In 2008, mental health advocates hailed the Mental Health Parity and Addiction Equity Act as “historic;” putting an end to what Sen. Edward Kennedy called “the senseless discrimination in health insurance coverage that plagues persons living with mental illness.” The law requires most group health plans to offer coverage for mental health and substance use disorders equal to that provided for medical problems. Two years later, the Affordable Care Act extended this mandate by designating mental health and addiction treatment as one of 10 “essential benefits,” and requiring that Medicaid, as well as private individual and small group plans also provide equal benefits for behavioral health and medical services.

Mental health problems are the leading cause of disability in the U.S. and the Centers for Disease Control and Prevention estimate that more than a quarter of adults report having a mental illness at any given time. About half of us will experience mental illness during our lifetime. The intent of the parity legislation is clear; to improve access to desperately needed mental health and addiction services for millions of underserved Americans. Health plans are barred from creating higher deductibles or charging larger co-payments for mental health and addiction disorders treatment. Enrollees no longer have annual and lifetime caps on coverage or face highly restrictive limits on inpatient stays and outpatient visits to behavioral health providers. The Department of Health and Human Services (HHS) estimates that through Medicaid expansion alone, some 32 million individuals could gain access to behavioral health coverage for the first time by 2020.

It all sounds great on paper. But in practice, we are not even close to achieving true parity. Last year, more than half of all people with mental illness still did not receive the treatment they need. And although some 16.4 million more Americans have been able to obtain insurance coverage — and therefore mental health benefits — under the ACA, significant disparities in mental health treatment rates continue to persist between whites and racial and ethnic minorities. As the authors of a new report in Health Affairs put it, “gains in insurance coverage alone are not likely to push forward meaningful reductions in mental health treatment disparities or increase consistently low overall substance use treatment rates.”

In part, the lingering stigma of mental illness prevents some people from seeking the care they need. But structural barriers, including lax government enforcement of parity laws and a growing shortage of providers — particularly psychiatrists and therapists who accept insurance — play a far larger role in subverting the goals of mental health parity laws.

Let’s start with enforcement. Multiple agencies oversee compliance with the parity laws, including state insurance boards, Medicaid, HHS or the Department of Labor, depending on how and where an individual is insured. Figuring out who to contact when there’s been a violation of parity laws can be difficult, especially when people are experiencing mental health problems.

Furthermore, although obvious discrepancies between behavioral and medical coverage are not all that common, according to Kaiser Health News, many insurers have figured out how to limit mental health costs through more subtle strategies that are harder to track. These include frequent and rigorous utilization review and so-called “fail first” therapies that require providers to try the least expensive therapies first even if they might not be the most effective. The KHN authors note, “Among the more murky areas is ‘medical necessity’ review — in which insurers decide whether a patient requires a certain treatment and at what frequency.”

A survey conducted by the National Alliance on Mental Illness found that patients were twice as likely to be denied mental health care (29 percent) based on “medical necessity” review than other medical care (14 percent). When denials do occur, patients rarely challenge them — not surprising in light of findings by the American Psychological Association that only 4 percent of respondents even knew that health insurers are required to provide coverage for mental health and substance-use disorders on par with medical coverage.

A shortage of psychiatrists, particularly child psychiatrists, is another particularly intractable problem limiting access to mental health services. Reasons for this shortage include an aging psychiatrist population, a small percentage (4 percent) of medical school graduates choosing psychiatry residency programs, and payment models that reward patient volume versus the value of talk therapy and psychoanalysis. HHS has identified roughly 4,000 health professional shortage areas for mental health nationwide — counties, parts of counties or other areas where there is only one psychiatrist for 30,000 or more people. Wisconsin, a state that has professional shortages in nearly all its counties, meets just 20 percent of all need for mental health care among its residents.

The dwindling number of all mental health professionals who choose to accept insurance exacerbates the shortage. A recent study published in JAMA Psychiatry revealed that only 55 percent of psychiatrists accepted private insurance in 2009 to 2010 as compared to 88.7 percent among physicians in other medical specialties. This represented a 17 percent decrease since 2005 to 2006. For Medicaid beneficiaries, the picture is even bleaker: only 43 percent of psychiatrists participate in the program vs. 73 percent of doctors in other specialties. As health plans offer narrower networks in hopes of lowering costs, gaining access to mental health providers is becoming even more difficult. An investigation conducted by the Mental Health Association of Maryland, for example, found that only 14 percent of the psychiatrists listed in all of the qualified health plans on the Maryland exchange were actually accepting new patients and available for an appointment within 45 days.

In New York and other big cities, there is certainly no shortage of psychotherapists willing to administer to self-paying clients. Getting in to see a psychiatrist can be more challenging, but patients who can afford to pay out of pocket definitely have an advantage. Wait times to see a child psychiatrist (as common as unicorns in some areas) average 7.5 weeks even when parents are willing to pay out of network; for Medicaid patients the wait time stretches to three months. The refusal of many mental health professionals to accept insurance — particularly Medicaid — is leading to what Stanford University psychiatry professor Keith Humphreys calls “a culture of mental health haves and have nots.” Thomas Insel, director of the National Institute for Mental Health writes in his blog, “It would be a sad irony if in the era of parity only those who could afford to pay out of pocket could get access to effective psychosocial treatments.”

What has to happen before we can even approach mental health parity? A bipartisan bill approved by the Senate Health, Education, Labor and Pensions Committee (HELP) spells out some key steps that could speed the process:

• address shortages in the mental health workforce
• strengthen enforcement of the mental health insurance parity law
• invest in early intervention programs, so people get the right care at the right time
• promote integration of primary and mental health care

Addressing shortages would include implementing policies that encourage students to pursue psychiatry (e.g., loan forgiveness programs) and to create incentives for non-physician providers (e.g., nurse practitioners) to work in mental health-related areas.  Another would be to reimburse mental health practitioners in a more equitable way — recognizing that a 30 or 45-minute psychotherapy session may offer greater benefit to a troubled patient than a 10-minute visit to renew a prescription. Finally, integrating mental health into a collaborative model of primary care could help improve access to care — for example, a pediatric practice that includes a child psychiatrist or therapist on site to help diagnose and treat young patients struggling with behavioral health issues.

We have a long way to go. People with untreated mental health and addiction issues continue to be disproportionately unemployed, chronically homeless and cycling through the criminal justice system. Almost a quarter of state prisoners have a recent history of a mental health condition. As the opioid addiction crisis builds around the country, demand for services is increasing at the same time that treatment centers are experiencing serious addiction counselor shortages.

Parity legislation is an important — and yes, historic — step, but until we confront provider shortages, improve patient access to treatment, and enforce insurers’ compliance with the law, mental health, and addiction services will remain out of reach for far too many Americans.

Naomi Freundlich is a journalist, policy expert and health advocate who blogs at Reforming Health.

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