While there have been substantial gains on the issue of parity – making addiction and mental health coverage equal to physical health coverage – much work still needs to be done, especially for children, according to Ron Manderscheid, Ph.D., Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors (NACBHDD) and the National Association for Rural Mental Health.

“Children can’t speak for themselves on the issue of parity,” Manderscheid says. “That’s why it’s very important for the Department of Health and Human Services (HHS) and state health insurance commissioners to protect the rights of children around parity. Any child who has health insurance coverage through the individual marketplace under the Affordable Care Act (ACA), or through the ACA’s Medicaid expansion is entitled to parity protection, but we don’t really know how well it’s working.”

The estimated 8.4 million children enrolled under the Child’s Health Insurance Program, which is part of Medicaid, are not covered by parity protections, Manderscheid noted. “The field has so focused on problems with implementing parity with adults that children haven’t gotten equal attention in this process,” he said.

The Mental Health Parity and Addiction Equity Act, which requires larger employer-based insurance plans to cover psychiatric illnesses and substance use disorders in the same way they do illnesses such as cancer and multiple sclerosis, was passed in 2008. The law applies to private health plans covering more than 50 enrollees that offer behavioral health services.

The Affordable Care Act, passed in 2010, requires that mental health and substance use benefits be offered as part of new insurance plans as Essential Health Benefits. The law extends parity to all insurance plans offered through state health insurance marketplaces, to insurance offered through the individual and small group markets, and to new coverage offered through state Medicaid expansion. However, the federal government did not release regulations covering parity under the Affordable Care Act until the end of 2014.

Before the parity law was passed, health plans often imposed limits on treatments for substance use disorders, such as restricting the number of visits, and requiring higher cost-sharing. Since the law has taken effect, an estimated 860,000 additional adults with serious mental illness have gained health insurance, Manderscheid says.

“The concept of parity is simple, but the implementation of it is incredibly complex,” said Manderscheid. The trickiest part of parity is a concept called non-quantitative treatment limitations, which are processes that managed care firms use to determine who will and won’t get care, he explains.

One of the greatest challenges to achieving parity, Manderscheid says, is enforcement. Currently, the burden chiefly falls on the consumer to report to the federal or state government if their claims for addiction or mental health treatment are denied. “The enforcement burden should fall on HHS, state insurance commissioners and the insurance companies themselves,” he said.

In October, the White House Mental Health and Substance Use Disorder Parity Task Force issued a report that concluded that overall, state-level substance use disorder parity laws have helped to increase the treatment rate by approximately 9 percent across substance use disorder specialty facilities and by about 15 percent in facilities that accept private insurance. This effect was found to be more pronounced in states with more comprehensive parity laws.

NACBHDD and a number of other advocacy groups issued a response to the report that stated, “While we commend this Final Report as a positive step in the right direction, too many of the findings still place the burden of real action squarely on the shoulders of Americans living with these conditions and their family members.” The groups noted, “A complaint-based approach does not protect the rights of people, especially those who, as a result of their mental health condition or addiction, are often unable to self-advocate. We must simplify and streamline the overly complex health insurance process so that all patients can easily access the high-quality care they need, when they need it.”

The 21st Century Cures Act, signed by President Obama in December, has a section that specifically addresses parity enforcement. “It authorizes HHS to do technical assistance and training, but it doesn’t put any teeth into enforcement,” Manderscheid said. “There are no financial penalties for violating parity.”

There is great uncertainty surrounding the future of the ACA, and therefore the future of parity, Manderscheid says. “I believe parity is a bipartisan issue,” he said. “Who would argue you shouldn’t get care for substance use or mental health issues?”
He is concerned that if ACA is repealed hastily, parity protections will inadvertently be lost.

“We’re arguing that if ACA is repealed without having a replacement in place, it will create absolute chaos in the insurance market,” he said. “We need to know what the consequences will be for parity, and for access to care, including for children.”