Despite a decade of laws aimed at ensuring equitable access to behavioral health services, the United States Government Accountability Office (GAO) has found that federal agencies may not be doing enough to ensure that behavioral health parity is being enforced across employer-sponsored health plans. The GAO’s recent report reveals troubling gaps in oversight and enforcement, underscoring a continuing struggle to guarantee that mental health and substance use disorder services are treated on equal footing with other medical and surgical services. As a result, advocates are calling for stronger oversight of employer-sponsored group plans to ensure compliance and address disparities in care.
The GAO Report: Uncovering the Gaps in Federal Oversight
The report, which reviewed policies, guidance, and reports from the Department of Labor (DOL) and the Department of Health and Human Services (HHS) — the two primary federal agencies responsible for overseeing parity compliance in group and individual health plans — found that most federal reviews and investigations into parity compliance are reactive rather than proactive. In fact, the vast majority of these reviews are initiated only after a consumer complaint has been filed. This lack of proactive oversight has raised alarms, particularly for behavioral health advocates who argue that the current system is insufficient in ensuring that insurance plans comply with the law.
The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires that insurance coverage for mental health and substance use disorders be no more restrictive than the coverage for medical and surgical services. Despite this, the report found that federal agencies had not evaluated the effectiveness of their current practices in ensuring compliance with parity standards for employer-sponsored group plans. This failure to assess the success of enforcement efforts is particularly troubling given the continuing complaints and disparities in coverage.
As the report highlights, these gaps in oversight are not just a matter of bureaucracy — they have real-world consequences for millions of Americans. The disparity between behavioral health and physical health services is not a thing of the past. In fact, a recent study revealed that behavioral health services are still far more likely to be out of network, and often face lower reimbursement rates than their physical health counterparts. And, as this gap widens, individuals with mental health or substance use disorders continue to face significant barriers to accessing care.
Shawn Coughlin, executive vice president for government relations and public policy at the National Association of Behavioral Health (NABH), expressed frustration with the findings of the GAO report. NABH, a nonprofit trade organization representing behavioral health and substance abuse providers, has long advocated for better enforcement of parity compliance.
“For years, NABH has heard from our members — who receive complaints from patients and withstand parity violations every day — that the current compliance process is woefully inadequate to determine whether health plans are following the law,” Coughlin said in a press release. “This is unacceptable.”
Coughlin’s statement underscores a critical issue: the current system is not effectively addressing the widespread violations of the law. As the report points out, in fiscal years 2017 and 2018, the DOL completed only 302 reviews of behavioral health parity compliance out of a total of 2.2 million plans. Of those reviews, nearly all were initiated in response to consumer complaints or other information about potential noncompliance unrelated to behavioral health parity. This reactive approach is simply not enough to address the ongoing disparities in access to behavioral health care.
The Need for Proactive Oversight
The GAO’s findings make it clear that federal agencies need to adopt a more proactive approach to ensuring parity compliance. In its report, the GAO recommended that both DOL and HHS evaluate their oversight practices to determine whether they are truly effective or if a different approach is needed. The report also suggested that the agencies examine how they can better identify potential violations of the MHPAEA before they become widespread issues.
For advocates like Coughlin and the NABH, these recommendations offer hope that changes are on the horizon. “We’re encouraged that GAO has recognized these gaps and made recommendations to DOL and HHS to evaluate their oversight practices,” Coughlin said. “However, it’s crucial that these recommendations lead to tangible changes and a stronger commitment to enforcing parity compliance.”
The need for proactive oversight is not just a theoretical concern — it has tangible, real-world implications for individuals seeking behavioral health services. Research consistently shows that people with mental health and substance use disorders face significant barriers to care, particularly when it comes to insurance coverage. These barriers include high out-of-pocket costs, limited network access, and, in many cases, outright denial of coverage for necessary services.
When behavioral health services are more difficult to access than medical and surgical services, the consequences can be dire. For individuals struggling with mental health or substance use issues, delays in treatment can exacerbate conditions, increase the risk of crisis situations, and, in some cases, lead to loss of life. Ensuring that behavioral health services are subject to the same coverage requirements as physical health services is crucial to improving outcomes and ensuring equitable care for all Americans.
Behavioral Health Disparities Persist
The GAO report’s findings align with long-standing concerns raised by behavioral health advocates. Despite the passage of the MHPAEA, which mandates that insurance coverage for mental health and substance use disorders be comparable to that for medical and surgical services, compliance has been a persistent issue. Many individuals with behavioral health needs still face significant disparities in their coverage, including higher out-of-pocket costs, limited provider networks, and restrictions on the types of services covered.
One major issue is the continued practice of “parity violations,” where insurance plans impose more restrictive limits on mental health and substance use disorder services than on medical or surgical services. For example, insurance plans may impose stricter limits on the number of therapy sessions allowed, or they may refuse to cover certain types of behavioral health care altogether, even though these services are necessary for treatment. These types of violations undermine the intent of the MHPAEA and leave many individuals without access to the care they need.
The findings in the GAO report come at a time when behavioral health care is more critical than ever. The COVID-19 pandemic has exacerbated mental health and substance use challenges for millions of Americans, leading to increased demand for services. At the same time, the workforce shortages in behavioral health care continue to strain the system, making it even harder for individuals to access care in a timely manner.
A Call for Stronger Enforcement and Accountability
The GAO report has provided a stark reminder of the need for stronger enforcement of parity laws. While federal agencies have made some progress in overseeing behavioral health parity compliance, much more needs to be done to ensure that all health plans are following the law. Advocates, such as the NABH, are calling for stronger accountability and enforcement to guarantee that individuals seeking behavioral health care are not subject to discrimination or barriers to access.
The recommendation for a more proactive and comprehensive approach to oversight is a step in the right direction. However, it will require sustained effort and commitment from both DOL and HHS to ensure that parity compliance is not merely an afterthought. The GAO’s report serves as a critical reminder that, while progress has been made, there is still much work to be done to ensure that all Americans have equal access to the mental health and substance use disorder care they need.
Ultimately, the goal is clear: to create a healthcare system where mental health and substance use disorders are treated with the same urgency and care as any other medical condition. Ensuring that behavioral health parity is enforced across all health plans is a critical step toward achieving this goal.
