In Fresno, people with Medi-Cal insurance often have far more mental health resources than those with private insurance, says Matthew Tatum, CEO of Sierra Meadows Behavioral Health.

One of the reasons Tatum started Fresno-based Sierra Meadows Behavioral Health was a lack of available options for mental health care in Fresno.

“At that time, we only had outpatient therapy and then inpatient psych hospitals. So, anybody who fell in between in terms of their mental health symptom severity, like in the moderate range or moderate to severe range, there are no services for people,” Tatum said.

But Fresno’s missing middle isn’t unique. Across the nation, those with employer-backed insurance often struggle to find care.

In 2008, U.S. Congress passed the Mental Health Parity and Addiction Equity Act requiring insurers to treat coverage for mental health needs the same as they would for physical health. But care providers and insurers were left to figure out what exactly that meant, Tatum said.

A “Wild West” of patchwork legal decisions left the competing industries on their own to figure out what to charge and what to pay, Tatum said. The result has largely been therapists and psychologists simply not accepting insurance — leaving patients with private insurance having to pay cash for care.

Biden’s Rules Are Supposed to Provide Clarity

On Sept. 9, President Joe Biden finalized rules ordering insurers to make sure their networks and payments are not more restrictive than with physical medical care. It also requires prior authorization rules for treatments prescribed by psychologists not be any more stringent than those prescribed by medical doctors.

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But the rules now have the industry divided. Some of the nation’s largest insurers say coverage will decrease and costs will go up.

Tatum and others say what’s always been needed is enforcement. Enforcement could provide the needed predictability for therapists to get paid for their work. Tatum called for a governing body to oversee enforcement.

While Medi-Cal operates on a single set of rules with the state to regulate to enforce the rules, the same doesn’t apply to commercial insurance, he said.

“You have dozens and dozens of health insurance companies that are all to some degree allowed to set their own rules,” Tatum said. “And so I think that makes things way more complicated than enforcement from a medical level.”

Fresno a Microcosm of Mental Health Care for Middle Class

Moderate levels of depression might be when a person is functioning, but they struggle to do so, Tatum said. Someone with mild symptoms might not want to go the gym. It becomes more serious when that feeling extends to things like work.

“I don’t feel like going to work and I’m going to bail early and risk getting in trouble or risk my job, or I’m just going to sit at my desk and stare at my screen,” Tatum said. “Not out of choice, but out of the onslaught of depressive symptoms.”

Those feelings can progress to suicidal thoughts, especially if untreated.

In the Central Valley, Tatum didn’t see the level of resources available for the 35% to 40% of the Fresno community with employer-based health insurance he would see in other large cities.

Medi-Cal patients not only have access to many of the same therapists as those with private insurance, but they have access to county programs, including inpatient care.

For inpatient care, whether substance abuse or depression, costs can be as much as $60,000 a month.

When Tatu, started Sierra Meadows, he was told there wouldn’t be a market for inpatient care covered by private insurance. The perception had long been there wouldn’t be enough demand considering Fresno’s conservative attitude toward mental health.

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It took some education for outpatient therapists to learn that there were options for their more chronic patients who can’t maintain their sobriety or who have continual emotional episodes.

Once they learned about available resources, Tatum saw a big demand, especially after the COVID pandemic. When Tatum first opened, it was him and two other employees. Last week, they onboarded their 200th employee, he said.

Biden Rule Change Doesn’t Address Core Problems: Insurers

Unless a patient has the cash to pay for treatment, finding a therapist or counselor who accepts insurance can be difficult, said Amanda Nugent Divine, CEO of Kings View Corp.

“Unlike in physical health, more mental health professionals can run a successful practice without taking any insurance and so they do to avoid the headache and low reimbursements from the insurance companies,” said Amanda Nugent Divine, CEO of Kings View.

That compounds the problem by creating a “woefully inadequate” network of providers, further increasing out-of-pocket costs. Nugent Divine said those increases would likely sabotage attempts at parity.

That shortage of providers undermines attempts at increasing access to coverage, said the Association of Behavioral Health and Wellness, the Blue Cross Blue Shield Assocation and the ERISA Industry Committee in a joint statement. The groups, largely backed by insurance companies and employers, said the Biden rules do not address the real problems of coverage, such as connecting patients to providers, expanding telehealth and improving training.

“Rather than increase access to mental health and substance use disorder care, the new rule could reduce access to quality of care and increase costs so significantly that employers may be forced to drop mental health care coverage entirely — coverage that is currently provided voluntarily,” the news release stated.

Enforcement Is Needed: Providers

In 2008, when insurers first had to provide for mental health and substance abuse services, they didn’t know how much care costs or how long they should approve services for, Tatum said. And in many cases, providers used that uncertainty to gouge insurance companies, Tatum said.

That led to a pull-back in coverage rates.

“One way insurance companies can control their costs is decreasing authorizations, meaning giving people less time or denying people services for particular conditions they think may not qualify them for a certain level of care,” Tatum said.

Tatum gives the example of residential detox, which is as close to medical as the industry gets. Even with clear symptoms and treatment, it’s still a fight to get authorization, he says.

One outpatient therapist Tatum spoke with told him he was only making $12 an hour after insurance payments and overhead. That therapist closed his practice.

Both the American Psychiatric Association and the American Counseling Association praised the Biden action.

“Ensuring that insurance benefits for mental health care and substance use disorder services are equivalent to other types of health care is critical,” said Todd Guila, director of government affairs and public policy with the counseling association. “Despite the Mental Health Parity and Addiction Equity Act being enacted by Congress in 2008, insurance coverage disparities continue.”

Tatum said a governing body to enforce consistency would help, and a hotline could assist patients who don’t think they’re being treated fairly.

“If they want to regulate these things well, there has to be a forum in which people can voice their concerns when things are not going according to plan,” Tatum said.