If you break your arm, you go to the doctor, your insurance (usually) pays. Why is it so much harder to get health insurance to pick up the tab if you have a mental health breakdown?

That's the question President Joe Biden asked yesterday, as he touted new rules he says will get insurance to pay for mental health care more often.

The regulations are part of a proposed rule that would strengthen existing policies already on the books and close loopholes that have left patients with too few options for mental health care covered by insurance.

Biden specifically criticized the reauthorization process — where insurers make patients jump bureaucratic hurdles to get their care paid for.

"You get referrals to see mental health specialists," Biden said at a White House press conference Tuesday, "but when you make the appointment, they say, 'I can't see you until your doctor submits the paperwork and gets special permission from the insurance company.' Gimme a break."

A landmark law in 2008 called the Mental Health Parity and Addiction Equity Act tried to fix the parity issues, but insurers found loopholes and ways to avoid paying for care.

For example, it might appear as though an insurer has a good list network of mental health professionals. But in fact many of those therapists and doctors won't take new patients, or are no longer practicing, or are too far away.

Or sometimes insurers would require paperwork to authorize treatment — repeatedly — in order to keep getting treatment. Some families NPR interviewed said the reauthorization could be almost daily.

Serious mental illness is often a life or death situation, but if insurance doesn't cover care, it's a huge out-of-pocket cost. Paying directly, without insurance, for something like inpatient substance abuse treatment can easily cost $100,000 — or more. So even families with resources often end up tapping every source of cash and credit they can.

A Michigan family NPR spoke to last year did just that, mortgaging their house and racking up a bill over $250,000 to care for her son who was suicidal. (NPR agreed not to use the family's last name because it would identify a minor with mental illness.) "All of our savings are gone. How are we going to send our kids to school? How are we going to, like what are we going to do, how are we going to recover from this? I don't know," said mom, Rachel. "Those thoughts in your mind — there's no space for that when you are just trying to keep your child alive."

Out of desperation, some families impoverish themselves to qualify for public insurance like Medicaid. Some forego care and let conditions worsen into a bigger crisis, or end up in the ER.

Here are the three policy changes in Biden's proposed rule:

Accountability with data. The White House is trying to address the fact there's not a lot of good data — or even clear definitions — to track how patients are affected by insurers' policies. So it hasn't been possible to hold insurers accountable. Under the new rule, the government will be requiring insurers to report on the outcomes of their coverage, showing that the offer patients eqaul access to medical and mental health care.

Attention to payments and policies. The rule says insurers can't use techniques like prior authorization and narrow networks of few therapists to deny care. It also says insurers have to use similar ways of setting out-of-network payment rates for mental health care as for medical care.

Expand coverage by closing a loophole. The original mental health parity law said health plans offered by state and local governments didn't have to comply. Updates to the law changed that and this proposed rule implements the change. It means about 200 health plans serving 90,000 people will get the coverage.

The health insurance industry says it agrees with the administration's goals of achieving parity of coverage between mental and physical care, but says the problem is there are not enough physicians and therapists to go around.

"Access to mental health has been, and continues to be, challenging primarily because of a shortage and lack of clinicians," Kristine Grow, a spokesperson for America's Health Insurance Plans, said in a statement. [Copyright 2023 NPR]