than those with diabetes.
According to the study’s lead author, Wendy Yi Xu, these numbers indicate that patients with diabetes and heart failure generally had better access to in-network providers, reducing their need to seek costly alternatives.
“We saw that people with heart failure and diabetes didn’t go out of network as often and didn’t pay nearly as much for their care, probably because they were able to find care within the network,” Xu told Ohio State News.
Limited Provider Participation and Low Reimbursement Rates
One of the major contributing factors to this disparity is the limited participation of behavioral health providers in insurance networks. Many mental health professionals opt to remain out-of-network due to inadequate reimbursement rates from insurers. This limits the pool of available providers and forces patients to either pay high out-of-pocket costs or forgo treatment altogether.
“Much of this disparity is likely due to the limited availability of behavioral health care providers in insurance plans,” Xu explained. “The participation rates by these providers are generally low, a problem that is fueled in large part by low reimbursement rates for clinicians, including psychiatrists.”
Low reimbursement rates not only discourage providers from joining insurance networks but also contribute to the ongoing behavioral health workforce shortage. Without competitive compensation, fewer professionals enter the field, exacerbating the already limited supply of mental health specialists.
The Impact of Parity Laws and Where They Fall Short
The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 was designed to prevent insurance companies from imposing stricter limitations on mental health and substance use disorder treatments than those placed on medical and surgical care. However, as this study demonstrates, parity in theory does not always translate into parity in practice.
While the law mandates that mental health benefits be comparable to physical health benefits, it does not address the underlying issue of network adequacy. If insurance plans do not have enough in-network behavioral health providers, patients have no choice but to seek out-of-network services, leading to higher costs and limited treatment options.
The Nationwide Shortage of Behavioral Health Providers
The issue of network adequacy is further compounded by the nationwide shortage of behavioral health workers. Even if insurance companies were to offer better reimbursement rates, the shortage of qualified professionals presents a significant obstacle to increasing access to care.
According to the Health Resources and Services Administration (HRSA), as of 2023, over 150 million Americans live in designated Mental Health Professional Shortage Areas (HPSAs). This shortage disproportionately affects rural communities, where mental health care providers are scarce, and access to in-network services is even more limited.
The Burden on Patients and the System
The financial burden placed on patients seeking behavioral health treatment has broader implications beyond individual hardships. When mental health and substance use disorders go untreated due to financial barriers, the overall health care system suffers. Untreated behavioral health conditions often lead to increased emergency room visits, hospitalizations, and even incarceration, all of which contribute to higher costs for insurers, taxpayers, and society as a whole.
Furthermore, the inability to access timely and affordable behavioral health care can lead to worsening mental health conditions, lost productivity, and reduced quality of life for millions of Americans.
Moving Toward a Solution
To address these challenges, policymakers, insurance providers, and behavioral health advocates must work together to:
- Increase Provider Reimbursement Rates: Insurance companies must offer competitive reimbursement rates to attract more mental health providers into their networks. This could help increase the number of in-network providers, ultimately reducing out-of-pocket costs for patients.
- Expand Behavioral Health Workforce Development: Efforts must be made to recruit and train more behavioral health professionals, particularly in underserved areas. Loan forgiveness programs, grants, and incentives for providers willing to practice in shortage areas could help bridge the gap.
- Strengthen Enforcement of Parity Laws: While MHPAEA was a step in the right direction, more stringent oversight is needed to ensure compliance. Federal and state agencies must enforce network adequacy requirements to prevent insurers from limiting access to behavioral health services.
- Increase Telehealth Utilization: Telehealth services have emerged as a viable solution to improve access to behavioral health care, particularly in rural and underserved communities. Expanding insurance coverage for telehealth visits and incentivizing providers to offer virtual care could improve accessibility.
- Promote Public Awareness and Advocacy: Patients and providers must be empowered to advocate for better mental health coverage. Raising awareness about the importance of mental health parity and pushing for legislative changes can drive systemic improvements.
Final Thoughts
While progress has been made in addressing mental health parity, this study underscores the ongoing financial and accessibility disparities between behavioral and physical health care. Americans with mental health and substance use disorders continue to face higher out-of-pocket costs and more frequent encounters with out-of-network providers, making essential treatment less accessible.
To truly achieve parity, systemic changes must be made to improve insurance network adequacy, increase provider participation, and ensure fair reimbursement for behavioral health services. Without these reforms, millions of Americans will continue to struggle to afford the mental health care they need—perpetuating a cycle of unmet needs, poor outcomes, and financial hardship.
By prioritizing mental health as much as physical health, we can take a significant step toward a more equitable and effective health care system for all.
