The State Role in Mental Health Parity and Addiction Equity Act Implementation
The Mental Health Parity and Addiction Equity Act emphasizes that behavioral health is an important component of an individual’s overall health; however, the Mental Health and Substance Use Disorder Parity Task Force highlights opportunities to improve enforcement of insurance beneficiary protections in this legislation.
Substance Abuse and Mental Health Services Administration (SAMHSA) has reported that approximately one in five, or 43.6 million, American adults have experienced some form of mental illness in the past year, and eight percent, or 20.2 million had a substance use disorder. Yet nearly 60 percent of these adults with mental illness did not receive mental health services in 2014, and black and Hispanic Americans utilize mental health services at about half the rate of white Americans and a third the rate of Asian Americans, as reported by the National Alliance on Mental Illness (NAMI). Thus, behavioral health parity, coupled with access to health insurance, is an issue of health equity and is one that affects major segments of the American population.
The U.S. Congress passed the Mental Health Parity and Addiction Equity Act in 2008, mandating that insurance providers must cover mental health and substance use benefits in equal scope, length, and duration as the physical health benefits covered under a health insurance plan. Though it does not mandate mental health coverage, it requires equal standards of coverage. This legislation fosters improved access to behavioral health and substance use disorder services and supports the notion that mental health is as critical to overall wellbeing as is physical health.
Why has mental health parity remained in the spotlight?
While this federal legislation ensures that behavioral health is incorporated into an individual’s health needs, governmental enforcement of behavioral health parity has room for improvement. There has been uneven implementation of parity requirements, and patients have often had to advocate for themselves, though many may be unaware that parity protections exist at all. For instance, a national study by NAMI found that insurers deny mental health and substance use claims at a rate double to medical claims. Furthermore, limited and uneven access to in-network mental health and substance use providers also remains a barrier to true parity.
In October 2016, the president’s Mental Health and Substance Use Disorder Parity Task Force released a final report outlining federal and state progress in enforcing the legislation and recommendations for continued efforts to ensure comprehensive, consistent insurance coverage. In addition, the SAMHSA published a complementary white paper highlighting approaches in parity implementation and enforcement at the state level. The report recommends for state agencies to collaborate across many stakeholders, including state public health and behavioral health agencies, insurance commissioners, and communities. These collaborations require open channels of communication and ongoing efforts to collect data, create standardized tools to assess network adequacy, and design requirements for essential health benefits that are consistent with parity requirements. There may also be a role for state public health leaders in implementing information campaign targeted towards communities or individuals who are at risk of use and addition to raise awareness of the dangers of use and how to access treatment and benefits.
Alignment with the 2017 ASTHO President’s Challenge: Public Health Approaches to Preventing Substance Misuse and Addictions
The 2017 ASTHO President’s Challenge centers around public health approaches to preventing substance misuse, addictions, and the related consequences, with an emphasis on prevention and early intervention. To support this challenge, ASTHO President and Chief Medical Officer for the Alaska Department of Health and Social Services Jay Butler provides a Substance Misuse and Addictions Prevention Framework, which illustrates how this public health challenge must be addressed through multiple levels of prevention. The Mental Health Parity and Addiction Equity Act aligns with the president’s challenge in that it enables health providers to better reach patients before an acute health event and crisis:
- At the primary stage of prevention, mental health and substance use parity legislation can increase access to services that promote protective factors and reduce the need for individuals to self-medicate. For example, this can ensure access to care that addresses mental health or social factors that can lead to bigger health issues or addictions in the future.
- At the secondary level of prevention, parity legislation can improve patients’ access to care and support providers’ ability to diagnose and treat existing addictions and substance use disorders.
Mary Ann Cooney, ASTHO’s chief of health systems transformation, explains, “Would we ever deny insulin to a diabetic or delay surgery to set a compound fracture? Of course not. Mental and behavioral healthcare services are as critical to population health as standard care offered through medical and surgical benefits. This is abundantly clear to the individuals and families who have been impacted by mental illness or substance use disorders. Public health and healthcare providers are in a position to better understand and communicate the overall influence untreated mental or behavior health care has on population health. For example, challenges related to poor social support or housing instability are frequently tied to behavioral health and may not arise in physical healthcare visits.”
It is clear that mental health and substance use treatment should be held and covered equally to the healthcare services covered through traditional medical and surgical benefits. Parity legislation is a step toward improving health equity and has the potential to prevent and address mental illness and substance use at multiple levels of intervention. Public health has a role to play in raising awareness on the need for and the systemic challenges to achieving parity, and ensuring that individual patients are treated holistically and have access to the services that will help them attain the highest possible level of healthcare.
Anna Bartels is an analyst for health systems transformation at ASTHO, where she supports the Integration Forum’s activities and projects related to payment and delivery reform.