Trumps Rollback of Rules for Mental Health Coverage Could Lead More Americans to Go Without Care
by Maya Miller and Jeremy Kohler ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as theyre published. During his first term, President Donald Trump frequently turned to the issue of mental health, framing it as a national crisis that demanded action. He linked it to opioid addiction, mass shootings and a surge in veteran suicides and he later used it to argue against COVID-19 lockdowns and school closures.At times, he backed up his rhetoric with action. His administration issued tens of millions of dollars in grants to expand community mental health services and continued funding contracts to help federal regulators enforce the parity law, which requires insurers to treat mental and physical health care equally.But just months after Trump returned to the presidency this year, his administration paused new rules issued in President Joe Bidens final months that were designed to strengthen mental health protections and hold insurance companies accountable when they unlawfully denied coverage. That pause came after an industry group that advocates for large employers on issues related to employee benefits filed a lawsuit seeking to block the new rules.Whats more, Congress has curtailed funding for the Employee Benefits Security Administration, or EBSA, a small agency in the Department of Labor that enforces mental health parity in most employer-sponsored health insurance plans. The squeeze is largely due to the expiration of temporary supplemental funding Congress approved just weeks after Biden was elected president but before he took office.While the impact of these changes is hard to measure, federal employees, policy experts and front-line workers warn that suspending the rules and cutting enforcement funding could have serious consequences. They say it could mean longer waits for help when patients challenge insurance decisions, fewer investigations of insurers and employer health plans over possible violations of federal mental health protections, and more people going without care theyre legally entitled to.Their long-term predictions include more untreated mental illness and growing anger at insurers. Imagine if you are a parent calling about lifesaving care your kid needs, said Ali Khawar, who was second in command at EBSA before stepping down at the end of the Biden administration. With less money and fewer employees, he said, the agency isnt equipped to open new investigations quickly.The suspended rules were meant to strengthen enforcement of the 2008 Mental Health Parity and Addiction Equity Act. The failure to provide the same level of access to mental health care as physical care has been well documented by researchers as well as by a recent ProPublica investigation. We found that insurers often block care, underpay mental health providers and make it hard for patients to find help sometimes with deadly consequences.The rules, released in September 2024, required health plans to gather and report detailed data on how they restrict or deny mental health claims. If the plans found disparities when compared with medical care, insurers had to explain what they were doing to close those gaps, a requirement the Trump administration put on hold.In his first term, Trump positioned himself as an advocate for expanding mental health services and strengthening parity enforcement. His commission on opioid abuse even recommended giving EBSA more authority to penalize insurers that violate the parity rules, though Congress never approved the proposal.But after returning to office, his administration has moved to roll back several Biden-era initiatives, from solar energy grants to student loan relief. The new parity rules were no exception.Days before Trumps second inauguration, the ERISA Industry Committee, or ERIC, a trade group representing large employers on employee benefits policy, sued to block the regulations. After that, the Trump administration went to court to ask to have the lawsuit paused while it considered whether to rescind or modify the rules.A federal judge granted the request, and the Trump administration promised not to enforce them during the litigation or for 18 months afterward.ERIC says that the new rules went beyond what Congress intended when it created the mental health parity law and were too vague and burdensome. But advocates for the new rules said the action effectively gutted the parity laws strongest protections.The expectation was that these rules would be incredibly significant in driving better compliance, Khawar said. So now that it is on hold, it is a significant benefit that will never be realized.James Gelfand, ERICs president and CEO, said he believed the Biden administration went too far.While we do support mental health parity generally, we dont support this rule, he said. We dont think that the Biden administration had any authority to write it. He added that it created an impossible standard that we cant meet, and that rules were purposely vague so they could choose to enforce against whoever they wanted, whenever they wanted.EBSA, which safeguards workplace benefits for 150 million Americans, has always had to make do with a small staff, and it was struggling even under the Biden administration, which backed its mission. In a 2023 report to Congress, the agency acknowledged that with one investigator for every 7,700 health plans, its resources are limited compared to the vast universe that it regulates.Those limits showed in the results: Between February 2021 and July 2024, EBSA conducted 150 investigations and issued just 70 letters finding violations of the parity law though in many other cases, the agency worked with insurers and employers to resolve problems without a formal violation finding.And now it is pressing ahead with far fewer employees. The Senate Appropriations Committee has proposed holding EBSAs base funding at the same level as last year but without the temporary boost Congress provided under the December 2020 No Surprises Act. That law, designed to protect patients from surprise medical bills, included extra funding to help EBSA handle a surge in complaints and new responsibilities.That funding expired a few months after Biden left office. With that support now gone, EBSAs workforce is set to drop by nearly one-fifth from two years ago, from 831 workers in 2024 to 687 or fewer employees in 2026.The Senate Appropriations Committee signaled that mental health parity enforcement was still a priority, including a note in its bill report saying it supports additional efforts directed toward systemic and targeted audits of health care coverage provided by employee-sponsored plans and to ensure parity between mental and physical health care coverage as required by current law.Gelfand said his group wanted EBSA to be robustly funded so it could work to help employers comply with the law. But he said that until EBSAs mission changes, his organization supports not adding funding.Although many of the positions were lost through attrition in the months leading up to the expiration of No Surprises Act funding and the start of Trumps second term, other staffers left soon after Trump took office through voluntary separation packages.Neither the White House nor representatives for EBSA responded to questions about the paused rules or the reduced funding.A front-line worker said with so many departures, key institutional knowledge was lost. The losses have hit hardest in two key areas: The benefit advisers, who field calls from people around the country facing insurance denials they believe are wrong, are down by about 30%. The investigative staff, which leads the in-depth probes into insurance practices, has shrunk by nearly 40%, according to current and former employees. As a result, investigators are juggling higher caseloads and people seeking help are facing longer delays.EBSA oversees a wide range of employee benefits, including retirement plans, health coverage and protections under federal labor law. In recent years, enforcement of mental health parity laws has grown to make up about 25% of its investigative work, according to current and former officials.The agency has the power to help millions of patients who have health insurance through their workplace. When investigators reveal systemic violations, they can require whats known as a global correction, forcing insurers or plan administrators to fix a problem across multitudes of plans and patients. For example, after an investigation by EBSAs Kansas City office, a major claims administrator agreed to stop denying drug testing tied to substance use treatment, reprocess more than 3,000 claims and return nearly $2 million to patients and providers.For some families, it can be a matter of life or death.During the darkest months of the pandemic, a Massachusetts woman, who asked that her name be withheld to protect her teenage daughters privacy, watched her child unravel. Isolated at home, the girl started following social media videos of people cutting themselves and soon began doing the same. She became severely anorexic and started talking about suicide.The parents got their daughter admitted to a residential treatment center, believing it was her best chance of improvement. But their insurer denied coverage, leaving them with more than $80,000 in bills. What followed was a two-year battle for reimbursement. So she turned to the Department of Labor for help. An EBSA investigator took the case, helping her navigate the complex claims process and advocating for her in negotiations with the insurer.Last year, the insurer agreed the claim had been inadvertently denied in error and agreed to repay most of what the family had paid.
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