[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





  AN EXAMINATION OF FEDERAL MENTAL HEALTH PARITY LAWS AND REGULATIONS

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 9, 2016

                               __________

                           Serial No. 114-167





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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Chairman Emeritus                    Ranking Member
JOHN SHIMKUS, Illinois               BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania        ANNA G. ESHOO, California
GREG WALDEN, Oregon                  ELIOT L. ENGEL, New York
TIM MURPHY, Pennsylvania             GENE GREEN, Texas
MICHAEL C. BURGESS, Texas            DIANA DeGETTE, Colorado
MARSHA BLACKBURN, Tennessee          LOIS CAPPS, California
  Vice Chairman                      MICHAEL F. DOYLE, Pennsylvania
STEVE SCALISE, Louisiana             JANICE D. SCHAKOWSKY, Illinois
ROBERT E. LATTA, Ohio                G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington   DORIS O. MATSUI, California
GREGG HARPER, Mississippi            KATHY CASTOR, Florida
LEONARD LANCE, New Jersey            JOHN P. SARBANES, Maryland
BRETT GUTHRIE, Kentucky              JERRY McNERNEY, California
PETE OLSON, Texas                    PETER WELCH, Vermont
DAVID B. McKINLEY, West Virginia     BEN RAY LUJAN, New Mexico
MIKE POMPEO, Kansas                  PAUL TONKO, New York
ADAM KINZINGER, Illinois             JOHN A. YARMUTH, Kentucky
H. MORGAN GRIFFITH, Virginia         YVETTE D. CLARKE, New York
GUS M. BILIRAKIS, Florida            DAVID LOEBSACK, Iowa
BILL JOHNSON, Ohio                   KURT SCHRADER, Oregon
BILLY LONG, Missouri                 JOSEPH P. KENNEDY, III, 
RENEE L. ELLMERS, North Carolina     Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California7
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota

                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
JOHN SHIMKUS, Illinois               ELIOT L. ENGEL, New York
TIM MURPHY, Pennsylvania             LOIS CAPPS, California
MICHAEL C. BURGESS, Texas            JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
LEONARD LANCE, New Jersey            JOHN P. SARBANES, Maryland
H. MORGAN GRIFFITH, Virginia         DORIS O. MATSUI, California
GUS M. BILIRAKIS, Florida            BEN RAY LUJAN, New Mexico
BILLY LONG, Missouri                 KURT SCHRADER, Oregon
RENEE L. ELLMERS, North Carolina     JOSEPH P. KENNEDY, III, 
LARRY BUCSHON, Indiana                   Massachusetts
SUSAN W. BROOKS, Indiana             TONY CARDENAS, California
CHRIS COLLINS, New York              FRANK PALLONE, Jr., New Jersey (ex 
JOE BARTON, Texas                        officio)
FRED UPTON, Michigan (ex officio)

                                  (ii)
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     2
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................     3
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     4
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     5
    Prepared statement...........................................     6
Hon. Ben Ray Lujan, a Representative in Congress from the State 
  of New Mexico, prepared statement..............................    57

                               Witnesses

Pamela Greenberg, MPP, President and CEO, Association for 
  Behavioral Health and Wellness.................................     8
    Prepared statement...........................................    11
Michael A. Trangle, M.D., Senior Medical Director, Behavioral 
  Health Division, HealthPartners Medical Group, Regions Hospital    20
    Prepared statement...........................................    23
Matt Selig, Executive Director, Health Law Advocates, Inc........    32
    Prepared statement...........................................    35

                           Submitted Material

Letter of August 31, 2016, from Carmella Bocchino, Executive Vice 
  President, et al., America's Health Insurance Plans, to Cecilia 
  Munoz, Chair, White House Mental Health and Substance Use 
  Disorder Parity Task Force, submitted by Mr. Pitts.............    59
Letter of September 7, 2016, from Katrina Velasquez, Policy 
  Director, Eating Disorders Coalition, to committee and 
  subcommittee leadership, submitted by Mr. Pitts................    73
Letter of September 8, 2016, from the American Association on 
  Health and Disability, et al., to Members of Congress, 
  submitted by Mr. Pitts.........................................    77
Statement of Patrick J. Kennedy, II, a Former Representative in 
  Congress from the State of Rhode Island, submitted by Hon. 
  Joseph P. Kennedy..............................................    79
Letter of December 16, 2015, from Renee Binder, President, 
  American Psychiatric Association, to Mr. Kennedy, submitted by 
  Mr. Kennedy....................................................    81
Letter of January 28, 2016, from R. Jeffrey Goldsmith, President, 
  American Society of Addiction Medicine, to Mr. Kennedy, 
  submitted by Mr. Kennedy.......................................    83
Letter of January 2016, from Kitty Westin, Member of the Board, 
  et al., The Emily Program Foundation, to Mr. Kennedy, submitted 
  by Mr. Kennedy.................................................    85
Letter of August 31, 2016, from William C. Daroff, Senior Vice 
  President for Public Policy and Director of the Washington 
  Office, The Jewish Federation of North America, to the White 
  House Mental Health and Substance Use Disorder Task Force, 
  submitted by Mr. Kennedy.......................................    86
Letter of September 8, 2016, from Mary T. Giliberti, Chief 
  Executive Officer, National Alliance on Mental Illness, to Mr. 
  Pitts and Mr. Green, with NAMI report ``A Long Road Ahead: 
  Achieving True Parity in Mental Health and Substance Use 
  Care,'' submitted by Ms. Matsui................................    88

 
  AN EXAMINATION OF FEDERAL MENTAL HEALTH PARITY LAWS AND REGULATIONS

                              ----------                              


                       FRIDAY, SEPTEMBER 9, 2016

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 9:00 a.m., in 
Room 2322, Rayburn House Office Building, Hon. Joseph R. Pitts 
(chairman of the subcommittee) presiding.
    Members present: Representatives Pitts, Guthrie, Shimkus, 
Murphy, Burgess, Blackburn, Lance, Bucshon, Brooks, Collins, 
Green, Capps, Castor, Matsui, Lujan, Schrader, Kennedy, 
Cardenas, and Pallone (ex officio).
    Staff present: Adam Buckalew, Professional Staff, Health; 
Rebecca Card, Assistant Press Secretary; Blair Ellis, Press 
Secretary; Jay Gulshen, Staff Assistant; Heidi Stirrup, Health 
Policy Coordinator; Jeff Carroll, Democratic Staff Director; 
Tiffany Guarascio, Democratic Deputy Staff Director and Chief 
Health Advisor; Samantha Satchell, Democratic Policy Analyst; 
Andrew Souvall, Democratic Director of Communications, Outreach 
and Member Services; Arielle Woronoff, Democratic Health 
Counsel; and C.J. Young, Democratic Press Secretary.
    Mr. Pitts. The subcommittee will come to order.
    Before we begin, I want to make a note that Members may be 
filtering in and out throughout the hearing. Unfortunately, 
with the condensed September session, there are a number of 
scheduling conflicts this morning. But we wanted to be sure to 
have this important hearing before Congress recessed at the end 
of the month.
    With that being said, the Chair recognizes himself for an 
opening statement.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Today's Health Subcommittee hearing will examine the 
Federal mental health parity laws and regulations. In 2008, 
Congress passed a bill requiring most group health plans to 
provide more generous coverage for treatment of mental 
illnesses, comparable to what is provided for physical 
illnesses. This Mental Health Parity and Addiction Equity Act, 
MHPAEA, which followed the Mental Health Parity Act of 1996, 
the MHPA, requires equivalence or a parity in coverage of 
mental and physical ailments. Parity means that insurers need 
to treat copayments, treatment limits, prior authorization for 
mental health, substance use disorder the same way they treat 
for physical health care.
    The MHPAEA originally applied to group health plans and 
group health insurance coverage and then was amended by the 
Affordable Care Act to also apply to individual health 
insurance coverage as well as Medicaid benchmark and benchmark-
equivalent plans.
    With more than 11 million Americans who suffer with severe 
mental illness, such as schizophrenia, bipolar disorder, major 
depression, this issue is vitally important for individual 
patients as well as families seeking appropriate care for their 
loved ones.
    Since there seems to be ongoing discussions or protections 
as envisioned in the mental health parity laws previously 
enacted, it is timely for this committee to consider ways to 
streamline the mental health parity system.
    Title VIII of the Helping Families in Mental Health Crisis 
Act, authored by committee member Tim Murphy of my home State, 
Pennsylvania, and Eddie Bernice Johnson of Texas, offers eight 
provisions concerning mental health parity, such as improved 
compliance guidance and disclosure support.
    Of particular interest to our Democratic committee members 
is a proposal by Representative Joe Kennedy of Massachusetts, 
H.R. 4276, the Behavioral Health Coverage Transparency Act of 
2015, and this bill offers one of the many approaches to 
modifying parity requirements.
    Today, we have three expert panelists who will provide 
testimony and answer questions on the strengths and challenges 
of mental health parity standards. And I look forward to the 
testimony today.
    [The prepared statement of Mr. Pitts follows:]

               Prepared statement of Hon. Joseph R. Pitts

    The subcommittee will come to order.
    The chairman will recognize himself for an opening 
statement.
    Today's Health Subcommittee hearing will examine the 
Federal mental health parity laws and regulations.
    In 2008, Congress passed a bill requiring most group health 
plans to provide more generous coverage for treatment of mental 
illnesses, comparable to what is provided for physical 
illnesses. This Mental Health Parity and Addiction Equity Act 
(MHPAEA), which followed the Mental Health Parity Act of 1996 
(MHPA), requires equivalence, or parity, in coverage of mental 
and physical ailments.
    Parity means that insurers need to treat copayments, 
treatment limits, and prior authorization for mental health and 
substance use disorder the same way they treat them for 
physical health care.
    The MHPAEA originally applied to group health plans and 
group health insurance coverage, and then was amended by the 
Affordable Care Act (ACA) to also apply to individual health 
insurance coverage as well as Medicaid benchmark and benchmark-
equivalent plans.
    With more than 11 million Americans who suffer with severe 
mental illness such as schizophrenia, bipolar disorder, and 
major depression, this issue is vitally important for 
individual patients as well as families seeking appropriate 
care for their loved ones.
    Since there seems to be ongoing discussions on protections 
as envisioned in the mental health parity laws previously 
enacted, it is timely for this committee to consider ways to 
streamline the mental health parity system.
    Title VIII of the Helping Families in Mental Health Crisis 
Act, authored by committee member Tim Murphy of my home State, 
Pennsylvania, and Eddie Bernice Johnson of Texas, offers eight 
provisions concerning mental health parity, such as improved 
compliance guidance and disclosure support.
    Of particular interest to our Democrat committee members is 
a proposal by Rep. Joe Kennedy of Massachusetts, H.R. 4276, the 
Behavioral Health Coverage Transparency Act of 2015. This bill 
offers one of the many approaches to modifying parity 
requirements.
    Today, we have three expert panelists who will provide 
testimony and answer questions on the strengths and challenges 
of mental health parity standards.

    Mr. Pitts. I yield the balance of my time to the vice chair 
of the full committee, Mrs. Blackburn.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Chairman.
    To our witnesses today, we thank you.
    I want to thank the chairman for calling the hearing, and I 
want to thank all of my colleagues for the great work that we 
all did together as a team to pass that mental health reform 
package through the House, get it through the House in July. 
And I think it was significant that both sides came together on 
what I see as a very important issue today.
    As we talk with you all, I am going to want to highlight 
some items pertaining to the Zika virus. I do have tremendous 
concern about what we see happening here.
    Wall Street Journal had an article, and I would like to 
submit this for the record, Mr. Chairman. Researchers in the 
FDA now are mentioning that, with the Zika virus, we could 
potentially, probably will see an uptick in mental illness, 
Parkinson's, diseases of that nature, dementia, et cetera. And 
we know that the virus is fast-spreading, fast-growing--I think 
16,000 cases now in the U.S. and our territories. And I am 
quite concerned about the parallels between the virus and some 
of the mental health issues that we have. So I do want to 
highlight that. And, Mr. Chairman----
    Mr. Pitts. Without objection, so ordered.
    Mrs. Blackburn. I appreciate that, and I yield back my 
time.
    Mr. Pitts. Is anyone seeking time?
    Mr. Shimkus. Mr. Chairman, just briefly.
    I want to welcome the panelists. And I go to a local 
healthcare provider in the mental health space, John Markley 
from Centerstone, Illinois. And I asked him these very same 
questions: What can be done to be helpful? And he listed just 
three things real quick: The Federal Government should use 
additional specific guidance to State regulators on plans on 
how to implement the Federal parity law, identify parity 
violations, and enforce the law in both public and private 
insurance. The Federal Government should issue additional 
guidance detailing the parity law transparency requirements and 
modeling for issuers an appropriate disclosure of coverage and 
plan design. And the Federal Government, Federal and State 
regulators should robustly enforce requirements of the Federal 
mental health, substance use disorder parity law prospectively 
during plan approval and retrospectively through complete 
investigations. And I will probably hear some of that from the 
testimony from our panelists.
    And I appreciate the time, Mr. Chairman, yield back.
    Mr. Pitts. The Chair thanks the gentleman.
    I also have a UC request. I ask unanimous consent to submit 
the following letters from America's Health Insurance Plans to 
the President's task force; a letter from the Eating Disorders 
Coalition; a letter to Congress from 43 organizations 
representing providers, professionals, patients, family 
members, and consumers.
    Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. The Chair now recognizes the ranking member of 
the subcommittee, Mr. Green, 5 minutes for an opening 
statement.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, for having this 
important hearing.
    To our witnesses, thank each of you for taking your time 
out and being here this morning.
    For too long mental health and substance use care has been 
siloed from the rest of the healthcare system and stigmatized. 
Perhaps the biggest barrier to accessing care has been higher 
cost, lack of coverage for mental health, and substance use 
care on par with the physical health care.
    To begin to address this, Congress passed a Mental Health 
Parity Act in 1996. The law prohibited employer-sponsored group 
health plans from setting higher annual or lifetime dollar 
limits on mental health benefits than any other benefits. The 
Paul Wellstone and Pete Domenici Mental Health Parity and 
Addiction Equity Act in 2008 built on this first step and 
provided protections regarding equality of coverage for medical 
and surgical benefits and mental health and substance use 
benefits. This was further strengthened by the Affordable Care 
Act in 2010.
    While the progress has been made, there is much room for 
improvement. Since MHPAEA was enacted in 2008, insufficient 
enforcement, inconsistent compliance, spotty disclosure of 
medical management information and other implementation 
barriers to accessing mental health and substance use services 
with equivalency to physical health services has mooted the 
promise of the law for many. Today, we will be hearing with 
witnesses from the current state of parity laws and on-the-
ground enforcement. Without strong enforcement of the parity 
law, millions of people continue to struggle to get health care 
they need.
    I look forward to learning more about this critical, 
important issue, and I thank you. And I would like to yield a 
minute and a half to my colleague from California, Doris 
Matsui.
    Ms. Matsui. Thank you, Mr. Green.
    What we really want to do today is treat mental illness as 
a disease and afford the same prevention, early intervention, 
and treatment that we strive to have for physical illnesses. We 
are starting to make progress, but we have much more work to 
do.
    Mental health parity is an essential part of comprehensive 
reform. Parity is designed to ensure that insurance companies 
cover mental health benefits the same way they cover physical 
health benefits. Congress started this effort with a Mental 
Health Parity Act in 1996, and we have continued to build on it 
since then. We have made great strides with the Affordable Care 
Act by applying the concept of parity to more types of plans 
and more types of benefits and adding mental health and 
substance use disorder to the list of essential health 
benefits. Yet we need to make sure that these laws are being 
applied and enforced consistently.
    We included provisions to strengthen the parity law and the 
mental health reform bill this committee worked hard to pass 
before the August recess.
    I also support the ideas my colleague, Representative 
Kennedy, has put forth to take these provisions a step further. 
I look forward to hearing from the witnesses today and what we 
can do moving forward to ensure that everyone has access to the 
treatments and services they need.
    I yield back to the ranking member.
    Mr. Green. Thank you. I thank my colleague for her work.
    The time has come now to actually enforce the mental health 
parity laws. Over the last 20 years, as both a State legislator 
and a Member of Congress, I have watched how we have tried to 
improve it, but it has not been successful.
    So, Mr. Chairman, I thank you for calling this hearing 
today, and again, hopefully, if not this session, then early 
next session, we can continue to work on making sure we provide 
the parity that mental health has with our physical illnesses 
in our insurance policies.
    Does anyone else want time from my side?
    I yield back my time.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the ranking member of the full committee, Mr. 
Pallone, 5 minutes for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. I just want to thank you, Mr. Chairman, and 
Mr. Green for this hearing on the state of mental health parity 
in America, because current mental health parity law requires 
that insurers treat mental health and substance use disorder 
care the same way they treat medical or physical care, and that 
includes copayments, treatment limits, and prior 
authorizations.
    Today, more than 41 million adults have some form of mental 
illness, but in 2014, less than half of them received mental 
health care. And more than 20 million people over the age of 12 
have a substance use disorder, but only 2.6 million received 
treatment at a specialty facility in 2014. Perhaps this can be 
explained in part, because the majority of Americans do not 
know that there are mental health parity protections in current 
law.
    This Congress, we have had several important conversations 
on the challenges facing our mental health system. And we 
recently passed a bipartisan mental health bill in the House, 
and I am pleased that we are here today to continue that work 
by having a more indepth discussion on mental health parity.
    The last time we made major improvements to mental health 
parity laws was in 2010 when we passed the Affordable Care Act. 
The ACA expanded both parity protections and health insurance 
coverage, making early treatment and prevention services more 
accessible to millions of Americans. Under the ACA, all new 
individual and small group insurance plans are mandated to 
cover mental health and substance use disorder services as one 
of 10 essential health benefits. In addition, the ACA expanded 
parity protections for mental health and substance use disorder 
services to individual health plans and certain Medicaid plans. 
So this essentially means that these plans must provide 
coverage for mental health and substance use disorder services 
at the same level as coverage for other medical services.
    So, today, I am interested in hearing from our witnesses 
about how our current parity laws are being implemented and 
enforced, because without proper enforcement, those laws will 
not have the impact we hoped for them to have.
    And, finally, I would like to thank Congressman Kennedy for 
his strong leadership on this topic and for requesting this 
hearing. He sponsored legislation this Congress that contains 
important parity provisions that were not included in our 
House-passed mental health bill. It is clear that we can and 
should be doing more to ensure that Americans are able to 
access necessary mental health and substance use disorder 
services, and I hope this hearing will shed some light on what 
steps we can take going forward.
    So I would like to yield the remainder of my time to 
Congressman Kennedy.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Thank you, Mr. Chairman. Good morning and thank you to our 
witnesses for joining us. We're here this morning to have a 
discussion on the state of mental health parity in America. 
Current mental health parity law requires that insurers treat 
mental health and substance use disorder care the same way they 
treat medical or physical care. This includes copayments, 
treatment limits, and prior authorizations.
    Today, more than 41 million adults have some form of mental 
illness, but, in 2014, less than half of them received mental 
health care. And more than 20 million people over the age of 12 
have a substance use disorder, but only 2.6 million received 
treatment at a specialty facility in 2014. Perhaps this can be 
explained in part because a majority of Americans do not know 
that there are mental health parity protections in current law.
    This Congress, we've had several important conversations on 
the challenges facing our mental health system, and we recently 
passed a bipartisan mental health bill in the House. I'm 
pleased that we're here today to continue that work by having a 
more in-depth discussion on mental health parity.
    The last time we made major improvements to mental health 
parity laws was in 2010 when we passed the Affordable Care Act. 
The ACA expanded both parity protections and health insurance 
coverage, making early treatment and prevention services more 
accessible to millions of Americans. Under the ACA, all new 
individual and small group insurance plans are mandated to 
cover mental health and substance use disorder services as one 
of 10 Essential Health Benefits. In addition, the ACA expanded 
parity protections for mental health and substance use disorder 
services to individual health plans and certain Medicaid plans. 
This essentially means that these plans must provide coverage 
for mental health and substance use disorder services at the 
same level as coverage for other medical services.
    Today I'm interested in hearing from our witnesses about 
how our current parity laws are being implemented and 
enforced--because without proper enforcement, our parity laws 
will not have the impact we hope for them to have.
    Finally, I'd like to thank Congressman Joe Kennedy for his 
strong leadership on this topic and for requesting this 
hearing. He's sponsored legislation this Congress that contains 
important parity provisions that were not included in our 
House-passed bill. It's clear that we can and should be doing 
more to ensure that Americans are able to access necessary 
mental health and substance use disorder services, and I hope 
this hearing will shed some light on what steps we can take 
going forward.
    I look forward to hearing from our witnesses today--and I'd 
like to yield the remainder of my time to Congressman Kennedy.

    Mr. Kennedy. I want to thank the ranking member and the 
ranking member of the subcommittee, Mr. Green.
    I also want to thank Chairman Upton and Chairman Pitts for 
allowing us to have this hearing today and for their leadership 
on mental health and continuing to make mental health parity a 
priority for this committee.
    I also want to thank Mr. Selig for his work and the work of 
Health Law Advocates, which has touched thousands of patients 
and families across Massachusetts. It is a privilege to have 
you representing our Commonwealth today, sir.
    And to all the tireless advocates out there who have helped 
inform our efforts in this committee, without your support, we 
wouldn't be where we are today. I thank you.
    When the House passed this committee's mental health bill 
in July, it was a needed step forward in our efforts to fix a 
deeply flawed system. But our work is far from over, because no 
matter how many providers we train, grant programs we fund or 
community health centers we expand, failure to ensure basic 
insurance coverage for those services means the vast majority 
of working and middle class families can't afford them, and 
that is why I am grateful for today's hearing.
    Parity, the simple idea that substance use disorder and 
heart disease should be treated the same is the law. That is 
not what this debate is, in fact, about. But without proper 
enforcement and transparency, the law is little more than empty 
words. It is meaningless to the patients and families who need 
and deserve the access the Mental Health Parity Act, the Mental 
Health Parity and Addiction Equity Act, and the Affordable Care 
Act were intended to guarantee. And that lack of enforcement 
and transparency has devastating consequences.
    I recently read a story of a mother whose son Matt lost his 
life after an insurance company continually refused to cover 
long-term treatment for his substance use disorder. She wrote 
that she, quote, ``used to wish that Matt had cancer, at least 
he would have received timely, nonbiased treatment.''
    Beneath the heartbreaking stories and anecdotes are 
statistics to back them up. Claims for mental health care are 
denied at nearly twice the rate as claims for physical health. 
Twenty-four out of 25 insurance companies in California charged 
higher copays or coinsurance for mental health care than 
physical health care, according to investigation by State 
regulators. Guided by those stories and statistics, I 
introduced the Behavioral Health Coverage Transparency Act to 
force insurers to disclose the rates and reasons for denials 
for mental health care while holding insurers accountable for 
any violations through random audits. Beyond those provisions, 
it would create a portal where patients not only lodge 
complaints but learn more about their coverage options. That 
lack of accessible information is a major roadblock to health 
care. My own legislative director, a health policy expert, 
spent over 2 unsuccessful hours on the phone with her insurance 
company last week trying to get the medical necessity documents 
she is entitled to by law and still has yet to receive them.
    Parity is a promise we made to millions of Americans who 
suffer from mental illness. It is not just a legislative 
technicality or regulatory minutia; it is their lifeline. We 
haven't yet made good on that promise. We are allowing insurers 
to hide behind a curtain of proprietary information and a broad 
language of denial. Unless and until this committee becomes 
serious about ensuring parity as a lived reality for patients 
and the families who love them, meaningful mental health reform 
will remain out of reach.
    In this body, those reforms begin in this committee room, 
and I hope that my colleagues will join me in calling for 
parity to be included in any conference report that reaches the 
President's desk.
    Thank you. I yield back.
    Mr. Guthrie [presiding]. Thank you.
    The gentleman yields back.
    All opening statements have been concluded, and all members 
have the opportunity to submit statements for the record.
    I would like to introduce the panel we have before us 
today. First, I will introduce all three. Then we will have 
their opening statements. Ms. Pamela Greenberg, president and 
CEO, Association for Behavioral Health and Wellness; we also 
have Dr. Michael A. Trangle, senior medical director, 
Behavioral Health Division, HealthPartners Medical Group; and 
Matt Selig, executive director, Health Law Advocates.
    Thank you for coming today, and you each have 5 minutes to 
summarize your testimony, and your written testimony will be 
placed in the record. If you notice the lights, you will get a 
yellow light when you get close, and then when the red light, 
it would be time to sum up if you haven't concluded at that 
point.
    And I will begin with recognizing Ms. Greenberg for 5 
minutes.

    STATEMENTS OF PAMELA GREENBERG, MPP, PRESIDENT AND CEO, 
  ASSOCIATION FOR BEHAVIORAL HEALTH AND WELLNESS; MICHAEL A. 
   TRANGLE M.D., SENIOR MEDICAL DIRECTOR, BEHAVIORAL HEALTH 
 DIVISION, HEALTHPARTNERS MEDICAL GROUP, REGIONS HOSPITAL; AND 
   MATT SELIG, EXECUTIVE DIRECTOR, HEALTH LAW ADVOCATES, INC.

                 STATEMENT OF PAMELA GREENBERG

    Ms. Greenberg. Good morning, Vice Chairman Guthrie, Ranking 
Member Green, and distinguished members of the subcommittee. 
Thank you for the opportunity to testify before you today.
    My name is Pamela Greenberg, and for the last 18 years, I 
have served as the president and CEO of the Association for 
Behavioral Health and Wellness. ABHW is an association of the 
Nation's leading specialty behavioral health companies. These 
companies provide an array of behavioral health services to 
over 170 million people in both the public and private sectors. 
Since its inception in 1994, ABHW has actively supported mental 
health and addiction parity. And we believe that it is 
important to diagnose and treat mental health and substance use 
disorders at an early stage. ABHW is an original member and at 
one point chair of the Coalition for Fairness in Mental Illness 
Coverage. In my testimony today, I will provide a brief 
overview of MHPAEA, discuss compliance and enforcement, and 
discuss some next steps as we continue to move forward with 
parity implementation.
    MHPAEA, as members have already said, expands upon the 
Mental Health Parity Act of 1996 that created parity for annual 
and lifetime limits between mental health and physical health 
benefits. MHPAEA applies to plans with over 50 employees. It 
does not mandate coverage for mental health and substance use 
disorders. The law and regulations state that financial 
treatment and nonquantitative treatment limits can be no more 
restrictive than those on the physical side. Additionally, the 
law requires the disclosure of medical necessity criteria and 
the reason for denial. The law also provides that if out-of-
network services are available on the physical health side, 
they must also be available on the mental health side.
    It is important to note that parity was not intended to be 
the panacea for all mental health and addiction issues. For 
example, parity does not address our workforce shortage issues 
nor does it look at the quality of care that is being provided.
    The Affordable Care Act extended MHPAEA to individual 
markets, small group, and qualified health plans. Parity also 
applies in Medicaid and TRICARE.
    Since MHPAEA's passage in 2008, our member companies have 
had numerous meetings with the regulators to help us better 
understand and operationalize the regulations. Our member 
companies have teams of dozens of people from multiple 
departments working diligently to exchange information and 
perform the required analyses.
    The analyses are complex. For example, in order to complete 
the parity analysis, ABHW member companies review a variety of 
documents, including summary plan documents, medical necessity 
criteria, and medical management program descriptions. And then 
they document the underlying processes, strategies, evidentiary 
standards, and other factors considered by the plan. And then 
they review these findings with the organization's legal team 
and recommend any needed changes. Our members have been audited 
for parity compliance at both State and Federal levels.
    The DOL and HHS have been enforcing MHPAEA through 
investigations and health plan audits. In its January 2016 
report to Congress, the DOL reported that, since October 2010, 
they have conducted 1,515 MHPAEA investigations and cited 171 
violations. HHS has also received complaints and, to date, has 
been able to avoid litigation by resolving the issues through 
voluntary changes by the health plans. Regulating agencies have 
also issued multiple sets of frequently asked questions and 
fact sheets.
    This year, President Obama established a White House Mental 
Health and Substance Use Disorder Parity Task Force that is 
going to--that is working to improve parity. I ask that our 
comment letter to the task force be included in the record.
    To say that parity is not being implemented and enforced is 
a misrepresentation. It is important to recognize the strides 
that have been made and work together to develop best practices 
to move forward. We have to make sure that we are not so rigid 
with our implementation of parity that we end up ignoring the 
differences that exist between behavioral and physical health 
and, as a result, compromise quality care.
    Further discussion is needed on the disclosure issue. 
Transparency and disclosure of information to consumers is 
important, but we also have to keep in mind the results of a 
new research paper that found that 86 percent of participants 
could not define deductible, copay, coinsurance, and out-of-
pocket maximum in a multiple-choice questionnaire. Recent 
legislative attention in the area of disclosure has contributed 
to the issuance of additional guidance. What is missing from 
this discussion has been the volume and technical nature of 
these documents. There needs to be a more concise option for 
consumers to understand how their health plan has implemented 
parity without burying them with hundreds of documents.
    Some ideas to consider include the development of a 
document that a plan would use to explain how they have 
performed the parity analysis. Another idea is to provide 
examples that would include scenarios of questions a consumer 
might ask and then also the documents they may want to request 
to answer those questions. A third area that needs additional 
attention is education to all stakeholders as to what is and 
isn't included in parity. HHS is working with States and the 
National Association of Insurance Commissioners. DOL has issued 
a compliance assistance guide and the check sheet to assist 
employers, and SAMHSA has information on their Web site.
    If I could just finish up. Our members are faced with 
disparate and sometimes incorrect interpretations by State 
agencies enforcing the Federal law, and we would like to see 
more consistent enforcement. We also support the release of the 
identified information that are found by the regulators.
    And, finally, if I could just bring two issues to your 
attention, and those are the disclosure of substance use 
records related to 42 CFR in part 2 and meaningful use 
incentives for behavioral health providers. We hope that the 
committee considers those issues at a later date.
    Thank you for the opportunity to testify today, and I look 
forward to ongoing discussions as we move forward.
    [The prepared statement of Ms. Greenberg follows:]
    
    
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    Mr. Guthrie. Thank you for testifying.
    Dr. Trangle, you are recognized for 5 minutes.

                STATEMENT OF MICHAEL A. TRANGLE

    Dr. Trangle. Thank you, Vice Chairman Guthrie, Ranking 
Member Green, and all the committee members.
    I am Michael Trangle. I am a practicing psychiatrist and 
also a senior medical director for HealthPartners Medical 
Group, one of our hospitals, and have been really actively 
involved in kind of efforts we have been doing to make things 
better. I am very involved in quality improvement, leading 
initiatives to improve depression outcomes outpatient, reduce 
readmissions for people coming from psych units, trying to 
lengthen the lifespan of folks with serious mental illnesses in 
our State, and just work hard on that.
    I am from an integrated organization where there is a 
health plan medical group of about 1,800 docs, hospitals. The 
health plan covers 1.36 million lives. We have got 22,500 
employees. I know that we are all working hard to try to 
produce parity, both clinicians like me and administrators who 
know the details of the law and the policy in a way that I 
don't, to try to really make sure we understand and are fully 
implementing it.
    I want to talk about some of the efforts we are doing in 
the real world at the ground level to try to make things 
better. One initiative that we have been very successful with 
is, with our public radio station and NAMI and other 
organizations, doing a campaign to reduce stigma called Make It 
OK, which actually helps access. There is so much shame 
involved and avoidance of getting involved in treatment that, 
if you can start conversations, people would be willing to 
either listen to their primary care doc or bring it up and get 
going. I know that, for our members, we measure closely and 
look for improvements. We are at a 96 percent member 
satisfaction of either very satisfied or satisfied for access 
to behavioral health resources in our system.
    We have come up with ways that we have offered--we think it 
is so good to our employees as well as all of our patients, 
whether they have our health plan or not and are health plan 
members--where they can go online on the Internet and 
participate in a cognitive behavioral therapy treatment program 
at their leisure, at their own pace, to improve depression and 
anxiety care.
    We have created an algorithm, based upon claims, to look at 
who is at high risk to not do well in the next 6 months. And I 
can give you an example of one of my patients who is a 44-year-
old woman--married, three kids, lives in the burbs--who started 
seeing me as an outpatient for depression and anxiety and, 
despite my best efforts, wasn't getting better. Then I realized 
she was probably abusing substances. And then when I talked to 
her, she wasn't interested or willing to do treatment. She got 
worse. She ended up getting drunk, passed out while smoking in 
bed. Her house burned down. Thankfully, her kids and husband 
got out safely, but she had between 20 and 30 percent burns. 
She got hospitalized in a burn unit in a hospital that is not 
integrated with our system but part of our health plan network, 
was there for about 3 weeks, came out, and still was even worse 
than before. She was still depressed, anxious. She had started 
abusing opiates, because she had pain now, as well as drinking.
    And we had a healthcare coordinator that was working with 
this person because of our algorithm. And her job is to reach 
out and talk to all the various places and people involved in 
her care. She reached out to the hospital and found out that 
the patient was actively suicidal there and had been civilly 
committed and was under court order to undergo and participate 
in psychiatric care, supposedly under my direction. She had not 
filled out a release of information, lied to me about it, but 
this care coordinator discovered this. And then all of a 
sudden, I could have a real honest discussion with her. And we 
got her into a dual-diagnosis CD treatment facility. And it is 
about 2 years later now and she is still off opiates and 
alcohol and not really depressed, still struggles with anxiety, 
but her life is turned around. And it was all because of this 
kind of extraordinary care coordination that spanned different 
levels of care and systems of care that probably saved her 
life.
    I agree with the workforce shortage. You know, we find that 
we are doing a lot of things to try and put psychiatrists and 
therapists in our primary care clinics. And there is a shortage 
of health psychologists. There is a shortage of psychiatrists. 
We have been taking efforts, in partnership with NAMI, to do 
extra training, to get physician's assistants and nurse 
practitioners and clinical nurse specialists to increase our 
pool of prescribers.
    We are working hard to improve the flow of psychiatric 
patients. We have patients accumulating in the ED waiting to 
get into psych units, and people on psych units who can't get 
out waiting to get into group homes and residential treatment 
centers. And we need to partner with counties and States who 
are responsible for those things, and they have budget 
shortages, and there are not enough.
    And I see I am going to run out of time. But one other 
thing that we have been trying to work on, but it is hard, is 
kind of payment reform so that we can flow our money to pay for 
outcomes and can then afford to have care managers in our 
clinics reaching out to patients between visits, reaching out 
to make sure, ``It has been so long, you haven't rechecked, how 
are you doing with your depression,'' and making sure they come 
in and that they are getting into remission. And it requires 
partnerships in ways that I don't think is usually talked 
about. That is viewed as the public sector. We are viewed as 
the private sector. And we have got to work together. And when 
we do that, we can sort of get patients out of the hospital 
sooner into group homes and then our EDs. We are overflowing 
our safe space or locked space for psych patients. We can get 
them into the inpatient unit.
    And a lot of what we are doing really involves kind of 
taking disparate partners and agreeing to a vision and then 
trying to work together, but it is very hard because the 
funding streams are not braided. I see I am going to be out of 
time pretty shortly.
    Mr. Guthrie. If you could just summarize. I mean, I will be 
a little lenient, but if you could just summarize.
    Dr. Trangle. You know, in a lot of ways, there are also new 
models of care where we are trying to sort of really truly 
integrate behavioral health resources with health plan 
resources, both delivery system--and this care coordination is 
another way of doing this. We have programs where, if I have my 
patient and they don't get their refills for their 
antipsychotics, I will hear about it because of the health plan 
feeding that data to me. The patient hears about it. We can 
reach out and try to capture them so they don't get psychotic 
and really struggle. We do the same thing with depressed 
patients. And it really helps a lot.
    We have initiatives where we have got people like me going 
or telemedicine going to primary care clinics. Primary care 
docs will talk about their depressed patients and their issues 
and their struggles. I will give advice. And for 2 hours a 
week, I can sort of leverage what primary care is doing for 
about 100 patients, so leverage the shortage of psychiatrists.
    [The prepared statement of Dr. Trangle follows:]
    
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    Mr. Guthrie. We also have the chance to reiterate some of 
this during our question-and-answer period. We appreciate it 
very much. Thank you. Thank you for that testimony. It is very 
informative.
    Mr. Selig, you are recognized for 5 minutes.

                    STATEMENT OF MATT SELIG

    Mr. Selig. Vice Chairman Guthrie, Ranking Member Green and 
members of the committee, thank you very much for the 
opportunity to appear before you today as you examine the 
parity law and regulations. I am grateful that you have 
convened this hearing.
    My name is Matt Selig, and I am the executive director of 
Health Law Advocates. HLA is a nonprofit public-interest law 
firm with a mission to improve access to health care for low-
income Massachusetts residents. We provide pro bono legal 
assistance to low-income clients who have been denied needed 
health care.
    HLA has made mental health and substance use disorders 
parity a priority for more than a decade. We try to improve 
access to mental health and substance use disorders care by 
making the protections of the parity laws, both Federal and 
State, a reality for those we represent. HLA represents 
approximately 70 clients each year who have been denied 
coverage for treatment of mental illness or substance use 
disorder. This work gives us an up-close look at the problems 
consumers have when trying to access treatment. We also see how 
current parity laws and regulations are implemented and 
enforced. HLA works very closely with other advocates across 
the country with a strong interest in parity. As a result, we 
have a broader perspective on the insurance problems people 
face when they need treatment and how the parity laws are or 
are not addressing the problems.
    While we and others believe there is much more important 
work still needed to achieve true parity, I want to express 
HLA's appreciation to you and as well as State legislators and 
regulators across the country who have made significant gains 
achieving parity already. We are particularly gratified that 
parity has been very much a bipartisan issue in Congress, and 
that has been true in Massachusetts as well.
    In Health Law Advocates' experience with clients, 
individuals have more difficulty accessing mental health and 
substance use care than other types of care because of barriers 
created by many insurers. Our assessment corresponds with the 
findings of the National Alliance on Mental Illness report 
issued last year, which found that twice as many families 
reported that a member of their family was denied coverage for 
mental health care as for general medical care.
    Our lawyers have identified certain types of mental health 
and substance use treatment that are particularly susceptible 
to coverage denials. I will mention some, but this is not meant 
to be exhaustive: residential treatment for substance use 
disorders, eating disorders, and other severe mental illness; 
applied behavioral analysis for autism spectrum disorder; 
medication-assisted treatment; and outpatient psychotherapy 
more than once per week.
    HLA represents clients of all ages, but we devote 
particular resources to helping children access mental health 
and substance use disorder care. Over the years, we have seen 
families struggle to obtain coverage for kids, especially for 
services such as neuropsychological evaluations, wraparound 
community-based care, autism services, and stepdown care from 
acute treatment.
    In our work, we have witnessed many different ways 
insurance practices frustrate treatment for our clients that 
appear to run counter to the parity laws. For example, we have 
seen repeated early terminations of coverage for residential 
substance use treatment, regardless of the severity of our 
clients' symptoms; doctors being required to titrate 
medication-assisted treatment as a condition of coverage, even 
when mandatory titration is not the standard of care; treatment 
providers subject to onerous requirements to justify care; and 
termination of services arbitrarily based on age or alleged 
lack of parental participation.
    These examples involve clients who were fortunate enough to 
have at least connected with a provider. We also represent 
clients of all ages but particularly children who have great 
difficulty finding a qualified and appropriate provider in 
their insurer's network.
    In closing, I wish to offer a few recommendations to 
improve on current parity laws and their implementation. We 
strongly support H.R. 4276, Congressman Kennedy's Behavioral 
Health Coverage Transparency Act. There is no question that we 
need greater disclosure of information by insurers. Detailed 
information about how plans ensure that mental health and 
substance use disorder claims are treated equitably and the 
standards utilized to evaluate the medical necessity of 
treatment should be made public and written in language 
consumers can understand.
    There should also be greater enforcement, including 
enhanced penalties of requirements to provide detailed 
information to members about the basis for coverage denials and 
comparative information on medical management of physical 
conditions. When HLA requests this information on behalf of our 
clients, we rarely receive it. This prevents us from 
determining whether our clients' parity rights have been 
violated. An explicit private right of action in the parity law 
would also allow consumers to enforce this right themselves.
    Consumers should also have access to an easy-to-use process 
for filing complaints when their right to equitable mental 
health and substance use disorder coverage has been violated. 
This would help consumers access the treatment they need and 
identify trends in noncompliance. The complaint process and 
consumers' rights under the parity law should be broadly 
promoted by Government agencies to increase understanding among 
consumers.
    The Federal Government should also assist carriers' 
compliance by publicizing and continually updating its 
adjudication of parity complaints to create an administrative 
common law for what constitutes a violation of the parity law. 
Neither insurers nor their members should have to guess what 
treatment limitation practices are illegal.
    Finally, we recommend that Federal and State agencies 
conduct random audits of health plans to ensure parity 
compliance. These inquiries and other reforms will serve as a 
check on self-reporting by plans and identify problem areas 
where Federal or State enforcement is needed--more enforcement 
is needed. That targeted enforcement will ensure that parity is 
not only the law of the land but a reality for people suffering 
with mental illness and addiction.
    Thank you again very much for the chance to testify.
    [The prepared statement of Mr. Selig follows:]
    
    
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    Mr. Guthrie. Thank you very much.
    I want to thank each witness for your testimony, and I will 
begin the questioning and recognize myself for 5 minutes for 
that purpose.
    As Chairman Pitts discussed during his opening remarks, 
there have been continued discussions on the safeguards 
envisioned in previously enacted mental health parity laws.
    Ms. Greenberg, one of the most recent documents ABHW 
published is a letter in response to the President's task 
force. You urge the administration's working group to engage 
with stakeholders on clinical differences, additional tools for 
States, release of the identified information, disclosure 
clarifying guidance and parity and confidentiality rules.
    I would like to focus on the clinical differences in 
disclosure and confidentiality rules. In this letter, you 
write, and I quote: ``Parity is important, but so is quality. 
We have to make sure that we are not so rigid with our 
implementation of parity that we end up compromising on quality 
care of consumers,'' unquote.
    Please help me better understand how clinical autonomy to 
achieve improved quality outcomes in caring for patients with 
mental health and substance use disorders can be impeded by 
burdensome or, better yet, one-size-fits-all regulations.
    Ms. Greenberg. Sure. Thank you, Congressman, for that 
question. I think that our concern as we have moved forward 
with parity implementation is we have behavioral health and we 
have medical. And there are some things that are more clear-
cut, like the copayments and the coinsurance and things like 
that. But then there are other things about the treatment that 
is needed or when you check in with a provider to see how the 
treatment is going. And those are things that differ based on 
illness, and they are not so cookie-cutter that you say, oh, 
exactly what you are doing on the medical side should be the 
same thing that is done on the behavioral health side.
    And we would just like to see some flexibility within the 
parameters of clinical guidelines. So it wouldn't just be 
because we say we should do it this way, then it is OK, but the 
clinical guidelines may justify a difference in some areas on 
behavioral health. And that language was included in the 
initial interim final rule and then was deleted in the final 
rule. And so I think just recognizing that there are some 
differences that do exist and, when clinically appropriate, 
those should be allowed.
    Mr. Guthrie. Dr. Trangle, as a medical director, would you 
like to comment on that?
    Dr. Trangle. You know, I am not a policy guy. I am still 
seeing patients, and I do a lot of quality stuff. So I can't 
comment on the details of the law. But I know that, clinically, 
all the time we are trying to improve talking to primary care 
docs, seeing their lab results, making sure they can see what 
we are doing. And in some sense, one of the things mentioned in 
the prelude had to do with chemical dependency. And we are 
struggling in our system with ED docs not seeing what meds or 
what is going on in CD treatment parts of our facility or what 
is going on in outpatient clinics and overmedicating people 
because we are not sharing some of that data with each other. 
It is just really important to be able to talk together.
    It is an interesting place where stigma plays out. We have 
primary care docs that, in some sense, will kind of be afraid 
to talk about somebodyis depressed, you know, and shy away from 
it. But if they can see that we have talked about it, because 
we have a shared electronic medical record, they know it is OK, 
all of a sudden they can help us follow up and they can help us 
measure are they getting better or not.
    Mr. Guthrie. OK. Thank you.
    Let me get to my next question.
    Ms. Greenberg, you note that certain transparency and 
disclosure efforts may be well-intentioned but inadvertently 
overwhelm patients with thousands of pages of documentation, 
but other advocates have asked for even more access to benefits 
details. Would you please share a more efficient and effective 
way to help patients better understand parity, fairness?
    Ms. Greenberg. Sure. The documentation that is available to 
patients or should be made available to patients includes a lot 
of information that health plans are using, either their 
analyses or the documents that they had to look at to get to 
what parity should include.
    And while those documents are available, we would also like 
to see some type of summary of the analysis instead of--our 
concern is that if we hand the patient a box or two of 
documents, that will overwhelm them. And, also, they are very 
technical, and it will be a little bit difficult to go through. 
So if we can talk about a uniform analyses that people would 
hand out first to explain to patients how parity was determined 
and then kind of go from there as more documents are needed 
and/or provide guidance to patients as to what documents are 
appropriate to ask for for their situation--not that they 
couldn't have more but that at least at first they are getting 
just the documents that they need.
    Mr. Guthrie. OK. You, also, in the coordination that Dr. 
Trangle was talking about--our committee is really looking at 
coordination. We know that that is important. But in regard to 
substance use disorders, you comment that multiple signed 
patient authorizations are necessary to achieve true 
coordination. How does this limit quality of care?
    And then, Mr. Selig, would you comment on the fact that 
there are so many multiple signed documentation, is that a wall 
that the Federal Government should try to remove?
    Actually, I am out of time. I don't want to go because we 
are kind of against votes.
    Mr. Selig. If you could clarify which signed documentations 
you are referring to.
    Mr. Guthrie. Well, you know what, if I get into that, I am 
going to really get into that. I will put that in the record. 
We will give you a question for the record. Otherwise, it is 
going to take longer. We are running against--votes are going 
to come sometime midmorning, I understand.
    That concludes my questions.
    I will recognize the ranking member, Mr. Green, 5 minutes 
for questions.
    Mr. Green. Thank you, Mr. Chairman,
    Millions of Americans, as many as one in five, have a 
mental illness. One in 10 Americans will have a substance 
disorder in their lifetime. And 75 percent of them will not 
seek treatment. The lives of these individuals and their 
families and their communities will be significantly changed 
for the better with access to the treatment they need.
    Congress did our part. We passed a parity law requiring 
health plans and Medicaid and Medicare and the private market 
to cover mental health and substance use treatment to the same 
extent as they do medical and surgical services. We passed the 
Affordable Care Act, which significantly expanded access to 
health coverage.
    However, without strong enforcement of the parity law, 
millions of people continue to struggle to get the health care 
they need.
    Mr. Selig, as a legal advocate, you are well aware of the 
importance of strong parity implementation and enforcement. I 
am sure you know how complicated and confusing insurance 
benefits can be and how hard it is to fight with an insurance 
company to get coverage for the benefits you need, especially 
when you are sick and need it the most.
    My first question is, how hard is it for consumers to get 
the information they need in order to figure out whether their 
insurer is meeting the requirements of parity?
    Mr. Selig. Well, it can be very difficult, Mr. Green. As I 
mentioned in my statement, when we are working with consumers 
who have been denied coverage and they try to request 
information from their plan explaining why the service has been 
denied and providing the backup documentation comparing the 
medical management techniques for mental health and physical 
health, it is documents that really are rarely provided. And I 
recall Mr. Kennedy mentioning a member of his staff having the 
same experience.
    So it is very difficult to get that information typically. 
It is clearly requested by our team members at HLA, and we 
don't get it. That being said, that information is difficult to 
understand. And we would favor information being made much 
clearer for the consumer. I think having boxes of information 
that indicate the process for determining when services are 
covered not only is complicated but it also I think speaks to 
the extreme scrutiny that services are given when people are 
trying to get coverage for them.
    So we would definitely favor clearer information be given 
to consumers and also clearer information on where people can 
get help if they don't feel equipped to try to understand the 
materials that they are given, so, as Congressman Kennedy's 
legislation provides, a central portal where people can go and 
indicate that they feel as if they have been, generally 
speaking, unjustly denied coverage for care, and maybe they 
don't feel equipped to go through the documents and do the 
parity analysis themselves, but have an agency look at that 
complaint for them in a systematic and general and uniform way.
    Mr. Green. And I know with our mental health bill we 
passed--it is still in the Senate--we didn't put that provision 
from Representative Kennedy in, but it is one we intend to do.
    Since 2010, we know there are only 140 cases in which the 
Federal Department of Labor has found parity violations. It 
seems unlikely that the parity has been implemented so 
comprehensively nationwide that there are only 140 violations. 
What steps can we take to ensure the law is fully enforced?
    Mr. Selig. Well, thank you for that question. I would say 
several things, and many of them are embodied in Congressman 
Kennedy's bill, which I think is on the mark in many ways. We 
do feel like Federal reporting requirements for health plans 
are important, for health plans to be required to demonstrate 
how they are complying with parity and have that information 
public.
    We also think that random audits of health plans are 
important as a check on the self-reporting that insurance 
companies do. We also, again, believe strongly that there must 
be a simplified consumer complaint process and much greater 
public education that will help people understand what their 
rights are under the parity law and how to vindicate those 
rights and understand when a denial is inappropriate or maybe 
when it doesn't violate parity.
    I also support some of the provisions for sure in the 
legislation that the committee did pass. The compliance program 
guidance document that was included in that legislation I think 
would provide a very valuable, as I said in my opening 
statement, kind of common law, a record of how the Government 
has interpreted certain limits by health plans and to give 
health plans and insurers a greater understanding of what are 
appropriate denials and what aren't.
    Mr. Green. Thank you. We are out of time. But we even have 
problems with the physical health, because I have folks who 
think they have insurance, and they show up at the hospital 
that is on their network, and all of a sudden they find out--
nowadays, the practice of medicine, there are different 
providers that are not part of that system. So when they leave, 
they find out they are out of network. And so it is confusing, 
both--the mental side probably worse than the physical side, 
but we have those problems there.
    Thank you, Mr. Chairman.
    Mr. Guthrie. Thank you.
    I am going to try to stick to the 5 minutes as much as 
possible so we can get more questions in. There is actually a 
memorial service for 9/11 coming up this morning as well.
    Dr. Bucshon from Indiana, you are recognized for 5 minutes.
    Mr. Bucshon. Thank you very much, Mr. Chairman.
    First of all, I would just like to outline, you know, 
again, the problem, and it goes across all socioeconomic 
statuses. I have a high school friend in my class who recently 
died at age 54. She had schizophrenia. Their life expectancy is 
shortened. She had two children and her husband divorced her 
and changed the children's names. And she ended up on the 
street because of really probably a multitude of factors, but 
one of those was her ability to get treatment.
    I also had a high school friend who came home for Christmas 
break in college and broke up with his girlfriend and a couple 
weeks later committed suicide at college. No other indication. 
But the question in my mind is, you know, on college campuses, 
was there any indication that he was struggling?
    And that is true, because my son, one of his fraternity 
brothers who graduated in May and who had a job just committed 
suicide at age 22.
    So this is really something we need to address. Twenty-two 
veterans a week we are losing. I just wanted to outline the 
problem, as we all know, but for the record.
    And it is important to know that most mental health 
patients have other medical issues. In Indiana, there are a 
couple centers close to my district--Centerstone in 
Bloomington, Hamilton Center in Terre Haute--that coordinate 
both traditional medical problems and mental-health-related 
issues, including substance use disorder.
    So, Dr. Trangle, this is a subject that is really--also, I 
was a medical doctor before I was in Congress. I was a surgeon. 
So I understand this.
    Why do you think it has been so difficult to get mental 
health parity and treatment for mental health issues? I mean, 
they can be chronic problems, I understand. But, you know, 
diabetes, congestive heart failure, these are all chronic 
problems. Why? I mean, I think we all know probably the answer. 
But, in your experience, why are we still struggling to be able 
to have parity in how people are treated because they happen to 
have a mental health issue?
    Dr. Trangle. I think the tradition in medicine is to have 
things siloed up, you know, and not thinking holistically, not 
having people be physically in the same place, not sharing the 
same EMR, and not talking about these things.
    Some of the examples you mentioned--diabetes, 
cardiovascular disease, heart failure--have a significantly 
increased incidence of depression. If somebody has an AMI and 
they are depressed and you don't recognize it, they will have 
higher mortality, not because of the physiology, because they 
don't do their cardiac rehab. We need to screen for depression 
throughout all of primary care, throughout health plans' 
members, and then make sure for those that are screening 
positive we follow up. Ideally, you follow up in primary care 
clinics where you don't have to get somebody to get over their 
own stigma and go to a more embarrassing place of a mental 
health clinic. You need to be able to virtually talk to the 
primary care docs and help them with advice, with 
recommendations, with consults, things like that.
    Mr. Bucshon. Mr. Selig, maybe you can help, because you are 
involved in dealing with trying to help people get coverage. I 
mean, as a healthcare provider, still for years I have had this 
issue. I mean, I had patients that were inpatients that I did 
open heart surgery on that clearly had mental health issues. I 
diagnosed a number of people who were bipolar and depressed and 
everything and had a hard time getting--there is a physician 
shortage, which we can address.
    But, in your mind, what is your opinion, what is the 
impetus for difficulty getting coverage for, say, depression 
versus diabetes? I mean, it doesn't make a lot of sense, 
really. I mean, do you have any insight into that?
    Mr. Selig. Well, I have a couple of thoughts about why the 
parity law, which is, you know, a landmark law, why it is hard 
to--has been hard to implement. First of all, there is a 
patchwork of agencies that have to enforce the law. So we have 
the Federal Government, which directly enforces it with self-
insured plans and also can provide guidance to State agencies. 
And then you have 50 State agencies, divisions of insurance, 
and also Medicaid offices that all have to enforce the law in 
all different ways. So there is a patchwork of interpretations 
of the law.
    Mr. Bucshon. I guess the question is, why would you need to 
have to interpret it? Why do you need a parity law in the first 
place? You see what I am trying to get at? I don't know if we 
can answer that question today.
    Ms. Greenberg. Dr. Bucshon.
    Mr. Bucshon. Yes, Ms. Greenberg, do you have any insight?
    Ms. Greenberg. If you don't mind for a second, Mr. Selig.
    I think part of the issue too is that there is a great 
stigma associated with mental health and addiction. And so we 
have treated typically mental health and addiction in our 
healthcare system differently than behavioral health. That is 
not the right answer, not the right thing to do. But people are 
afraid to talk about their mental health and addiction for fear 
of being ostracized or----
    Mr. Guthrie. We are going to have to get more questions in, 
so hopefully you will have the opportunity to answer further 
through some other questions moving forward.
    But I would like to recognize Ms. Matsui from California.
    Ms. Matsui. Thank you very much. And I would like to thank 
all the witnesses for being here today to testify on such an 
important issue.
    One of the main reasons that I have heard with parity 
enforcement stems from the fact that there are different 
Federal and State agencies responsible for overseeing and 
enforcing the parity law. This patchwork is a little bit of the 
nature of the game. The Federal law sets a standard, and States 
can make more strict parity laws, which California does. And 
States are also responsible in large part for making the rules 
for their own Medicaid programs.
    Mr. Selig, can you give an overview of the patchwork of 
State and Federal enforcing agencies?
    Mr. Selig. Sure. I will pick up and repeat a little bit of 
what I was just speaking about and try to do it quickly. So 
there is a patchwork of enforcement agencies that enforce the 
parity law. So you start with the Federal Government, which 
enforces the law for self-insured plans directly, because those 
aren't under the regulatory purview of the States. Each State 
has a division of insuranceand an office of Medicaid that 
enforces the law for those respective plans. You also have the 
TRICARE agency also, as Ms. Greenberg indicated, has a separate 
enforcement mechanism too. So there are several different 
agencies that have responsibility for making sure the parity 
law is implemented and enforced.
    Ms. Matsui. OK. Well, because much of the enforcement tends 
to be at the State level, especially for Medicaid, it follows 
that the States should learn from one another about best 
practices to ensure consistency for consumers. SAMHSA put out a 
report regarding best practices from seven States. For example, 
the California Insurance Commissioner's Office worked closely 
with California's exchange, Covered California, to design 
benefits under the parity law.
    Ms. Greenberg, is the SAMHSA report helpful to your member 
companies? And what else can we be doing to share best 
practices, such as interagency coordination, across the 
country?
    Ms. Greenberg. Sure. Yes. The SAMHSA document, which was 
released quite recently, is very helpful. We were actually 
interviewed as a part of that report. And I think sharing of 
the best practices is one of the most helpful ways to assist 
with parity implementation. And one of the other things that 
can be done, as has been mentioned by I think all of us, is the 
sharing of the identified information.
    So whether it be a problem that is found or something 
positive that is found by any of the agencies that Mr. Selig 
suggested that are doing the implementation, if they can let 
people know, this is a problem that we found, and this is how 
it should have been treated; or this is how the change was made 
to become parity compliant; or this is an instance where a plan 
is parity compliant, and these are the things that they are 
doing that we, the auditors, have found helpful. I think that 
information and those best practices or, in some cases, 
unfortunately, worst practices would be helpful to us.
    Ms. Matsui. But how can we encourage more sharing of 
information at a level where actually things get done?
    Ms. Greenberg. I think to talk--reports like the SAMHSA 
report, to talk with States and encourage them to release the 
information, and also to talk with the Federal agencies, which 
we and other stakeholders have, to encourage them to share that 
information.
    Ms. Matsui. OK. Well, thank you.
    There are today up to 30 million Americans experiencing 
eating disorders during their lifetimes. However, one in 10 of 
these Americans will receive treatment due to a lack of early 
identification and treatment coverage.
    You know, the Paul Wellstone and Pete Domenici Mental 
Health Parity and Addiction Equity Act was designed to ensure 
health insurance plans covering mental disorders and substance 
use disorders would provide the same favorable level of 
coverage as they would for medical/surgical benefits. Since the 
law has been finalized, we have heard that there are still gaps 
in coverage for mental health disorders, especially for people 
with eating disorders.
    With my colleague, Congressman Lance, we led the effort to 
include provisions to clarify coverage of eating disorders 
benefits, including residential treatment, within the mental 
health bill that passed the House before the August recess.
    Dr. Trangle, in your experience, what is your understanding 
of how private health insurance contracts handle eating 
disorders?
    Dr. Trangle. Thanks for the question. I think it is a great 
one. As my organization has grown, we combined with another 
organization, and we now own something called Melrose Eating 
Disorder Center. And our organization is really intent upon 
trying to simultaneously improve the measure of the quality, 
patient satisfaction, and making it more affordable.
    As we kind of integrated this eating disorder place into 
our hospital, into our system, we looked at it from all 
different directions. What is the quality? Were they measuring 
outcomes? They weren't. What was the expense? It turned out our 
employers were complaining about the expense and the number of 
high-buck cases and were thinking about excluding eating 
disorders from their benefit sets, the self-insured employers. 
We looked at it and basically said: We want to shift this a 
bit. And we created levels of care, like intensive outpatient 
treatment teams, to be mobile and work with them and much more 
intensive. It helped us reduce the length of days for 
inpatient. We created more outpatient resources. Ultimately, 
people are in care longer, but it is at less expensive levels 
of care. The cost has gone down, and the outcomes have gone up.
    Mr. Guthrie. Thank you.
    Ms. Matsui. Thank you.
    Mr. Guthrie. You might want to submit more of that to the 
record. If you want to answer more, you can submit that to the 
record. I appreciate it very much.
    Mr. Collins of New York, you are recognized for 5 minutes.
    Mr. Collins. Thank you, Mr. Chairman.
    Dr. Trangle, if you could speak closer. When I ask you a 
question, I am going to maybe 4 inches from the mike, because 
that is how sensitive they are.
    Anyhow, I want to thank the witnesses for coming, and I 
don't think there is a family in America that is not impacted 
by mental health at one stage or another. It is such a 
multifaceted problem, I think. Unlike some traditional medical 
issues, I actually believe mental health is almost 
individualized to so many contributing factors. It is hard to 
take six patients that may seem similar and say that it is all 
the same thing. So, again, I think this is a very useful 
hearing to kind of deep dive: What is going on? How we can do 
better?
    Just as a point of interest, my district includes the only 
veteran suicide center in the United States. So every veteran 
who would have that unfortunate urge to commit suicide, when 
they call in, they end up at a call center in Canandaigua, New 
York. So I have spent a significant amount of time there 
talking to those who are answering the phone calls. And it just 
became clear that the problems ranged from opioid abuse to PTSD 
to then PTSD leading to more opioid abuse and substance abuse. 
It is such a tragic thing that is going on in this country and, 
in some cases, with the youth.
    So, again, I appreciate all your testimony. But I also know 
there is a balance between State regulations, Federal 
regulations, more regulations that we have to address.
    So, Dr. Trangle, I will just maybe ask my first question to 
you.
    Mr. Collins. As a clinician, would more Federal rules, more 
Federal disclosures, and more Federal audits, because that is 
what we are here, the Federal Government, would this help in 
any way streamline care, or as a clinician do you feel that 
more regulations at the Federal level would potentially burden 
a system that is already pretty highly regulated, as Mr. Selig 
pointed out?
    Dr. Trangle. Yes. Let me try and answer that. I almost feel 
like I am living in parallel universes. I think about what----
    Mr. Collins. If you stand a little closer, like 4 inches--
--
    Dr. Trangle. It feels like I have these conversations with 
patients and families--I am going to eat it while I talk.
    Mr. Collins. That is--we will use that.
    Dr. Trangle. I feel like I live in a world where I am 
talking with patients and families kind of in the clinic, and 
the kind of information they want is really sort of--like last 
week there was a social worker seeing someone. And the patient 
was someone who was chronically depressed and I think beginning 
to get a little bit manic and having some kind of thought 
disorder. And we talked about what do we need to do. You know, 
there was not necessarily a clear suicidal thought, a little 
vague thought about a bridge. And the discussion was, does this 
person need to be in an inpatient unit, which means being 
locked up and much more restricted? Do they need to continue to 
see somebody once a week? No. Ultimately, we came up with the 
idea this person should go to a partial hospital program where 
they would see a psychiatrist every day, they would get started 
on an antipsychotic, talk about suicide, make sure they were 
safe. And it was not all or nothing.
    You know, you need to have some checks and balances, and 
people that are making the recommendations know what the 
resources are and what is the right care at the right level of 
care at the right time.
    We have similar checks and balances that we struggle with. 
Somebody came to me and said: I read about Ketamine and I know 
it works for depression and I want you to change--and our 
depression scores showed that she was actually getting better 
but not fast enough for her. And she said: I want you to order 
Ketamine and I want the health plan to pay for it. And this 
didn't even go to the health plan review. I said: I am up on 
this literature. And Ketamine has a number of individual 
studies showing rapid response for depression, but it doesn't 
last. As soon as you stop getting the IV Ketamine, you get 
depressed again. It is not going to be a good solution long 
term.
    You know, how do you have checks and balances to make those 
decisions and not have people like primary care docs who don't 
necessarily know all the details saying: This is what I am 
recommending, but somebody with more knowledge is involved and 
gets the right care at the right time for the patient? It is a 
separate issue. But more is not always better. It is what you 
share and what you communicate.
    Mr. Collins. Yes. Thank you.
    I guess, Ms. Greenberg, let me ask you kind of a similar 
question. There are so many State enforcement laws, as 
Representative Matsui, you know, alluded to a Federal, State, 
et cetera, et cetera. Do you think that the State enforcement 
laws at that level are adequate for the oversight and parity 
standards or do we need more Federal intervention?
    Ms. Greenberg. I think what we need is more uniformity in 
the enforcement. Whether you are a State or whether you are the 
Federal Government, the parity laws should be enforced 
consistently and uniformly. And if there can be some direction 
in that area in terms of education and what are the questions 
that an enforcer, no matter where they sit, should be asking to 
determine whether or not a plan is parity compliant, that would 
be very helpful. I don't know that it has to be legislative. I 
think the regulators are working to get there.
    Mr. Collins. Yes. Well, again, my time has expired. I want 
to just thank all the witnesses. This is such a complicated 
issue. And I thank Representative Kennedy for asking that we 
hold this hearing. And I think it is being useful. And I yield 
back.
    Mr. Guthrie. Thanks for that. I appreciate it.
    Mr. Kennedy from Massachusetts, you are recognized for 5 
minutes.
    Mr. Kennedy. Thank you. And I appreciate the kind words 
from Mr. Collins.
    A couple of quick points here. First, for Mr. Selig, I want 
to thank you again for your tireless work on behalf of the 
patients and their families. We hear anecdotes time and again 
about patients who struggle to get access to the care that they 
need. In your experience, what is the greatest barrier to that 
care, and is it insufficient reimbursement, inadequate 
networks, shortage of suppliers? And we will start there.
    Mr. Selig. Thank you, Mr. Kennedy, very much. And thank you 
for your very hard work on this issue.
    I think that there are many barriers to mental health and 
substance use services. And insurance barriers are certainly a 
leading one, and that is obviously the topic of today's 
hearing. That being said, there are other barriers to mental 
health and substance use care that I think are worth noting.
    Workforce shortages, which has been mentioned today----
    Mr. Kennedy. Can I push you on that one.
    Mr. Selig. Sure.
    Mr. Kennedy. And I just ask just because the timing is 
brief, we have restrictions here. But all of you have mentioned 
workforce shortages in your testimony. And, Dr. Trangle, you 
went into this in some detail.
    For programs that you put forth, loan forgiveness, 
reimbursement rates, would you support movement on all of those 
to address the workforce shortages issues? Ms. Greenberg.
    Ms. Greenberg. Would we support--yes.
    Mr. Kennedy. Yes. Dr. Trangle?
    Dr. Trangle. Absolutely.
    Mr. Kennedy. And Mr. Selig?
    Mr. Selig. Oh, 100 percent. Absolutely. Loan forgiveness 
and better reimbursement would be critical for that.
    Mr. Kennedy. Great.
    Ms. Greenberg, my cousin Patrick served in the House, and 
he worked tirelessly to pass a groundbreaking mental health 
parity law. And again, I want to thank you for your early 
support for that legislation and for ABHW's work. Years later, 
we worked to try to implement the spirit and the letter of the 
law. And the final rule for mental health parity clearly 
indicates that it, quote, ``requires the criteria for planned 
medical necessity determinations with respect to mental health 
or substance use disorder benefits be made available to any 
current or potential beneficiary or contracting participant 
upon request in accordance with regulations,'' end quote.
    One of the challenges we hear over and over and over again, 
including from my legislative director who spent, again, 2 
hours on the phone with an insurance company whose folks, 
representatives, had no idea what she was talking about, to the 
extent that they said: That information doesn't exist. And she 
said: Well, then you are not in compliance with Federal law. I 
can go through the minute-by-minute readout.
    I understand the fact that this is very complex, and most 
experts in this room would still struggle with that level of 
complexity. But the complexity can't be the barrier to 
information for a patient to be able to get access to that 
care. So how can we--how can parity be strengthened--the 
enforcement of parity--and the legislation that we have 
authored doesn't try to touch the actual requirements around 
parity. It merely says: Shine a spotlight on it to make sure 
that the information is available so that we can ensure that 
parity is being complied with.
    So if the issue is complexity, and it has been 10 years 
since this law has been passed, can't we find a way to simplify 
some of the information so that consumers can digest it?
    Ms. Greenberg. Yes. I would like to work with you and 
others that are interested in this topic to try to find what is 
that kind of concise document that we can give out. And I think 
that would help insurers understand, OK, what are the 
components that should and need to be given and also help with 
consumers, because they would have then an understandable 
document.
    I will say that I agree with you, the medical necessity 
criteria should be disclosed. That is part of the law. Many of 
our member companies have it up on their Web site. And in that 
specific situation, if that is still an issue, I would like to 
help with that as well.
    Mr. Kennedy. Great. And great that that was one specific 
company. And, you know, there is obviously many plans and 
challenges out there. But one of the challenges that we also 
hear over and over and over again is that there should be a 
central clearinghouse for--essentially, a database for issues 
and complaints that arise so that information again can come in 
a centralized location so that regulators, advocates, patients 
can understand what services they can get, what is covered, 
what isn't, given the complexity of this law, and the 
challenges for it. That is part of what is contemplated in our 
legislation.
    And I would love to get your thoughts on, again, how we can 
ensure that the transparency requirements--we shine a greater 
light on that transparency.
    Ms. Greenberg. Sure. And we do support the idea of a 
consumer portal that I know is in your legislation. And also we 
would say, and I think you do as well, deidentified 
information.
    Mr. Kennedy. Of course.
    Ms. Greenberg. And people always remind me to say not just 
the problems but also deidentified but show the good things 
that have happened and where there have been success stories in 
parity, because there are some of those as well.
    I don't know, Congressman, whether legislation is necessary 
to do this. I think, you know, that strict and strong 
conversations with the regulators. And, frankly, we have 
already seen, as a result of the attention you have brought to 
this issue, guidance issued in the last few months on the--more 
guidance issued on the disclosure topics. So you are shedding a 
sunlight on it.
    Mr. Guthrie. Thanks. We are going to--I hate to----
    Mr. Kennedy. No, Mr. Chairman.
    Mr. Guthrie. Mr. Kennedy, do you have other things----
    Mr. Kennedy. I have a number of documents I would like to 
introduce for the record. And, again, I appreciate the time. 
But a letter from a number of advocacy organizations, testimony 
from former Representative Patrick Kennedy, and a couple of 
letters from other advocacy organizations that I would like to 
submit for the record.
    Mr. Guthrie. Without objection, so ordered.
    Mr. Kennedy. Thank you.
    [The information appears at the conclusion of the hearing.]
    Mr. Guthrie. Thank you, Mr. Kennedy. And I will compliment 
you on your passing of this as well.
    Mr. Schrader from Oregon is recognized for 5 minutes.
    Mr. Schrader. I yield my time to Representative Kennedy.
    Mr. Guthrie. Representative Kennedy is recognized.
    Mr. Kennedy. Mr. Schrader, you are a good man.
    So let's focus a little bit, since I have a couple more 
minutes, on the reimbursement issues.
    My understanding--again, Mr. Selig, we can start there--
well, actually, Dr. Trangle, we can start with you. 
Particularly issues around Medicaid. If you could talk a little 
bit about how low reimbursement rates affect, in your opinion, 
the access to care that professionals are able to provide for 
the poor.
    Dr. Trangle. You know, I know I read an article that came 
out just this past week, I think it was in JAMA, where they 
talked about--it did document some variability there, as well 
as sort of variability in how many psychiatrists were 
participating in what plans. So I know there is data out there 
nationally of how that plays out.
    In our area, I don't think we necessarily--what we have are 
psychiatrists that opt out of the system totally and will take 
cash only and take nobody with insurance, is the bigger issue 
in our area versus not taking one versus the other.
    Mr. Kennedy. Generally----
    Dr. Trangle. Workforce issues for general population, 
especially the mentally ill.
    Mr. Kennedy. So generally speaking, looking at insurance 
rates, reimbursement rates, private insurance generally 
reimburses at a higher rate than Medicaid would. Fair?
    Dr. Trangle. Correct.
    Mr. Kennedy. So one of the challenges that we have faced, 
even over the course of the past couple years, is that we have 
been searching for information about Medicaid's reimbursement 
rates for mental health services. Not the joint Federal/State 
program, CMS actually doesn't compile a national database of 
what those rates are.
    So I was wondering, Ms. Greenberg, is there some 
information that, given the companies that you represent and 
the scope that--the number of States that your companies 
practice in, that data clearly exists, it is just that the 
Federal Government doesn't have access to it because, in our 
conversations even with CMS, they have indicated the nature of 
a joint Federal/State program, that information is lodged in 
the States and many of those States aren't--they are not 
required at all to divulge that reimbursement rate information 
to CMS or to the Federal Government.
    You guys obviously deal with those issues on a daily basis. 
Is there a way that we can try to ascertain, that this 
committee can ascertain, what reimbursement rates look like for 
Medicaid across the country? Can you help with that?
    Ms. Greenberg. I would be happy to try. To be honest, it is 
not an issue that I have--or the question that I have asked 
before of our member companies. But I certainly would be happy 
to ask them that question and see--or maybe they don't--they 
don't have it or can't give it out, but maybe they know someone 
in the State level that can help with that. So yes, I would be 
happy to look into that.
    Mr. Kennedy. It just strikes me as we have heard some of 
the challenges of parity, but we have also heard from all of 
you today the struggles with workforce. If we are looking at 
struggles with workforce and Medicaid is the largest payer of 
mental health services in this country, that if we are not 
looking at reimbursement rates as one of the drivers for 
workforce shortage, then it is tough to address that issue for 
workforce if we are not looking at the compensation mechanisms 
for those professionals.
    Ms. Greenberg. Sure. Yes.
    Mr. Kennedy. Do you want me to keep going?
    Mr. Schrader. Sure.
    Mr. Kennedy. Great.
    So if I can continue, Ms. Greenberg, so insurance companies 
often state that they are making efforts to comply with the 
law. And in your testimony with mental health parity, your 
testimony, you indicated that. Why is it that given a good-
faith effort to comply with the law, why is it that 10 years on 
we are still struggling with the actual receipt of that 
information and struggling with patients being able to gain 
access to the care that they need when they need it and even 
understand what services are available to them?
    Ms. Greenberg. There are so many reasons. You know, it is, 
as I think everybody knows, it is a complex law and regulation. 
The regulations came much later than the actual law did. So 
enforcement of the law began--or, sorry--of the final 
regulations began in 2014. So while the law passed in 2008, the 
regulations haven't been in effect for as long a period of 
time.
    I think also we have seen some things, like some of the 
larger disclosure issues have come later through guidance that 
has been issued by the regulators versus the initial disclosure 
that specifically was around medical necessity criteria and 
reasons for denial. And through guidance we have seen that 
expand a little bit. So trying to get our head around, OK, what 
are those documents that you are talking about, what format, 
you know, as we have discussed here today, are you looking for 
that information? And it is--as I mentioned in the testimony, 
we have had dozens of meetings with regulators. There are gray 
areas, as there are with all regulations, that we have spent 
countless hours trying to understand.
    Mr. Pitts [presiding]. Thanks.
    Mr. Kennedy's time has expired. Dr. Schrader, we have a 9/
11 memorial service at 10:30 I know some of us are trying to 
get to.
    But Ms. Castor from Florida, you are recognized.
    So I apologize for cutting you off.
    Ms. Castor. Thank you, Mr. Chairman. I want to thank 
Congressman Kennedy and Congressman Green and all of my 
colleagues for continuing to focus on mental health parity for 
our neighbors back home. And thank you to the witnesses.
    There have been many significant changes to mental health 
parity and substance abuse parity over the past decade. And as 
a legislator, it is important to know what is happening in the 
real world, how does this play out for families.
    Mr. Selig, your organization, Health Law Advocates, 
represents Massachusetts residents in mental health and 
substance abuse disorder parity cases. You also communicate 
with other advocacy groups across the country that are engaged 
in similar work. Based upon your experience, what is the most 
common type of potential parity violation you encounter? Or are 
there a few different ones?
    Mr. Selig. Thank you for the question. There is no 
question, as I said, that among the people we represent, mental 
health and substance use care is harder to access than other 
types of care. That is our experience, and that is the 
experience that is communicated to us by other advocates and 
providers out across the country.
    The insurance limits that we see most frequently are things 
like arbitrary limits on things like residential stays for 
substance use disorders. You know, we have seen several 
patients, for example, who have lost their coverage for 
residential substance use treatment, regardless of their 
condition, after 2 weeks. It is like a hard stop and then that 
is it and then services are stopped. So that is something that 
we see as a significant barrier.
    The full range of scope of services is also something that 
we see not being provided to consumers. So especially 
intermediate services, intensive outpatient services. Again, 
residential care and other types of services that aren't acute 
and aren't outpatient are very common.
    As I mentioned, we also see unusual limits on medication 
assisted treatment that seem to be arbitrary and don't 
necessarily align with what our review of the medical necessity 
requirements are. So those are some. Also----
    Ms. Castor. But when you raise the issue with insurance 
providers, typically is it remedied or is it a fight?
    Mr. Selig. So, you know, it really runs the gamut. When we 
talk to health plans on behalf of our consumers, sometimes we 
are able to remedy the problem. We will be able to provide a 
certain amount of information or provide some clarity on the 
situation or an analysis of the parity law, in some cases, 
where we may say we think that this process counters the parity 
law and the health plan will change its course. In other 
situations, we will go to appeals internally with the health 
plan, externally, and we will raise the issues that way. And in 
a good portion of the cases, those appeals do result in an 
overturning of the decisions that are made by the health plan.
    So we have a pretty good record, I think, a very good 
record, actually, when insurance denials occur in changing the 
outcome.
    Ms. Castor. It is really too bad that folks need an 
advocate at all, because they are dealing with the personal 
issues every day. And thank you for what you are doing.
    Congressman Kennedy raised the point of Medicaid 
reimbursement rates. And I know my colleague, Mr. Green from 
Texas, would agree that the fact that Texas and Florida have 
not expanded Medicaid at all is a real barrier to so many of 
our families receiving the care they need. Do you have an 
opinion on what Medicaid expansion has meant for families and 
mental health treatment across the country?
    Mr. Selig. Well, I think the Medicaid expansion really has 
provided just incredible financial stability and support for 
State Medicaid programs which enable them to support the, you 
know, really the entire range of services that members are 
entitled to, but specifically mental health and substance use 
services, which are typically, you know, and historically 
shortchanged. So I think it has been just hugely successful in 
that way.
    More people are enrolled in insurance, obviously, because 
of the expansion. People have better coverage. And so I would--
you know, undeniably, the expansion has, in all sorts of 
different ways, helped people throughout the country access 
mental health and substance use services.
    Ms. Castor. I hope they hear that back home in my State 
capital. The most important thing for the mental health of a 
lot of my neighbors would be for the State of Florida to expand 
Medicaid. So thank you very much.
    And I yield back.
    Mr. Guthrie [presiding]. Thank you, Ms. Castor.
    I recognize Mr. Lujan from New Mexico for 5 minutes.
    Mr. Lujan. Thank you very much, Mr. Chairman.
    Well, I am a cosponsor of Congressman Kennedy's legislation 
and I applaud all the work that Congressman Kennedy is doing in 
this space to continue much of the work that has been done by 
the Kennedy family and carrying on with the work that was done 
by both Senator Paul Wellstone and Senator Pete Domenici, 
senior Senator from my home State of New Mexico.
    In New Mexico, right now, we have an issue before us where 
the State of New Mexico under Governor Susana Martinez 
unnecessarily suspended payments to 15 behavioral health 
providers, claiming fraud. And the system was thrown into 
chaos. Now, even though every provider has been exonerated by 
the attorney general of the State of New Mexico, many of these 
providers have been forced to close their doors. And we all 
know who is left out. It was patients. It was the people that 
needed help the most.
    And so, Mr. Selig, can you talk to us about what such a 
disruption means for someone struggling with mental health 
issues? If their provider is suddenly gone, the trust that is 
established to try to get back in that door, what does that 
mean to someone that is struggling with mental health issues to 
try to get the support they need?
    Mr. Selig. Well, that sounds like a very regrettable 
situation, and I am sorry to hear about that situation in New 
Mexico. We represent, again, a lot of people who have mental 
health services. And when they are denied coverage, their 
services are interrupted. And we have seen really catastrophic 
effects for people. Their conditions get much worse. Someone 
with a eating disorder, for example, which is a high priority 
for us, who needs a particular level of treatment and is denied 
that level of treatment and is only provided access to a much 
lower level of care, really, their life is going to be in 
danger. And that person is really gravely at risk. Also, there 
is absolutely a connection between lack of addressing mental 
health and substance use services and deterioration of other 
health conditions. So when people aren't getting mental health 
services, other health conditions will suffer too. So people 
aren't as able to attend to situations like perhaps heart 
disease or diabetes.
    So really, there is a cascading effect when people aren't 
able to access mental health and substance use care that I 
think is really life threatening and disruptive, you know, to 
their lives and livelihoods for sure.
    Mr. Lujan. Well, along the same questions that 
Congresswoman Castor was asking that Congressman Green had put 
on the table with concerns of States that did not have Medicaid 
expansion. In New Mexico right now, what we are seeing is the 
State recently made a decision to cut provider Medicaid 
reimbursement by $400 million. And especially with the shakeup 
with the mental behavioral health system, we have grave concern 
and we are looking for some support.
    But specific to the reimbursement rates, Mr. Selig, is a 
low reimbursement for behavioral health providers in the 
Medicaid program an impediment to ensuring robust access? And 
how can we encourage more participation of behavioral health 
providers in the Medicaid program?
    Mr. Selig. I mean, I think thereis no question. I mean, 
that is what we hear from providers. They would love to be able 
to provide the services, be reimbursed through insurance. I 
think the rates are an important factor alongside the other 
burdensome kind of criteria that health plans place upon them.
    But going back to the rates, I think that it is absolutely 
connected to the inability of consumers to access providers 
because they are not in the network, because providers choose 
not to accept insurance because of low reimbursement rates. In 
Massachusetts, we have recently been able to increase, 
actually, reimbursement rates for outpatient providers. So we 
really applaud our State government for doing that. I think 
there is more work to do in that area, but that has been very 
well received by the provider community in Massachusetts. And I 
think it is going to have some impact going forward. So we 
would encourage other States to do the same.
    Mr. Lujan. I appreciate that. And, Mr. Selig, the other 
question I had for you you actually addressed, which was the 
impact to someone's physical health if they are not able to get 
the mental health care that they need. And you described 
exactly that impact. So I appreciate you addressing that.
    And, Mr. Chairman, you know, while I hope that the 
committee and the Congress will move forward to support 
Congressman Kennedy's legislation, I think the aspects that 
Congressman Kennedy also raised, which was brought up by our 
panelists today, about the importance of making sure that we 
have enough providers available to see everyone that needs care 
is something else that we need to take seriously. And the 
mental and behavioral health bill that passed the United States 
House of Representatives currently still needs to be funded. 
And I think everyone on this panel would support full funding 
of that legislation. And so I look forward to working with our 
colleagues to get that done.
    Mr. Guthrie. Thank you.
    And Mrs. Capps from California, you are recognized for 5 
minutes for questions.
    Mrs. Capps. Thank you, Mr. Chairman. And thank you all for 
your testimony. And I want to echo the thanks to our colleague 
Joe Kennedy for making sure this topic is received in this 
hearing. I hope it won't be the last one. I hope it is the 
first of really getting into this issue and doing some of the 
work we haven't done yet. Because for too long we have 
artificially looked at behavioral health as totally separate 
and unrelated to physical health. My previous questioner just 
made that point. But I want to go into it.
    Because we know that the two are so intrinsically linked, 
we need to ensure that our public policy recognizes the 
important fact that if we ever really want to help our Nation 
become more healthy and productive, this topic needs to be 
addressed. I am proud of the work that Congress has done over 
the years to address parity between the behavioral health and 
physical health services. And I want to be clear. We have come 
a long way, but that is not enough. What we have done is not 
enough.
    Too many individuals are still falling through the cracks. 
Too many communities, as we have heard, are unable to support 
those in need of affordable behavioral health services, even 
though the treatments are there and the results have been 
documented. I believe we have missed an opportunity to take the 
next necessary steps to address this issue in mental health 
legislation we considered here in this committee earlier this 
year.
    So today's hearing is a chance to reinvigorate this 
conversation, help guide this committee to do what is necessary 
to ensure that individuals get the care they need when they 
need it.
    Mr. Selig, I know you have been questioned, but you see the 
shortcomings in this current system so well. And while we know 
that these issues affect all in need in one way or another, I 
wonder if you would speak a minute about the compounding 
effects on more vulnerable and underserved populations like 
children.
    It is estimated that at least 13 percent of children are 
affected by mental disorders in a given year. Unfortunately, we 
know that pediatric specialists are few and far between. So in 
your experience, how does this lack of coverage affect 
children? Are there any unique access issues faced by children? 
You mentioned eating disorders, and that is just one. Is there 
a difference for children in Medicaid and CHDP and those with 
private insurance?
    Mr. Selig. Well, thank you for raising that, and 
particularly, Mrs. Capps, for highlighting the needs of 
children. There is, you know, no higher priority for our 
organization than trying to access mental health and substance 
use services for children. We do see specific types of services 
that are harder--that children have difficulty accessing. I 
mentioned a couple of them.
    Children with autism, very difficult to access, especially 
applied behavioral analysis services. Eating disorders you 
mentioned, another. And there are also, I would mention, many 
children, simply there is a long wait for services. 
Authorization for coverage may be in place, but--and this 
particularly speaks to children on Medicaid in our State. There 
can be lengthy waits for services, and I think that also 
connects to the issue of the availability of providers.
    So I would say that, you know, children, as much as any 
other population, are impacted by this kind of thing. They have 
very special needs. They see different providers than other 
people, obviously, and their needs are complex and they are 
intermingled with school concerns and family concerns. And so 
we are very cognizant of the needs of children and pay very 
close attention to them.
    Mrs. Capps. Thank you. You know, I so agree. I noticed so 
many--the many years that I worked as a school nurse, having a 
child on a waiting list is--in Congress in so many ways, 
because they change so dramatically over the months. Sometimes 
it is years. And by the time they can be treated and seen, 
those symptoms they had have exacerbated and become so much 
worse. And so the impact is so much more than their health. It 
affects their education, their ability to learn and work. It 
sets them on a pathway that is destructive, not opportunity 
challenging.
    And it is clear to me that any barriers to getting the care 
they need are not only harmful for the child, they really 
impact our society as a whole. The whole family is affected by 
it. It is really an urgency. And that is why we have to make 
sure that these services become more available.
    Again, I want to salute my colleague Joe Kennedy, and 
pledge my support for making sure this topic stays on the table 
and that it actually goes somewhere further. Thank you very 
much.
    And I am yielding back.
    Mr. Guthrie. Thank you.
    I also want to thank Mr. Kennedy and Chairman Upton and 
Vice Chairman Pitts for working together to make this hearing 
come together. I thank the witnesses for being here. I think 
that concludes all of our questions.
    Mr. Kennedy. I will take them if I got time.
    Mr. Guthrie. Well, no, the 9/11 memorial is coming, and as 
of now--I want to remind members they have 10 business days to 
submit questions for the record. And I ask the witnesses to 
respond to the questions promptly. Members should submit their 
questions by the close of business on Friday, September 23.
    So you have an opportunity to submit more questions, Mr. 
Kennedy.
    And the subcommittee stands adjourned. Thank you for being 
here.
    [Whereupon, at 10:31 a.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                Prepared statement of Hon. Ben Ray Lujan

    The Paul Wellstone and Pete Domenici Mental Health Parity 
and Addiction Equity Act was a signature achievement of New 
Mexico's longest sitting Senator, Pete Domenici. It was through 
his perseverance and that of Senator Ted Kennedy and 
Representatives Ramstad and Patrick Kennedy that Congress 
finally passed The Parity Act.
    But it was just a first step. I thank my colleague and 
friend, Congressman Joe Kennedy, for his efforts to build on 
his family's legacy and I look forward to working together to 
secure passage of more robust legislation that expands coverage 
for some of our most vulnerable citizens.
    As we all know, parity laws are undoubtedly a crucial step, 
but laws mean very little without access to mental health 
service providers and mental health facilities.
    In my State, we do not have a functioning mental and 
behavioral health system. When the State of New Mexico decided 
to unnecessarily suspend payments to 15 behavioral health 
providers claiming fraud, the system was thrown into chaos. 
Now, even though every provider has been exonerated of the 
charges leveled against them, the damage has been done--
providers have been forced to close their doors and continuity 
of care has been disrupted for vulnerable New Mexicans.
    I hope today's hearing will bring light to the many 
challenges faced by our mental health system and will serve to 
educate all of my colleagues on the importance of strengthening 
mental health parity laws and expanding access. Everyone 
deserves to live their healthiest lives, and mental health is 
no exception.
    This should not be a partisan issue--it is simply the right 
thing to do.

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