Court decision endangers addiction and mental health coverage for 130 million Americans

More than 100,000 people die of preventable overdoses annually. Health insurers must stop denying insurance coverage to those who need it most.

I’m no stranger to being told “no” by health insurance companies that are supposed to have my back. Back in 2014, my addiction to heroin had taken everything from me. It was quickly chipping away at every aspect of my life—most notably, my health. I couldn’t afford to keep a roof over my head or even have a simple meal once a day, much less pay thousands of dollars out of pocket to my insurance company, but that didn’t seem to matter to them. They denied request after request for addiction and mental health treatment. Sometimes, they said that my problem wasn’t “bad enough.” Other times, I was told my condition was “too acute” for treatment. I was stuck in the middle. Every day, I was at risk for losing my life to an overdose.

I went to many treatment centers in my area but was told that without the “right” insurance I would have to wait for a scholarship bed to become available. The list filled a thick, three-ring binder. Pages and pages of names were before mine. When a bed opened, the front desk staff would start calling. The first person to answer was admitted. I remember the sense of hopelessness I felt as I saw the hundreds of names. What if I missed the call? What if I died before I could get the help I needed?

To say my recovery was a close call is the understatement of a lifetime. I know how fortunate I was to get that bed and the life-saving medical help I needed. Yet, after I entered treatment, another ordeal began. I had survived just to witness the deaths of my friends and loved ones. Dozens of people whose families loved them, people who deserved a chance—overdosed and died. Often, they were waiting on insurance approval for treatment. Those arbitrary limits on substance use disorder coverage led to recurrences of use, overdose, and even death.

Who holds insurance companies accountable?

Saying “no” to someone with a life-threatening illness is a death sentence. But insurance companies have always cared more about their bottom line than clinical standards. And holding them accountable—even in court—has proven nearly impossible. In 2019, the District Court ruled in one of the most significant health policy cases of the 21st century. Wit v. United Behavioral Health (UBH)decided that the nation’s largest insurer was wrong to use its internally developed standards of coverage instead of widely accepted clinical standards of care. The court decided that insurance companies must make “medical necessity” determinations consistent with accepted clinical standards.

The decision made it harder for companies to deny coverage based on arbitrary, profit-motivated, and internally developed criteria. It sided with patients. It was a step in the right direction.

Unfortunately, just a few months ago in March 2022, a three-judge panel in the Ninth Circuit Court of Appeals reversed Wit v. UBH. Insurers, they said, could use internal criteria to exclude certain people from accessing care. This reversal puts more than 130 million Americans’ health coverage and lives at stake.

Limiting health care coverage kills people

Patients—including people struggling with addiction and those in recovery and their families—have always pushed back against insurance companies. The Wit v. UBH decision was a huge win for millions of people seeking addiction treatment. It would have compelled insurers to change their practices for the better. Now, with the reversal of Wit v. UBH, we are in a worse position than before.

On top of the continuing COVID-19 crisis, our nation is in the midst of an unprecedented overdose crisis. Reversing Wit v. UBH is completely out of touch with clinical standards for addiction treatment. It is also cruel, impacting vulnerable people at a time when health care needs are at an all-time high. Over 30 advocacy organizations, three states, and multiple national associations (including the American Medical Association, American Hospital Association, and American Psychological Association) are urging the judges of the Ninth Circuit of Appeals to revisit the panel’s flawed ruling. They have submitted amicus briefs urging the Ninth Circuit to grant en banc review.

Simply put, United Behavioral Health is setting a bad example for other insurers. Doctors and other medical experts, including the U.S. surgeon general, support appropriate treatment plans that lead to long-term stabilization.

Courts must align with the medical community

The real-life implications of the three-judge panel’s ruling places over 40 million young people and adults seeking substance use treatment in 2020 at risk. Their lives are on the line. Overdose is now the leading cause of death for Americans aged 14-23. Yet, only 1.4 percent of them have received any substance use treatment in the past year. Without the support of the courts, the Wit v. UBH ruling only creates higher barriers to coverage. The need for addiction treatment is as pressing as ever. But if millions of people can’t access treatment, it may as well not exist.

The Wit v. UBH ruling as it stands means that those who need care won’t receive it. It permits insurers to effectively restrict access to treatment when people need it most. When insurance companies refuse to cover services, patients are forced to pay out of pocket. This disproportionately impacts lower-income families, LGBTQ+ people, and the BIPOC community. COVID-19 shined a spotlight on our health systems’ failure to support all Americans equitably. The court’s decision only exacerbates those flaws.

Millions of Americans are navigating a public health crisis while seeking addiction treatment. Access to health coverage is crucial and must be accessible. It’s time for the judges of the Ninth Circuit to act and revisit the panel’s flawed ruling. What matters more: insurance companies making profits, or the 130 million lives that hang in the balance? Survival shouldn’t be a matter of luck, money, or privilege. It’s something we all deserve—and insurance companies shouldn’t get to decide who deserves it most.

Ryan Hampton is a nationally recognized addiction recovery activist and community organizer, author, and person in long-term recovery from addiction.