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State Sen. Jim Beall is angry.

Four times now, he has introduced legislation to better enforce state and federal “parity” laws, which require equal treatment of mental and physical health problems. Four times, that legislation has failed.

As he enters his final year in the Legislature, the San Jose Democrat plans what he calls a “full-frontal assault.”

“I’m going to put even more effort into next year,” Beall said, “because I’m madder than hell about it.”

California’s parity mandate was signed into law in 1999, and a federal parity law followed in 2008. But the state has struggled to ensure those laws work‚ which helps explain why parity feels like an empty promise to so many Californians. More than half of Californians believe that most people with mental health conditions can’t get the services they need, according to a poll conducted last year by the Kaiser Family Foundation and the California Health Care Foundation.

Those who do get services often have to search hard and pay extra for them: California patients were more than five times likelier to have office visits for mental health or addiction problems from providers outside of their insurance plan’s network than patients seeking medical or surgical care, according to a new analysis by healthcare consultants Milliman Inc. Insurers here paid primary-care providers 15 percent more than they paid behavioral-health providers.

“We need stricter enforcement of mental health parity laws,” Gov. Gavin Newsom declared during his campaign. That didn’t happen again this year, although Dr. Tom Insel, Newsom’s top mental-health adviser, recently told CalMatters the administration intends to take “a fresh look at parity enforcement.”

“Instead of doing this topic by topic, let’s step back and find an overall plan, a blueprint, that tells us: What’s the system we want?” Insel said. “I don’t think the state’s done that for a long, long time.”

What state officials have been doing is rebuffing many attempts to tighten parity enforcement. The most recent failure: Beall’s 2019 bill to ramp up requirements for health plans to report parity-compliance data to state agencies each year instead of every three years, as it does now. The bill would have required the agencies to report results to the Legislature, and to post them on their websites to make them easily accessible to the public. Beall says that would help make the state less reliant on patient complaints to trigger enforcement. The bill also would have prohibited insurers from requiring prior authorization and “step therapy”—or making patients first try lower-cost medications before receiving other prescriptions to treat substance abuse.

With a public desperate for better mental health services, what is keeping the state from ensuring that health insurers and plans comply with state and federal parity laws?

Some note the lack of the kind of broad, emotionally affecting campaign that has moved the needle in other states. There’s also disagreement among mental-health advocates about whether Beall’s proposals would best address the problem.

The senator, for his part, has another explanation.

 “The insurance companies have too much power in Sacramento on the subject of mental health,” he said. “Whatever support I’ve gained has been countered by them effectively. … They’re the best lobbyists in Sacramento that money can buy.”


Industry representatives maintain that a crackdown is unnecessary, saying the real challenges relate not to compliance, but to a well-documented statewide shortage of mental-health providers.

“Health plans in California have made mental health a top priority, going above and beyond what the mental-health laws are requiring,” said Mary Ellen Grant, spokeswoman for the California Association of Health Plans. Many plans are putting behavioral health providers in primary care offices and using more telemedicine, she said. “We’re not aware of any legislation that would improve whatever it is that Sen. Beall thinks is the issue.”

Leanne Gassaway, a senior vice president for America’s Health Insurance Plans, warned “there will be 50 different flavors of auditing and reporting” if each state creates its own parity reporting tool. Instead, she recommended the federal government create a single one.

“We don’t have a problem with reporting,” she said.

States aren’t asking the right questions or getting granular enough data, said Dr. Henry Harbin, former CEO of the managed behavioral health care company Magellan Health. The result: California’s approach “has not produced the change you would expect it to have.”

Once a problem is identified, is the state doing enough to enforce it? 

Beall doesn’t think so, and neither does Meiram Bendat, a Los Angeles attorney and psychotherapist who won a much-touted case this spring. In that case, a Northern California federal court found that United Behavioral Health had wrongly restricted treatment for patients with mental-health and substance-abuse disorders in order to cut costs.

Bendat said that, over the years, many patients had asked the state Department of Managed Health Care for help with mental-health claims denied by United Behavioral Health. But he said the department, which oversees health plans that receive monthly fees to provide health care for their members, has failed to inform the public of any systemic, corrective action against the insurer.

He uses the terms “toothless and ineffective” to describe the department’s parity enforcement.

California allows plans to decide, for themselves, what makes a treatment “medically necessary” based on clinical standards. Critics, such as Bendat, contend plans often apply the wrong standard of care. Some other states require the use of medical necessity criteria determined by nonprofit, clinical specialty organizations.

“California is behind the curve in this regard,” Bendat said. “The abuses that we see by managed care are widespread and ruinous, and they need to be stopped,” he said.

Bendat and others do praise the work of the Department of Insurance, which covers a small fraction of the state’s health plans.

The Department of Managed Health Care said in an email that it “works diligently to ensure that health plans comply with state and federal requirements regarding mental health services.”

This includes surveying all licensed plans every three years, interviewing plan staff, reviewing enrollee files, and tracking complaints. In recent years, the department added two staff members and conducted focused comprehensive reviews of 25 health plans’ methodologies for providing mental health services. It then required those plans to eliminate impermissible day and visit limits, revise prior authorization requirements, and reimburse enrollees a total of more than $517,000. In the last decade, it has cited health plans dozens of times for mental health-related violations, resulting in more than $4 million dollars in fines—most levied against Kaiser in 2013.

The department says if patients feel they have been denied medically necessary treatment by their health plans, they can appeal to the state for an independent medical review. But critics say the vast majority of patients never appeal.


Sen. Beall is outraged by the swelling numbers of untreated individuals residing under doorways and overpasses.

“It sounds horrible, doesn’t it?” he said. “That’s because that’s what it is. It’s a horror.”

Beall was an undergrad studying urban planning and political science at San Jose State in the early 1970s when Gov. Ronald Reagan began shuttering the state’s mental hospitals at the same time traumatized veterans returned from Vietnam.

Years later, as a Santa Clara County Supervisor and liaison to the county mental-health commission, Beall learned how mental health and substance abuse impacted all corners of society: housing, criminal justice, health, education and foster care.

“We kept seeing people ending up in our system because private insurance wouldn’t cover them adequately,” he said.

After Beall was elected to the Legislature in 2006, he began trying to pass laws to strengthen mental health parity. One made it through the Assembly and died in the Senate. Another made it through the Senate and died in the Assembly. A third, which would have allowed additional penalties of $2,500 per patient per day for each parity violation, was vetoed by Gov. Jerry Brown, who said the state insurance commissioner already had “broad authority” on enforcement. The most recent bill never left the Senate.

 “I’m in a lot of pain right now. It hurts,” Beall said at a Sacramento forum on mental health organized by CalMatters a few days after the latest bill died. He has spoken publicly in the past about having a family member with schizoaffective disorder. “I tried four times, and it’s actually getting harder to get it passed. … My own colleagues killed it.”

The industry has opposed parity laws for a long time. Health insurers “fought tooth and nail” against California’s state parity law, stopping it twice in the 1990s before it ultimately became law, said the law’s sponsor, former state Assemblywoman Helen Thomson of Davis. A psychiatric nurse-turned-legislator, she said the law was eventually pared back to cover just nine serious mental illnesses because of this pushback.

In the case of Beall’s most recent bill, he says he had to remove the parity provisions, because staff and members of the Senate Health Committee didn’t agree with them. But he also insists that some of his colleagues are too connected to health insurers, allowing former staff members and legislators who work for the industry to use these relationships to stop his bills.

In the years that Beall has been trying to pass parity legislation, health insurers have contributed almost $10 million directly to winning candidates and industry lobbyists have spent more than $85 million.

Other states did pass parity-related bills last year, among them Colorado, Connecticut, Delaware, Illinois, New Jersey and Tennessee. A massive publicity effort featuring compelling personal stories, combined with negotiations, may be part of the equation—and part of what’s been missing in California. Health insurers have often dropped their opposition after intensive negotiations and media and education campaigns, said Tim Clement, director of legislative development at the American Psychiatric Association.

Clement, who was at the negotiating table in many of those states, but not California, called it “pretty close to impossible to get a bill passed if insurance industry-opposed.” He blamed California’s inaction partly on the lack of “a cohesive, boots-on-the-ground movement” for parity.

In Colorado—which just passed an expansive parity bill that will close loopholes, improve transparency and enforcement, and strengthen mental health prevention and screening—“we just were relentless,” said Lauren Snyder, state policy director with the advocacy organization Mental Health Colorado. That included working with media outlets to share personal stories of individuals harmed by lack of mental health care, and ads urging people to contact their legislators.

Such a movement was part of what eventually worked in California in the 1990s, said former Assemblywoman Thomson. She said she had a full-time public-relations person working on the effort to pass a parity law; that major newspapers in the state editorialized in its favor; and that many legislators gave personal testimonies about how a lack of mental health care had impacted their loved ones.

That law now has strong provisions for the coverage of medically necessary treatments for serious mental illnesses like schizophrenia and bipolar disorder, but does not cover a wide range of other mental-health conditions or substance-abuse disorders. Some parity advocates say California needs to ensure medically necessary treatment for more individuals, including those with substance-abuse disorders. 

Dr. Richard Pan, a Sacramento pediatrician who chairs the Senate Health Committee, wants to give plans more incentives to serve people with serious mental illnesses.

“No one wants to be known as the health plan with the best mental-health coverage or diabetes or asthma,” he said. His idea: a shared risk pool to reward plans that provide quality care for people with chronic conditions.


For a long time, Sen. Beall has “carried the mantle on (mental health parity), kind of alone,” said Sacramento Mayor Darrell Steinberg, a former state Senate leader who founded the Steinberg Institute to advocate for mental health policies.

Beall calls his inability to pass parity legislation thus far “my biggest failure as a legislator.”

Earlier this year, the Assembly passed a resolution calling on all relevant state agencies and the Attorney General to ensure that all health insurers are complying with federal and state parity laws. But a resolution, while it may raise awareness, is akin to a suggestion.

Beall says he’d like to introduce one more parity bill before he terms out—though he’s still working out the details.

“My style is to keep fighting and fighting and fighting,” he said with a laugh. “I don’t give up.”

Jocelyn Wiener is a CalMatters contributing writer. Her reporting is made possible by a grant from the California Health Care Foundation. CalMatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Local Issues

Elizabeth Brown’s bedroom holds a trove of evidence of her fight to save herself.

Preserved among Twilight novels, posters of Korean pop singers and cameras she used for her budding journalism career are clues about the Santa Rosa teenager’s agonizing struggle with the mental illness that claimed her life last year.

Next to her bed sits the lavender candle she lit to soothe herself. On her desk are the bunny slippers she wore when she was too depressed and anxious to leave the house. Taped to the wall are two plastic hospital bracelets from separate psychiatric admissions in 2017.

Underneath them hang four sticky notes, on which she had printed:

“channel all the anger, sadness, hurt into this one thing”

“you can have control”

“you can be beautiful”

“this pain is good.”

The cutting, the suffocating despair, the suicidal thoughts—those details live in the journal she hid behind a password on her laptop.

“She really tried hard,” says her mother, Seong Brown. “She believed in the medical system to help her.

“But they failed at every turn.”


Around California, people with mental illness—and their family members—talk about pleading with insurance providers for treatment.

Their stories share an underlying premise: Despite policy advances in the last two decades intended to compel insurers to provide equivalent levels of care for physical and mental illnesses, the reality on the ground still looks very different.

A poll released in January by the California Health Care Foundation and the Kaiser Family Foundation found that more than half of those surveyed thought their communities lacked adequate mental-health-care providers, and that most people with mental health conditions are unable to get needed services.

The state Department of Managed Health Care has cited health plans dozens of times in the past decade—penalizing them millions of dollars—for mental-health-related violations.

And earlier this month, a federal judge in Northern California ruled that United Behavioral Healthcare had wrongly restricted treatment for patients with mental-health and substance-abuse disorders in order to cut costs, in violation of federal law.

Not all problems with access to mental health care are illegal, but some almost certainly are, said David Lloyd, policy adviser at The Kennedy Forum, a nonprofit mental health advocacy organization founded by former congressman Patrick Kennedy.

“There’s a lot of evidence that discrimination by plans is happening,” he said.

Experts say mental health has been underfunded historically, in part because of prejudice against people with mental illness and substance abuse disorders.


California enacted a law requiring health plans to provide coverage for the diagnosis and treatment of severe mental illnesses in 1999.

A decade later, in a major victory for mental-health advocates, the state passed a law requiring health plans that offered mental health coverage to provide the same level of care they gave on the medical/surgical side. The law was strengthened again in 2010 when the Affordable Care Act listed mental health as an essential benefit that insurers were required to provide.

Insurers say they’re doing their best to comply with these laws but face a shortage of mental-health providers. Plans are working closely with state regulators and using a variety of methods, including virtual appointments, to meet these “serious challenges,” said Mary Ellen Grant, spokeswoman for the California Association of Health Plans, a trade group that represents insurers.

Most plans no longer limit the number of visits to a mental-health provider, nor do they charge higher co-pays or deductibles. But that hasn’t made access to mental and physical health care equivalent, said Lloyd of The Kennedy Forum.

The primary challenges for patients now exist in areas harder to track and quantify, including pre-authorization requirements and determinations of what is “medically necessary,” he said.

Parity laws are often so complex that it can be hard for people to know whether the barriers they face are actually illegal or just feel unfair, said Jennifer Mathis, policy director at the Bazelon Center for Mental Health Law in Washington, D.C.

“Most people aren’t able to figure this out,” Mathis said.

All many people know is that their loved one desperately needs help—and isn’t getting it.


In early January 2019, on the first anniversary of the day that Elizabeth Brown took the action that eventually ended her life, her parents, Seong and David, sat at the kitchen table in the immaculate Santa Rosa home that Seong, an architect, designed.

Seong retrieved an email from her husband’s colleague detailing cancer treatment his wife received from Kaiser Permanente. While Elizabeth descended into mental illness, their friend’s wife was treated by a team of oncologists, nurses, counselors, social workers and outside specialists.

“This is what she got,” Seong said. “And she’s still here.”

Citing federal privacy laws, Kaiser declined to comment on Elizabeth’s care. In a written statement, the company said, “This is a heartbreaking story, and our condolences go out to the Brown Family and her loved ones. While we can’t speak to any individual case out of respect for the privacy of those involved, the loss of any person greatly saddens every physician, therapist and nurse involved in that patient’s care. We review each case extensively and when opportunities to improve are discovered, we share that knowledge with our care teams.”

Elizabeth was a top student, her parents said. She earned a black belt in karate, played piano and was a violinist in the San Francisco Symphony Youth Orchestra.

After sophomore year, she applied to Bard College at Simon’s Rock in Massachusetts and started there before her 16th birthday. She made the dean’s list.

She also started having panic attacks. In May 2016, after her second year at Bard, she asked to see a therapist.

“Something’s not right, Mom,” Seong said she told her.

A few days later, Elizabeth first met with a Kaiser psychologist in Santa Rosa, beginning a treatment odyssey chronicled in 3,000 pages of medical records provided by her parents. The psychologist described “depression, self-criticism and self-destructive behaviors,” suggesting a self-forgiveness audio program and discussing cognitive behavioral therapy strategies.

As the months passed, Seong and David Brown grew increasingly concerned. Their daughter would head off to college, only to land in a hospital or threaten to kill herself and return home to California.

The family was dissatisfied with the frequency of sessions available through Kaiser. They were referred to an outside contractor, records show, but grew frustrated waiting to hear back. They eventually began paying $160 a session so she could see an outside therapist once or twice a week.

On Jan. 18, 2017, records show, Elizabeth tore up her parents’ house, searching for pills to swallow to kill herself. She found herself holding a kitchen knife and, frightened, called police. They took her to the hospital. Two days later, she was screened for an intensive outpatient treatment program offered through Kaiser.

“Patient’s mother is very worried that Patient will kill herself and requested a higher level of care,” the provider Elizabeth met with wrote in her notes.

Elizabeth agreed to try the Kaiser program—group therapy a few hours a day, several times a week, for two weeks. She was taking several medications, but they didn’t seem to be working, her parents said.

A letter she wrote herself during that time offers a window into her mindset.

“The depression drops you into a deep pit, leaving you to claw at the edges in an attempt to pull yourself out,” she wrote. “But there are people, resources, pieces of hope that will drop you a ladder—I promise. Even though you scream, and it seems like no one hears you, you will learn to help yourself. … You can rely on yourself; you are your own saving grace. Because in the end, you won’t be saved by IOP or medications or therapy—you will be saved by you.”

Around that time, records show, her Kaiser psychiatrist diagnosed her with bipolar disorder. Over the next few months, he changed her medications regularly and offered words of encouragement via email.

But a few weeks later, she was struggling again.


In 2013, the state Department of Managed Health Care levied a $4 million fine—one of the largest in its history—against Kaiser for deficiencies in providing timely access to mental health care and for violations of state parity law related to mental health education materials.

In an interview, Department Director Shelley Rouillard said Kaiser “actually is doing very well” at meeting the settlement agreement’s benchmarks.

In December, Democratic state Sen. Jim Beall of San Jose introduced legislation to require plans to report to the state annually on parity compliance—and for the state to make those reports accessible to the public.

That same month, Kaiser mental-health workers went on strike for five days to protest long patient wait times. Striking providers described not using the restroom all day and working through lunch, afraid that any call they don’t answer will leave a patient to suffer.

“The HMO is not going to go to oncology and say, ‘Our next available opening is in six weeks, so that’s what’s available,” said Kenneth Rogers, a psychologist with Kaiser in Elk Grove who serves as a shop steward for the union.

People on both sides of the debate agree that mental health workforce shortages are a big piece of the problem.

Kaiser has hired 30 percent more therapists since 2015, and pays the state’s highest rates, said Dr. Linda Kim, chair of regional mental health and addiction medicine and recovery services for Kaiser Northern California.

“I truly believe no other organization is doing more than what we are doing, in terms of aggressively hiring and in terms of truly innovating and finding new models of care that are evidence-based,” she said.

Professional associations representing psychiatrists and social workers say they often don’t want to work with insurers at all, citing low reimbursements and onerous administrative burdens.

One study found that only 55 percent of psychiatrists accept insurance, compared to an average for all health care professionals of 89 percent.

Sheree Lowe, vice president of behavioral health for the California Hospital Association, said health plans often require reauthorization every five days for hospitalized patients receiving mental-health or substance-abuse treatment—even for evidence-based care that routinely takes much longer. In some cases, clinicians have to wait up to two hours on hold in order to get that authorization, she said.

“That doesn’t happen if you go in with a fractured hip or with pneumonia,” she said.


Elizabeth returned to college in Massachusetts in the fall of 2017. She was quickly hospitalized twice. Doctors there diagnosed her with borderline personality disorder, her parents said, which was subsequently added to her Kaiser medical record.

That October, as the deadly Tubbs Fire moved closer to the hills around the home Elizabeth’s mother had designed, she hosed down her roof and bargained with God: “Take my house. Bring my child back.”

The house was spared. Elizabeth got sicker. Desperate, her parents made plans to send her to a residential treatment program in January 2018. It would cost $45,000 out-of-pocket.

On Dec. 4, 2017, Elizabeth emailed her Kaiser psychiatrist. “There is a lot to cover since we last met,” she said.

“It’s a 30 min visit to remind you and my part at this time is to refill your meds in the transition to your more intensive treatment,” he responded, according to Elizabeth’s medical record.

That afternoon, Seong sent the psychiatrist an email: “This is very critical and important for Elizabeth’s well-being because of her acute symptoms. She will be home more than a month and she needs an intensive outpatient therapy that is more than once a week.”

He responded that he understood, and that Elizabeth could return to the Intensive Outpatient Program or try to see a new therapist through an outside contractor. “That is the options I have available,” he wrote.

Seong developed a protocol when she was away from Elizabeth. She’d check in via text. If no response came within 15 minutes, she would call twice. If there was no answer, she’d race home.

On Jan. 10, 2018, Seong felt hopeful. Elizabeth texted that she was drinking coffee and reading a book. They made plans to buy new glasses frames after Seong came home from work.

In between texts to her mother, her parents said, Elizabeth also sent one to a friend. Its message, in essence: Send the police to collect my body. I don’t want my parents to find me.

This is an abridged version of the full story, which is available here at CALmatters.org—a nonprofit, nonpartisan media venture explaining California’s policies and politics. The coverage is funded by a grant from the California Health Care Foundation. Consumers experiencing access issues, or other issues with their health plans, can reach the state’s Department of Managed Health Care Help Center at 1-888-466-2219 or www.HealthHelp.ca.gov. If you or someone you know is having thoughts of suicide, there is help available. Call the National Suicide Prevention Lifeline 1-800-273-8255 (TALK) for resources and support.

Published in Features