Members of the U.S. Senate Finance Committee recently sent a clear message to health insurers: the time for excuses is over when it comes to parity law enforcement under the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. The law, now 13 years old, was designed to ensure that mental health and substance use disorder treatment coverage is no less favorable than coverage for physical health conditions. However, enforcement has been lax, and many patients still face significant barriers accessing mental health care.
During a Wednesday hearing, Committee Chairman Sen. Ron Wyden (D-Ore.) expressed deep frustration at the insurance industry’s ongoing failure to comply fully with the law’s provisions. Wyden recounted a conversation with an insurance executive who suggested insurers simply needed more time to understand MHPAEA. “Well, my message to them is time has run out,” Wyden declared. “We’ve heard from senators on both sides of the aisle — there’s a commitment to getting this fixed.” This renewed push for parity law enforcement reflects growing bipartisan consensus to hold insurers accountable.
Wyden’s motivation is deeply personal. He often cites his late brother Jeffrey, who lived with schizophrenia for decades before passing away in 2002. When the MHPAEA became law, Wyden believed it would be transformative. “I said this is for Jeff. This is one that’s gonna really liberate a lot of people,” he recalled. Yet, more than a decade later, many of the same access problems persist, highlighting the gap between legislation and real-world outcomes and the critical need for stronger parity law enforcement.
Legislative and Budgetary Actions Signal Renewed Focus on Parity Enforcement
The hearing adds momentum to ongoing legislative efforts that aim to improve mental health care in the U.S. A comprehensive legislative package addressing mental health, expected this summer, will likely include a strong emphasis on parity law enforcement. President Joe Biden’s recent State of the Union address reaffirmed this priority, calling for full parity between physical and mental health care as a key component of his “Unity Agenda.”
Biden’s proposed budget for the 2023 fiscal year — which begins October 1 — includes significant funding to bolster the Department of Labor’s capacity to investigate violations of MHPAEA. It also proposes extending parity law enforcement provisions more rigorously to Medicare, along with efforts to modernize mental health benefits for seniors. Sen. Catherine Cortez Masto (D-Nev.) highlighted the importance of this move, noting that Medicare coverage issues mirror those faced by families on private insurance.
“If you believe the old adage that as goes Medicare so goes the market, then the mental health coverage gaps in Medicare have consequences for private coverage too,” Cortez Masto said. This statement underscores how reforms in Medicare and stronger parity law enforcement can have ripple effects across the broader insurance landscape, potentially improving access and equity for millions of Americans.
Spotlight on Insurance Industry Practices: NQTLs and Ghost Networks
One of the core concerns discussed at the hearing was the use of non-quantitative treatment limitations (NQTLs) by insurers to limit mental health benefits. Unlike explicit dollar limits or visit caps, NQTLs are more subtle restrictions—such as prior authorization requirements, medical necessity reviews, or narrow provider networks—that disproportionately affect access to behavioral health services and undermine parity law enforcement efforts.
Sen. Elizabeth Warren (D-Mass.) pressed witnesses on how these NQTLs violate parity rules by creating unnecessary hurdles for patients seeking mental health care. “These limitations appear to be targeting behavioral health care more than other health benefits,” she said.
Andy Keller, president and CEO of the Meadows Mental Health Policy Institute, testified that NQTLs are a significant reason many mental health providers choose not to accept insurance at all, instead requiring cash payments from patients. This practice exacerbates access issues, especially for low- and moderate-income individuals, and reflects failures in effective parity law enforcement.
The committee also condemned “ghost networks,” a term used to describe provider directories that list clinicians as in-network but offer little to no real access. Patients often discover that listed providers are no longer accepting new patients, have extensive wait times, or do not offer the needed specialty services. This practice undermines the intent of parity laws and leaves insured individuals without meaningful options, further highlighting the need for rigorous parity law enforcement.
John Dicken, director of health care at the Government Accountability Office (GAO), shared findings from a recent GAO report that reinforced these access problems. Dicken noted that even insured consumers struggle to connect with behavioral health providers due to inadequate or misleading health plan networks.
“Challenges like these could cause consumers to face higher health care costs, delays in receiving care, or difficulties in finding a provider close to home,” Dicken said. He further explained that mental health services often require more restrictive approval processes than physical health care, creating unnecessary barriers to timely treatment — problems that stronger parity law enforcement seeks to address.
Integrated Care: A Complementary Approach to Improving Access and Outcomes
While enforcing parity laws is critical, committee members and witnesses emphasized that true progress requires a simultaneous push toward integrated behavioral health care. Integrated care models embed mental health services within primary care settings, improving coordination and reducing stigma.
Andy Keller called for Congress to launch an emergency initiative to expand integrated care across the country. “The most important thing Congress can do to improve behavioral health access is to invest in integrated care,” he said.
Dr. Anna Ratzliff, co-director of the Advancing Integrated Mental Health Solutions Center (AIM Center) at the University of Washington, urged the committee to consider funding for collaborative care models. She also recommended eliminating Medicare cost-sharing for integrated services and increasing reimbursement rates to better reflect their value.
Ratzliff described the collaborative care model as a proven approach that connects primary care providers with behavioral health specialists, enabling better patient monitoring and timely interventions. Importantly, studies have shown this model to be cost-effective. “For every dollar spent on collaborative care, about $6.50 is saved in total health care costs over subsequent years,” she said.
The Road Ahead: Bipartisan Efforts to Transform Behavioral Health Care
The Senate Finance Committee’s renewed focus on parity law enforcement and integrated care models reflects a broader commitment to reform the nation’s mental health system. Bipartisan support for these measures signals hope that the long-standing promises of parity and improved access can finally be fulfilled.
However, the path forward requires not only stronger enforcement but also greater transparency from insurers, expanded provider networks, and federal investment in innovative care models. Addressing these challenges holistically could ease the burdens faced by millions of Americans seeking mental health care and reduce the societal costs of untreated mental illness and substance use disorders.
As Congress moves toward unveiling a major mental health legislative package, the lessons from this hearing highlight the critical need for action — and the urgency to translate laws on paper into meaningful care for those who need it most. With continued pressure on insurers and increased federal funding, the vision of true mental health parity may finally become a reality through effective parity law enforcement.
