Understanding the Health Coverage Inequality

June 26, 2022

5 mins

Dane O’Leary

ABSTRACT

5 mins Health insurance companies are often reluctant to extend a level of coverage that’s even comparable to coverage of physical care. But why? Let’s discuss the mental and physical health coverage inequality.

Max Tillett was a healthy, athletic, football-playing teenager and the picture of perfect health until a helmet-to-helmet collision landed him in the hospital. The painkillers he was prescribed to assist with his recovery from his injuries turned him from a hometown hero into the subject of another tragic (and all-too-common) story of spiraling opiate addiction. 

During Max’s five-year battle with addiction, he regularly relapsed while dealing with his lingering head injuries, bipolar disorder, depression, and sleep disorder. Then he found a ray of hope when he checked into rehab. According to his mother, the rural landscape surrounding Max’s chosen drug rehab offered a change of scenery that he so desperately needed. Max really liked it there and seemed to be on the road to recovery at last…until United Healthcare ended his coverage at 21 days, which is less than half of the 45 days recommended by the rehab’s intake team.

In a letter denying him the additional coverage, United Healthcare said: “You have been able to get off drugs. You have made progress in the program. You do not have extreme health or emotional problems, including from coming off drugs. You do not need 24-hour nursing care. Your care could go on in a less restrictive setting, such as outpatient.”

Hoping to extend his coverage for the full 45 days, Max filed an appeal, prompting a second and equally callous response: “You have been able to move towards recovery by identifying triggers or issues that often lead to substance usage… Your mood and sleep have seemed to improve as well.” 

United Healthcare paid for the failed revival attempts after denying coverage for the addiction treatment that would’ve saved Max’s life.

Although United recognized that he needed additional treatment, the insurance provider was set on not covering the remainder of Max’s care in the residential setting. As a result, Max was discharged without further plans for treatment. Despite the best efforts of his friends and family, Max—who had just become a father—died of an overdose in September 2015, just mere two-and-a-half months later. 

Even though the company prioritized saving money over ensuring access to the right mental health treatment, United Healthcare was willing to cover the full cost of the medical bills resulting from the failed attempts to revive Max after his overdose, which exceeded $9,000 in total. Because according to policy, the attempts to revive him are considered “vital medical care,” meaning the expensive (and ultimately futile) treatments couldn’t be denied. Yet the company didn’t hesitate to deny continued coverage of the addiction treatment and mental health support that would have saved Max’s life, according to his mother.  

Max Tillett's parents hold a photo
Courtesy of Aaron Lavinsky, Star Tribune

What is the Mental & Physical Health Insurance Coverage Inequality? 

Max Tillett’s story is just one of the many examples of the health insurance companies undercutting our need for mental health care. Even though mental health and physical health are intimately linked, the reality is that they are simply not assigned equal weight. Specifically, health coverage for mental disorders and health coverage for substance abuse treatment receives far less coverage than for physical illness and medical crises. 

The Covid-19 pandemic highlighted this disparity as there have been countless people to relapse or escalate their substance abuse in response to stress, driving up overdose death rates to record highs.  

Despite proponents of mental health care being numerous and vocal, caregivers and mental health providers continue to receive lower payments than providers who cover physical health. This means patients don’t have access to valuable, and potentially life-saving, preventative treatments. 

Health insurance companies are yet to understand the value of preventative care for mental health.

Health insurance companies are yet to understand the value of preventative care, particularly for one’s mental health. On the one hand, it’s easy to write this off as typical insurance greed; however, when compared to the auto insurance industry, which has no issues spending time, money, and resources to prevent crashes and rewarding safe drivers, this disparity becomes a more glaring issue.  

Ultimately, risk determines insurance prices. Because of the pandemic and the emotional difficulties associated with quarantining, more people are at higher emotional risk and in more need of mental health treatments. This is an institutional problem that needs to be addressed to prevent more people from ending up like Max.  

However, there are several significant obstacles we must overcome before we can close the health coverage gap. 

Enforcement Obstacles 

Although there are laws against such inequalities already, insurance companies continue to fight them every step of the way. And enforcing the legislation isn’t easy: Investigations can take months or even years and insurance companies know that many people lack the time and resources to fight their decisions, denials, and underpayments. 

Unfortunately, bad situations can (and do) escalate fast. A person can end up dead long before he or she can receive a payout owed by the insurance company. Even before the pandemic, the odds of being forced into an out-of-network provider quintupled when faced with mental health issues versus physical health problems. 

This inequality has led to a secondary issue, which is that providers are basically being disincentivized from pursuing careers in mental health care. Fortunately, telehealth has eased certain burdens for providers of mental care with reduced cancellations and a higher patient-per-hour rate. But conversely, the answer to the inequality problem isn’t to turn the mental health system into an assembly line that cycles patients through, one right after the other. 

A Brighter Future 

Fortunately, some progress is being made. Congress gave the Labor Department’s Employee Benefits Security Administration expanded power to enforce these laws on insurance companies. This means the administration now has the power to threaten excise taxes or lawsuits and now requires written comparisons of physical and mental health coverage levels. In a sobering report, none of the 156 comparisons that have been submitted measure up to their standards. 

Enforcement to stop the coverage gaps have become a “top priority” for the administration as it moves forward with a focus on arguing against medical necessity limitations and expanding accepted standards of care. In the future, it’s possible that health insurance companies may recognize the cost-saving value of proactive and preventative treatment instead of adhering to a crisis-stabilization model since the former can save lives in addition to increasing quality of life. 

Never Alone Recovery Is Here To Help 

Drug rehabs in Indiana, as well as nationwide, vary between in- and out-of-network providers. As you search for “drug rehabs near me,” it can be quite difficult to tell the difference. Instead, you can call our toll-free number to have one of our treatment coordinators match you to the drug rehab that’s perfect for your needs. 

When you work with Never Alone Recovery, the best rehabs are within your reach, so be sure to reach out to our team today.


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