PROVINCETOWN — The mental health bill that became state law on Aug. 10 includes a dizzying array of provisions. There are titles that improve mental health access in schools and in prisons, programs that make it easier for mental health practitioners to begin work in Massachusetts, and a new rule that allows people with disabilities to continue to be covered by their parents’ health insurance even after they turn 26.
At the core of the law, however, is an effort to enforce the state’s 22-year-old promise of “parity” in mental health — that is, the idea that mental health care should be available and paid for in the same way that physical health care is.
The state’s first parity law was passed in 2000 and updated in 2008. The federal government passed parity laws in 1996 and 2008, and mental health is one of the 10 “essential health benefits” under the Affordable Care Act of 2010.
Nonetheless, the devil is in the details when it comes to health insurance. Low reimbursement rates for mental health care means that few providers actually accept insurance. Hospitals get reimbursed poorly for the care they give in their emergency rooms. In other words, access to care is a persistent problem because insurers have not been paying for it.
“The core foundation of this is enforcement of federal and state parity,” said state Sen. Julian Cyr, who was the Senate’s lead negotiator on the bill. “Even though we’ve had state laws related to parity on the books for almost two decades, it’s just been unenforced.
“This law clearly states all the requirements that insurers must have,” Cyr continued. “It establishes oversight and penalties. This is going to force a real change, particularly in the reimbursement rates.”
Massachusetts has one of the highest per capita rates of mental health practitioners in the country, Cyr said, but many of them do not accept insurance at all. “You may theoretically have insurance coverage,” he said, “but if there’s no therapist taking that care, how are you going to get access?”
The problem exists across the spectrum of mental health needs — from ordinary appointments with a therapist to emergency treatment for acute psychotic episodes.
“Reimbursement rates are so low that there’s no incentive for health-care providers to have a psych unit,” Cyr said. “A number of hospitals have closed those units. Cape Cod Healthcare closed their pediatric psych unit maybe a decade ago.”
As things stand now, it can take days or weeks to find an inpatient bed for psychiatric care, especially for minors. At a youth suicide-prevention forum held this spring in Truro, parent Beth Cook described her daughter’s long wait for an inpatient psychiatric bed at Cape Cod Hospital, according to a story about the forum in this newspaper. After six days, the family gave up on inpatient care and opted to drive daily to Pembroke, 80 miles away, for outpatient care.
“The emergency boarding crisis is catastrophic,” Cyr said. “You can be boarding in the emergency room for 14 days, waiting to get a bed” in a psychiatric unit.
The cost of the time spent waiting in the E.R. is not reimbursed. “The hospital doesn’t get paid for the days you’re there waiting to get care,” Cyr said.
The state’s latest attempt to undo these perverse incentives was largely due to Senate President Karen Spilka, Cyr said. Spilka has been open about her father’s acute psychotic episodes and the fear she and her brother felt as children, and she made this bill her “number one personal priority” after she became Senate president in 2018, according to Cyr.
“The senate president set the agenda here, and I think it really shows what’s possible when leadership shifts,” Cyr added.
Cyr also said that people are more open now about mental health challenges than they were in the past, and that many legislators have struggled to access care. Cyr pointed to his own history with depression and anxiety, which became acute when he was in college.
“I was lucky — there were pretty robust student health services at N.Y.U. — and that care helped me manage my anxiety and do things I never dreamed I could do,” Cyr said. “Even so, as a 30-something health policy wonk and state senator, it took me years to get my insurance to cover my mental health care. And even today it’s a bizarre reimbursement process that I don’t quite understand.”
The new law also contains some measures to amplify an approach called “alternative response,” which envisions a system for responding to mental health emergencies that is less centered on law enforcement than the current system. Currently, Bay Cove Human Services provides some emergency service programs on Cape Cod, but it is funded only for patients on MassHealth. The new law forces all insurance companies to help pay for emergency service programs, Cyr said.
Federal legislation recently turned the national suicide hotline into a new emergency phone number: 988. Massachusetts is hoping to expand its 988 line into a “one-stop shop” to help people access mental health resources of all kinds, including clinicians trained in emergency response.
“On Cape Cod, 70 to 75 percent of 911 calls are related to mental health, addiction, and domestic issues,” Cyr said. “You look at 911 response, and there isn’t even a call script for someone in an acute mental health crisis.”
Police will still be the first responders, especially in rural places like Cape Cod, Cyr said. But an expansion of emergency service programs means the police should have much easier access to mental health professionals who can help them respond to crises.
Wellfleet Police Chief Michael Hurley confirmed that mental health calls were a large part of police work now. He said he welcomes the newly enacted law, but he would like to see more resources devoted to prevention in addition to crisis intervention.
“When people are calling us they’re in crisis,” said Hurley. “We’re past prevention. The only tool in our box is to send the person to Cape Cod Hospital. If we could tackle prevention a lot more, with the support of clinicians and navigators, that would make a big difference. We need to come up with funding for that.”