- [Sam] Coming up on "Impact."

Some patients and providers are fed up with insurance company denials for mental health coverage.

- Let us do our job and you take care of members by paying for the treatment that they need.

- We'll examine the problem and explore potential solutions.

- [Senator] Possible (indistinct).

- [Sam] And Montana leads the nation and the number of legislators serving alongside a family member.

We'll see how closely related their voting records are.

- I mean, as a married couple, you know that you're not gonna think the same all the time.

- He follows me all the time.

No, and he follows me- - Oh, yeah.

He'll seriously.

- All the time.

- [Sam] A look at why service is running in so many families this session.

Those stories next on "Impact."

- [Announcer] Production of "Impact" is made possible with support from the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans, and viewers like you who are friends of Montana PBS.

Thank you!

- Welcome to "Impact."

I'm Sam Wilson.

A mental health crisis is tough enough without patients having to battle insurance companies for the care they need.

In fact, there are federal and state laws that require coverage for mental health care.

Despite this, Montana PBS's Anna Rau found some Montanans, especially patients with eating disorders, are still struggling to have their needs met.

- [Anna] For more than 40 years, Yvonne Field struggled with an undiagnosed eating disorder.

- [Yvonne] I didn't realize how (laughs) messed up my relationship was with food - [Anna] Field also wasn't aware that eating disorders come in all shapes and sizes - Because I'm in a larger body, for a lot of my adult life, I had medical providers telling me to lose weight and to go on restricted calorie diets.

So, I've gone through quite a bit of weight cycling, and one aspect of my eating disorder is that, you know, I can be really restrictive in what I eat.

I over-exercised for a period of time and I was doing really intense exercise, trail running, and ultra running.

And so, the amount of stuff that I had to do, eating disorder behavior-wise, to get my body in that state, to lose weight, and or to maintain it is pretty extreme.

- [Anna] Field became so obsessed with her weight that she began to realize she had a problem.

- Eating disorder looks like constantly thinking about food, constantly thinking about what you want to eat, what you don't want to eat, what you shouldn't eat.

It is so disruptive in your life and to the point where now you're isolating.

You're not going out with your friends because you feel bad in your body or you're not participating in activities because there might be food there.

- [Anna] Registered dietician, Paige Redden, was one of the first people Field met when she reached out to the Eating Disorder Center in Bozeman.

The center has roughly 60 clients receiving services at any given time.

Redden and the therapists here helped Field to see her unhealthy relationship with food and they helped her to uncover the real source of her pain.

- There's a whole spectrum of behaviors that are used to help manage food, manipulate the body, because underlying all of that is the anxiety and the depression and the trauma.

- You know, when you have something really bad tap into you when you're nine years old when that happens, you think it's your fault and you think it makes you bad.

And so, the diet industry and my medical provider saying, "Hey, we don't like your body either."

That was just, you know, a thing for me that really helped my eating disorder be like, "Hey, let me step in."

And they're punishing you for that and you can punish you for that, too.

- Eating disorders are a mental health disorder.

We have a lion's share of folks with sexual assault, traumas of neglect, and abuse as children.

- [Anna] Jenny Gochin is the clinical director at the Eating Disorder Center.

She says it surprises most people to learn that eating disorders are rooted in an additional mental health diagnosis, like depression or anxiety.

And that double whammy makes an eating disorder extremely serious.

- They are the second most fatal of mental health disorders after opioid addiction.

And anorexia nervosa has the highest rate of suicidality of all suicides.

- People often think that the food piece is the piece that has to be kind of tackled and conquered, and it is initially, but it's really the mental health piece that is what's underneath the eating disorder to begin with.

And that takes a long time.

It takes a lot of support - [Anna] And this is where insurance coverage can get dicey.

Redden and Gochin say some insurance companies balk when treatment morphs from stabilizing the patient physically to actually treating the underlying mental health disorder.

Field knows all about coverage denials.

She's had three different insurance companies since she started treatment.

One of them was great.

The other two... - They tried to deny coverage to even go at all to treatment.

At a certain point they said, "You're cut off.

We don't think you need care."

That actually causes a lot of mental anguish and difficulty.

And if you're also somebody who struggles to believe that you deserve care, that kind of message coming from an insurance company is really hard.

- It's devastating for patients that are working so hard to have an insurance say, "You're actually well now, that we think you're well."

- [Anna] Is that legal?

Can they do that?

- (laughs) I dunno if it's legal or not, but they do it.

It's done all the time.

- You need to follow the law.

So, you know, if you're not following the law, you know, it's probably a violation and it would be a problem.

- [Anna] David Dachs is the insurance services bureau chief at the Montana Commissioner of Securities and Insurance.

He says it's possible that some denials are running a foul of what's known as Mental Health Parity.

- It's really making sure mental health services and addiction substance abuse disorder services are provided on the same basis as medical-surgical.

- [Anna] Mental Health Parity is a federal law that's been on the books for 17 years.

It applies to all mental health disorders and treatments, not just eating disorders.

So, that includes bipolar, schizophrenia, and even autism spectrum disorder.

In 2010, the Affordable Care Act, or ACA, significantly expanded and strengthened Mental Health Parity.

- If someone's not gonna limit the number of times that you can be seen by your provider to treat your diabetes, then they shouldn't be limiting the number of times that you can see your provider to take care of your mental health.

So, it's- - Former state representative and mental health advocate, Laurie Bishop, says, "It just makes sense for insurance companies to cover mental health treatment."

Despite this, Bishop was concerned that the federal laws on parity were too tenuous with opponents of the ACA constantly threatening to repeal it.

So, in 2017, she introduced a bill to make Mental Health Parity a state law as well.

- To make sure that regardless of what happens at the federal level, we're gonna hold the floor under the protections for as many Montanans as we can.

- [Anna] Bishop says her bill looked dead many times, but they always managed to revive it.

The legislation squeaked through the house by a single vote.

- When I went to him and said, "Thank you and wow, I'm just so curious on what changed your mind."

He said, "It was a call last night from somebody in my district who just let me know how important this was."

And right there helped me understand the importance of people calling.

That personal encouragement made the difference on that day.

And if it were not for that, we would not be sitting here talking about it.

- [Anna] Bishop was elated.

Mental Health Parity was now a state law on top of the federal requirements, but the elation wouldn't last.

- I, even since Parity has gone into place, continue to hear from people that they struggle.

And I'll say it was really in regards to eating disorders that we, not the exclusive conversation, but where we were seeing a lot of that need.

- [Anna] Since eating disorders have both a physical and mental treatment plan, they are well-positioned to reveal any discrepancies in coverage between the two.

And while Bishop initially heard complaints from constituents demanding parity when the law was new in 2017, over the years, the knowledge has faded.

Do you think people know that insurance companies are required to cover their mental health treatment the same way they would cover medical-surgical?

- I don't think people know that at all.

- It is infrequent for people to really push back.

They might try an initial call to their insurance company.

But a lot of data tells us that people hit these walls or they get denied, and they just don't have the bandwidth, don't have the capacity, don't know who to call in order to get the support to get to the yes instead of the no.

And so, oftentimes, the no is what sticks.

- [Anna] A 2023 congressional report found 76 clear violations of the Mental Health Parity law among a group of insurance companies during a year-and-a-half time period.

On top of that, investigators also say many insurance companies were providing insufficient data to prove they are complying with the law.

In Montana, the commissioner recently began requiring insurance companies to provide data here about Mental Health Parity, but no one in the commissioner's office is drilling down into the data yet to see if there are any problems.

How often do you think they just take that no and think that's the end of it and they don't get the coverage or they don't complain to you guys?

- I think probably fairly often would be my guess.

- [Anna] Just two complaints over Mental Health Parity had been filed in the last two and a half years with the commissioner's office.

One complaint was found not to be a violation, the other was against an insurance company the commissioner has no jurisdiction over.

Dachs says, "This office does have teeth."

If they discover an insurance company is violating Parity laws, the commissioner can suspend or revoke licenses and even levy fines.

- As regulators, you know, we recognize, you know, there's a real disparity between the policy holder and a sophisticated insurance company that has lots of resources versus you kinda have this unilateral contract, you take the terms, that's what you have.

So, I do think it's important to have regulation of that industry to protect those consumers.

- Little pieces of cauliflower.

- [Anna] Consumers like Field who keeps on fighting despite the difficulties and the denials.

- It's kinda steeled her into knowing, "Wait a minute, you know, I'm the one doing the hard work.

I deserve coverage."

- It wasn't a choice that I've ever made in my life to have an eating disorder or to be harmed to the extent that I need this care.

So, I wish they could understand (sniffles) the effect it has on people when they deny and when you're... 'Cause for me, getting treatment and getting the right treatment feels like reparations for what happened to me when I was nine.

Actually having somebody say, "Yeah, that's important for you to be able to heal your PTSD, to heal your trauma, to heal your eating disorder, and to then have a better life and be able to live without that pain and sorrow."

That's the real, like, use of that insurance, right?

And I think I deserve that.

- [Anna] Fields says she knows many other patients deserve coverage as well.

She's hoping her story will encourage them to appeal denials and file complaints, because despite the laws, you have to be your own advocate for now.

For "Impact," I'm Anna Rau.

- In September, the Biden administration announced a federal rule that requires insurance companies to assess their out-of-network charges for mental health treatment to ensure they are no more onerous than those for physical care.

The rule also extended Mental Health Parity to state and government plans that had not been covered before.

While most state legislatures in the country meet every year, Montana is one of only four states in session every other year.

That means senators and representatives here are regular people with a not-so-average ability to drop everything bi-annually to become a lawmaker, though it takes a special kind of Montanan to serve.

Breanna McCabe reports that this session, the job is drawing two of a kind.

- Hey, Linda!

- We're all late.

- [Breanna] When Melissa and George Nikolakakos aren't at home- - Mr.

Chair Representative, thank you.

- [Breanna] You can find them in the house together, just a few rows away.

- I think it's best that we not sit right next to each other, though.

- Yeah, probably wouldn't work out so well.

- You know.

Yeah, it's too much (Melissa laughs) attention to the fact that we're a couple.

- [Breanna] Sue and Mike Vinton carpooled to the capitol when they can before parting ways to serve in separate chambers.

- I'm on basically my side of the building, Mike's on his side of the building, and we have different committees, and it's a really busy day.

- Thank you, Mr.- - [Breanna] Senator Daniel Zolnikov took to the floor early in the session to introduce his legislative connection.

- Representative Zolnikov is my wife.

The smarter, better-looking- - [Breanna] And the relatives don't stop with spouses.

- Everything else.

- I got my dad, the legislator, here, too.

- Speak to the bill.

- It seems like the political bug gets caught (chuckles) kinda in family areas here in Montana.

- [Breanna] Senator Matt Regier's older sister is Representative Amy Regier in the house.

- I started looking around at all the different families that are represented here.

There's a lot.

- [Breanna] Not only do brothers Jedediah and Caleb Hinkle serve in the house together.

- Secretary, please take the role.

- [Breanna] Their chair and vice chair of the House Fish, Wildlife and Parks Committee.

- Vice Chair Hinkle?

- Here.

- I still lurch forward to say I'm here when they call his name first for the roll call.

- And I do the same thing when they call his name last for the roll call.

(Jedediah laughs) - Chair Hinkle?

- Here.

- That is on Mr.

Chair.

- [Breanna] But there's one more related pair to share.

- Senator Jacinda Morigeau.

- Shout out Cousin Shane, the other Morigeau.

(laughs) I'm the other Morigeau, actually.

- [Breanna] Jacinda Morigeau joined her second cousin, Shane Morigeau, in the Senate this session.

- I could support this today.

- [Breanna] In case you lost count, that stacks up to seven sets, essentially 10% of Montana's citizen legislature.

And altogether, it's the most related pairs serving in any legislature nationwide.

- It's probably all the families that during Thanksgiving, they talk about politics and religion.

But I do feel like when one representative or senator terms out and has to pass that district onto another, there's a big trust issue.

You don't wanna lose ground with that district.

- Are there any amendments?

- [Legislator] None, Madame Chair.

- [Breanna] Back when Senator Sue Vinton was Representative Vinton facing term limits- - Thank you.

- [Breanna] She started seeing her husband in a new light.

- You kinda look around to see who's going to be a good replacement.

And I couldn't come up with anyone better than Mike.

- Yes, I mean, depending on the parcel, so- - [Breanna] The two own a general contracting company together in Billings.

And Mike says, "Being married to a legislator primed him to work with his wife in this role, too.

- Spouses of legislators are pretty engaged.

So, they're more knowledgeable than the average citizen, because they're talking with their spouses about things and they're watching what's going on.

So, if they have the inclination to run for office, then they're really a step ahead of everybody else.

- [Breanna] Plus, sharing a last name means they can also share campaign signs.

- Who would you trust more honestly than your spouse or your brother?

- [Breanna] Name recognition helped the Hinkle Brothers secure two neighboring house districts in Belgrade.

- [Caleb] And I think that did help.

That name is out there and it's a trusted name among conservatives and people who love freedom.

- [Breanna] Six of the family duos serving this session are Republicans.

- And then I like to say I'm just a little bit more conservative than him.

(both laugh) - [Breanna] Service has been the center of the Nikolakakos' marriage and they say a four-month stint in Helena is nothing compared to their 20 years navigating deployments.

And after George's first session in the house, he realized the legislature was one place they could be stationed together.

- What I saw, was like, "She'd be really good at this."

Like, she's connects with people really well.

She has a passion for issues and community service.

Like, these are the people you want in public service, but who normally don't run.

And so, you know- - It's intimidating.

- Yeah, there was some conversations there where I was like, "Actually-" - I'm not fan of, like, this part of it.

- "Actually, you're perfect."

(Melissa laughs) - Now that I'm here and doing it and, you know, anything else.

When something's new, and I never saw myself as a politician and a world that I didn't quite fully understand, you know, you're a bit reluctant.

It's like, "But now that I'm here, there's still so much I don't understand."

But I'm learning and, you know, I'm glad that he drug me along.

(laughs) - [Breanna] Those who share a household can still represent separate districts in Montana since legislators only need to live somewhere in the county where they're running.

But once session starts, most have to leave those homes behind and secure housing in Helena.

- And it's hard to find somebody that can have their lifestyle.

I mean, their family setting that they can just drop everything for four months and come down here.

I mean, even financially, it's tough.

So, there's a lot of things that have to line up.

So, to find a good candidate is tough.

- Yeah, it's not just a resolution.

- [Breanna] Matt Regier's dad, Keith Regier, spent 16 years in the legislature, giving his kids a front row seat to his service.

- You kinda learn alongside someone else that's doing it as you watch them do it.

It's a little bit like families that if their dad's a doctor and they decide they're gonna be a doctor, or their mom's a teacher and they decide they're gonna be a teacher.

It's a little like that.

- [Breanna] Each pair has its apparent similarities.

- So, we did not coordinate the ties.

- It was completely random.

- It was completely random.

We just happened to own the same tie gifted to both of us by his father-in-law.

- Mother-in-law.

- Mother-in-law.

- Yeah.

(chuckles) - [Breanna] Clearly, randomness is relative.

- [Chairperson] All those in favor- - [Breanna] So, we wanted to know how coordinated they are, where it matters most, their votes.

- My guess would be that we vote differently a little more than the others.

- Probably.

- [Chairperson] All those in favor vote aye.

- [Breanna] With an alphabetical tally, it's easy to compare related pairs in the same chamber.

And for the Nikolakakoses, there's no voting incognito.

- We have a big long name and it stands out on the board.

I feel like- - It might show- - People notice- - A little bit more.

- More.

- People notice our votes more.

- Yeah.

- [Chairperson] All those in favor vote aye.

- [Breanna] They've embraced it and even started referring to themselves as the Nikolacaucus.

- It's a joke.

We're not actually a caucus, right?

But, you know, it's kind of funny and it's cute, and so people like it.

- And it makes it easier- - And people can- - To say our name better.

- Pronounce our name.

- So, I tell people, "How do I pronounce?"

I say, "Can you say nickel and the word caucus?"

And it's close enough into Nikolakakos, but if you just say Nikolacaucus.

And I think it's helped?

- I think it's made it easier for people.

- Yeah.

Yeah, it's helped.

(Melissa chuckles) - [Breanna] So far this session, the Nikolakakos has voted the same way on all but 11 bills on third reading, putting them at 98% agreement, the highest of any family pair.

Father-son John and Steve Fitzpatrick represent two different districts, but have been voting the same more than 95% of the time.

But when they don't, it does warrant discussion.

- And my dad has his own worldview, which is very different than mine, which it's kind of fun, you know.

So, get to go talk with him and disagree with him.

And he takes disagree, which is fine, so... And then my mom will start questioning him about his voting.

So, it's very funny.

- She's always proud of her son, but frequently is disappointed in her husband.

But that's understandable, 'cause he's a blood relative and I'm just a guy she met in the bar.

- [Breanna] Those in the same chamber have a chance to change their vote based on what they see on the board.

- He follows me all the time.

- No, and he follows me- - Oh, yeah, he'll- - All the time.

- Seriously, he will see that I'm a no and something, and then all of a sudden, in my mind, I'm like, "Watch Caleb will go no."

And all of a sudden, Caleb goes no.

- [Chairperson] Are there any absentee votes?

- [Legislator] None, Madame Chair.

- I'd say it's about 50-50 on that.

- Oh, no.

- Yeah.

- Well, this topic remains a contention point.

The Hinkle Brothers officially agree 93.7% of the time.

Representatives in the 100-seat House have had more chances to synchronize, taking three times more votes this session than the 50-member Senate.

The only related pair of senators is the only duo of Democrats, the Morigeau Cousins.

They're voting together nearly 92% of the time, but the pairs seated in separate chambers see each bill at different times.

That includes husband and wife, Daniel and Katie Zolnikov voting in alignment 90% of the time.

- I'm gonna guess 90.

- That's what I was gonna say.

I would say 90 as well.

(Daniel laughs) - [Breanna] The Vintons are about right, they've taken the same stance on nearly 88% of bills.

- I'm gonna say we're probably 90% the same.

- I'm gonna guess 86%.

That's gonna be my number, 86.6.

- [Breanna] A pretty precise guess from brother Matt Regier, and that 86% ranks the siblings last in the long lineup of related pairs.

Still, almost all of them are aligning with their relative or spouse more often than they vote with their party with two exceptions.

At 86%, Amy Regier is just as likely to vote the same as her brother as she is with Republicans in the house.

And Mike Vinton votes with other house Republicans 89% of the time ever so slightly more than he votes with his wife.

- We don't discuss our votes very much at all.

- Yeah.

- I mean we'll discuss different bills, pros and cons, that type of thing, but we don't discuss votes.

- [Breanna] While family ties tend to be stronger than even party alliances, it's important to zoom out for context to see how often all legislators align to pass legislation.

- Are there any others with two votes?

- [Breanna] We often hear the vast majority of bills pass unanimously across parties, but our tracking shows that's only narrowly the case in the House where the board is coming up green 53% of the time.

Meanwhile, state senators are agreeing across the aisle less than half of the time, at 44% this session.

- [Chairperson] Those in favor of the emotional- - [Breanna] With legislators voting on nearly 2000 bills so far, there's not always time to get on the same page.

- I would say probably so far in this session, we probably only have seen each other maybe a half a dozen times at lunch.

- [Breanna] And so, when the Senate saw an amendment on one of Mike Vinton's bills, Sue Vinton had to ask- - I do.

- Her fellow senators how her spouse felt about it.

- Does the sponsor of the bill find this to be a friendly amendment?

- He was in a meeting, so we didn't get to talk about it much.

We talked a little afterwards and didn't get a yes or no from it.

- Sounds like my life, thank you Mr.

Senator.

(everyone laughs) - [Breanna] Legislators sign up for four months of long days that outsiders may never fully understand, but these lawmakers all have one person they can really relate to.

For "Impact," I'm Breanna McCabe - Montana had the potential for even more related Republicans, but two sets of spouses lost their primaries.

A sitting senator's wife also ran for the house and lost.

That's all for this episode of "Impact."

Next time, we sit down with former Montana Supreme Court Chief Justice Mike McGrath, for a conversation on his 42 years in government and the current rift between the court and the political branches.

And Montana's residential property taxes have been going up.

We look at what the legislature is doing about it.

From all of us here at Montana PBS, thanks for joining us.

We'll see you next time.

(calm outro music) (calm outro music continues) (calm outro music continues) - [Announcer] Production of "Impact" is made possible with support from the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans, and viewers like you who are friends of Montana PBS.

Thank you!

(calm outro music ends) (gentle piano music)