Separate but (Not) Equal

“She is still really sick; they can’t send her home…,” a desperate mom said to me by phone last week. Her daughter has anorexia nervosa. She has spent four days in inpatient treatment. Now her insurance company was ready to send her home. At 5’5″, this 17-year-old girl weighed 72 lbs and was still highly symptomatic. What if she had cancer?

The reality is that if the health problem you need to get covered by your insurance company is an eating disorder or anxiety disorder or any mental health problem, you’re likely to have more trouble than if it’s diabetes or skin rash or cancer – or virtually any other health problem.

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For too long, the strategy around health care coverage has been separate but equal. We know where that got us with education. It is the same for mental health.


Mental Health Parity: The Law. The Mental Health Parity Act of 1996 marks the beginning of the campaign for mental health parity in the US. Although this law stated that annual or lifetime dollar limits on mental health benefits be no lower than such limits for medical and surgical benefits, it had precious few teeth for enforcement. Thus, Paul Wellstone and Pete Domenici fought long and hard for the passage of the Mental Health Parity and Addiction Equity Act of 2008. Following years of advocacy, we might ironically note that this act made it into law by sneaking in as a rider on the coattails of the TARP bailout. No matter how it happened, the law states that insurance companies that offer mental health services could not provide different standards of coverage for mental illnesses compared to other health conditions – they couldn’t charge higher co-payments or set lower limits on services, and it requires insurance companies to provide specific details and reasons if they deny payment for treatment.


Mental Health Parity: The Loophole. The 2008 Act includes a great deal more coverage for mental health and holds companies more accountable, but it applies only to companies that offer mental health coverage as part of their plan. To circumvent this legislation, insurance companies segregated out mental health services as an optional rider so that they didn’t have to achieve parity with other health conditions.


Why is it so hard to deliver on parity? To be sure, it is difficult to articulate what is “equivalent” care and coverage when comparing anxiety disorders to asthma or bipolar disorder to leukemia. However, a standard is set for coverage of care for asthma and leukemia, and we need to establish equivalent standards for mental health conditions. People generally do recover from mental health conditions, and the earlier they get treatment the better. But the myth that people don’t get better and that mental health conditions will bankrupt the system result in gaps in service that guarantee that people with mental health conditions are in much worse shape before they get care, which also makes for poorer prognosis.


So it’s bad, but how bad is it? Individuals attempting to obtain mental health services are twice as likely to be denied coverage by a private insurer as compared to someone seeking medical or surgical care. A major part of the problem is that enforcement for mental health parity is spread across the Department of Health and Human Services, the Department of Labor, the Department of Treasury and state insurance commissioners – depending upon the type of health insurance plan – not exactly simple or efficient.


Common Struggle: One of the greatest hurdles to changing the situation is that no one really knows how difficult it is to get coverage for mental health needs until they or a family member covered by their insurance needs coverage – and then it’s too late. As individuals, we have had no way of knowing how big the problem is, and there has been no place to go to find out about other coverage denials… Until now.

Last week former Congressman Patrick Kennedy (D-RI) launched the online registry, You can register a complaint here, and your experience will be added to other complaints to provide a larger picture of how and where parity is failing. In the spirit of Margaret Mead, it is absolutely the case that together “thoughtful, committed citizens” can help change the world on mental health parity.

We have a long way to go to achieve mental health parity. Our 17-year-old with anorexia nervosa is home without care until her parents find care. Clearly, separate but equal did not work in education. It is also failing in healthcare. You can help change that at

Kathleen M. Pike, PhD

Kathleen M. Pike, PhD is Professor of Psychology and Director of the Global Mental Health WHO Collaborating Centre at Columbia University
[email protected]