Eliminating discriminatory treatment limitations is at the heart of federal parity law, but access to substance use disorder (SUD) treatment continues to face substantial barriers for the more than 20 million of people in the U.S. who have a substance use disorder.
Parity laws require health coverage programs, including Medicaid managed care, to cover behavioral health services in parity with medical / surgical benefits. Although parity requirements have applied to SUDs in addition to mental health conditions for a decade, parity noncompliance particularly impacts individuals with SUDs.
While parity requirements have been associated with increases in private insurance coverage of mental health services, the same has not occurred for SUD services. The share of total mental health treatment expenditures for private insurance has increased significantly, yet treatment for substance use disorder is largely still borne by public programs, especially Medicaid and other state programs.
It is important to note that many public programs, including Medicare, fee for service Medicaid, and the Veteran’s Administration, need not comply with parity requirements.
Although Medicaid managed care plans must comply with parity, states were only required to start monitoring compliance in the past few years and much of that is based on plans’ self-monitoring efforts. Therefore, people with SUDs are often left without good options to access the services they need.
They face problems accessing necessary services with parity in private insurance plans and at the same time have very few parity protections in the public programs they may turn to in order to access the services they need.
A big piece of ongoing parity non-compliance stems from the lack of complaints and enforcement. As the U.S. Government Accountability Office (GAO) noted in a recent report, parity compliance efforts are largely reliant on individuals filing complaints about a lack of parity. But in that same report, the GAO identified that health insurance plans may be unwilling to disclose information about coverage of services for fear of triggering complaints.
In a report that focused on the availability of parity information related to SUD services, reviewers with a high degree of parity knowledge found that regulators would not be able to accurately assess whether a plan was compliant with parity based on the information available from the plan.
Importantly, this same report found that the lack of transparency in plan documents about benefit and formulary coverage meant that it would be “challenging, if not impossible, for an average consumer to identify plan design features that raise ‘red flags’ for Parity Act violations.”
As NHeLP and other amici addressed in its brief in support of the plaintiffs in N.R. v. Raytheon, the disclosure requirements for mental health and SUD parity must be meaningful and meet the standards set by parity regulations and related federal guidance. The recent federal parity self-compliance toolkit reiterated these disclosure requirements and highlighted some of the common issues with access to SUDs that may be parity violations, such as overly restrictive access to life-saving medication assisted treatment (MAT).
These standards simply require plans to disclose information that should be readily available. The failure to properly disclose means that people cannot identify and complain about parity violations, meaning that people go without or suffer other harms due to parity noncompliance.
Where parity noncompliance remains, individuals cannot access the MH/SUD services they need to treat serious health conditions. For adults, a lack of parity for MH/SUDs often results in higher costs for those services, an inability to receive services-particularly at the intensity or frequency needed, failure to find providers, and thus ultimately, missed services.
For example, the Parity at 10 Consumer Health Insurance Knowledge and Experience Survey found that one in five of those surveyed reported difficulties finding a provider, one-third described denials, delays, or limitations on MH/SUD services, and for those denied treatment, 47% paid out of pocket and 34% did not receive the requested treatment. It is axiomatic that increased costs for services often results in people not accessing MH/SUD services because of the financial burden.
The impact of parity noncompliance goes beyond the increased costs or deprivation of services. A lack of parity may mean that people cannot access the care they need, especially the recommended type of care, such as medication assisted treatment for opioid use disorder. This may make it hard to find or maintain employment, pursue education or training, or maintain stable housing. There are additional indirect costs.
For example, the costs of turnover, lost productivity, absenteeism, and disability from MH/SUD have been estimated to be as high as $105 billion annually with an estimated cost of $78.5 billion associated with SUD in 2013. These costs are particularly prevalent among individuals with SUD, which has been associated with an estimated $78.5 billion in lost productivity in 2013.
While access to MAT is associated with a reduction in the incidence of drug-related criminal activity, improved family relations, and successful return to employment, less than 15% of people who need it are currently receiving treatment. Parity enforcement would go a long way in fixing that.
Mental health parity reforms have been marked by ever more sophisticated efforts from Congress to be more specific in what parity means and what is required of health insurance plans, but those same plans continue to move the goalposts. Therefore, meaningful parity disclosure is more important than ever, especially for SUDs.