I want to trust insurance companies. I want to believe that they understand the connection between mental and physical health and that health care costs would drop if we treated both equally and fairly. I want to believe that insurance companies put people before profits and that they play by the rules. But they don’t because there are no rules.

It’s been four years since President George Bush signed the Paul Wellstone & Pete Domenici Mental Health Parity and Addiction Equity Act and still we have no rules. Why is it taking so long for regulators to write rules requiring insurance companies to provide equal coverage for mental and physical health? How hard can it be to draft regulations that ban separate co-pays or higher deductibles for mental health treatment and medications? Come on. Four years? Herman Melville churned out Moby Dick in less than four years and I almost read it in four years.

Getting the Parity Act passed was a monumental accomplishment that capped a 12 year battle between parity advocates, such as former Congressman Patrick Kennedy, D-Rhode Island, and former Senator Jim Ramstad, R-Minn and the insurance industry. It was the greatest medical civil rights victory of our generation. The law would finally ensure that people with mental illnesses would get the care they need and that mental illnesses would finally be accepted as legitimate medical conditions. That has not happened.

Why?

Because there are no rules on how to implement the law and a law without rules isn’t worth the paper its printed on. It means insurance companies can continue with business as usual or worse – devise loopholes to avoid compliance – because there are no regulations telling them how to comply with the law. Worse yet, there is no enforcement – meaning insurance companies can disregard the law knowing there will be no punishment.

Is that happening? Judging from what I heard at a recent parity field hearing sponsored by ParityIsPersonal.org. Kennedy, who left the political spotlight after his father, Sen. Ted Kennedy, died, was the featured speaker. You would think Patrick Kennedy has had enough of politics and would have better things to do now that he has a wife and 7-month-old baby. But he is still at it and won’t let go until rules are put in place and are being followed.

Kennedy considers passage of the Parity Act his “crowing achievement” and he blames the insurance companies for blocking its implementation. He is traveling the country collecting violations of the Parity Law. On this night in Delray Beach, Florida more than 100 people filled a meeting room at the local library and filled out index cards with their stories.

“We need to put together a political campaign so they can’t feel they can get away with what they’re doing,” Kennedy told the crowd. Kennedy believes insurance companies “hide their decisions behind closed doors” and the among the most effective ways to verify compliance is by auditing insurance companies’ coverage practices.

On the public relations front, mental illness should be hooked to more popular illnesses, such as diabetes, heart disease and cancer because “physical illnesses are exacerbated by the pain of mental illness.” Kennedy said.

Also speaking at the field hearing was Irvin L. “Sam” Muszynski, a lawyer and Director of the American Psychiatric Association’s Office of Healthcare Systems and Financing and Co-Chair of the Parity Implementation Coalition. Muszynski is especially critical of Florida Blue Cross/Blue Shield, whom he says is doing and “end run” around the parity law by decimating provider networks: “Compliance is not a matter of saying “I’m in compliance.””

Ramstad could not attend the hearing but his outrage was evident during our phone conversation that afternoon. Ramstad called the lack of a final rule “unconscionable” and said never in his 18 years in Congress had he seen rule-making drag on for so long.

“There is still no enforcement of parity,” Ramstad said. “Insurance companies are running wild over people.”

Ramstad said he was told by officials in the Obama administration that they did not want to push two controversial health care bills at the same time. Instead the administration “put all its eggs in the Afforadable Care Act basket.” Ramstad lays the blame on Health and Human Services Secretary Kathleen Sebelius, Treasury Secretary Timothy Geithner, and Labor Secretary Hilda Solis, for failing to put rules in place.

Regardless of who wins the election, both Ramstad and Kennedy are confident that a final rule will be in place by the end of the year, although neither would explain why – after four years of delay – they are so optimistic now.

I walked out of the parity field hearing deeply optimistic and disturbed. The good news is that even a few years removed from office, Kennedy and Ramstad are on the insurance companies and regulators like a bad rash. These guys sound just as pissed off and determined as they were when I first interviewed them several years ago. They will not give up regardless of who is in office.

The bad news is that the insurance companies aren’t giving up, either. They have a wily stable of well-paid lawyers who have done a fine job of dissecting the Parity Act. They have found every whiff of a loophole and are devising ways to jump through and expand each one. Their power to stall, stymie and litigate away the implementation of parity is truly impressive in a diabolical kind of way.

The insurance companies know how to use stigma to their advantage. They know that people with mental illnesses, alcoholism and addiction don’t want to be outed. We’re not like the breast cancer crew – who boldly demand and support research and care. We’re quiet. We’re not going to march in the streets or sign petitions. We’re still afraid of what people – and insurance companies – will say if we’re outed.

So, tonight I will say a prayer for Kennedy, Ramstad, Muszynski and all our other advocates out there still slogging on – fighting the good fight. I will say a prayer for the still sick and suffering and those who love them. And I will even say a prayer for the insurance companies. Lord knows, they need it.