While the movement toward extending coverage beyond medical and surgical procedures to include mental health and (to a lesser extent) substance abuse is clear, the extents to which states are providing this "parity" are widely disparate. In 1996, Congress passed and President Clinton signed the Mental Health Parity Act, which requires that health plans provide parity by giving members the same annual and lifetime coverage limits for mental health benefits as they do for other health care. The new law, however, is limited in several ways. For example, it does not affect service limits, such as limits that an insurer can place on outpatient visits. It also does not affect cost-sharing mechanisms, such as deductibles. And it doesn't mention substance abuse. In the wake of the law's passage, 12 states had (by September, 1977) passed their own parity laws.

Early this year, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U. S. Department of Health and Human Services evaluated these state laws in a report, "The Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits," and concluded that most such laws are limited in scope or application. One of the most common limitations, SAMHSA reported, was failure to require parity coverage for substance-abuse treatment.

According to SAMHSA, five states-Arizona, Maryland, Minnesota, North Carolina, and Vermont- require that parity extend to substance-abuse treatment. But several other facets of the Vermont law, such as its refusal to provide various limitations and exemptions that are common in other states, make it the most comprehensive state effort to date in providing full parity for citizens needing treatment for mental health and substance abuse.

The Vermont law went into effect Jan. 1, 1998 and although it's still early to measure its effects, several initial outcomes are beginning to materialize. According to Kenneth Libertoff, executive director of the Vermont Association for Mental Health (VAMH), which worked for the bill's passage, opponents' allegations that parity legislation would prompt a stampede of companies into self-insurance have, to date, proven unfounded. He also said that a pro-parity coalition's estimate that premiums would rise by slightly more than 3 percent have been accurate.

"We have reason to believe that over the next year or two, the parity legislation will really be effective in terms of the way we saw it," Libertoff said. "We saw it as a way of creating a level playing field for consumers. Our goal was always to see this as a consumers' bill, not as a practitioners' bill. " "So far, the reaction has been positive, but we need time to sort out what the real access issues are. Are people really getting access to treatment? And is there some way of evaluating the quality?"

Many people in Vermont are well aware that the state's parity law is considered, at least potentially, a national model, according to Libertoff. And so VAMH is "working very aggressively, " in Libertoff's words, to develop a major evaluation of the Vermont program. After all, he points out, Vermont's parity law was something that many people worked hard to achieve for a long time.

In fact, the history of parity legislation in Vermont can probably be dated to 1985, when VAMH tried-unsuccessfully-to achieve legislation that would raise lifetime limits for mental-health coverage. Today, Libertoff says he learned valuable lessons from that experience when he came back to the Vermont legislature for the 1996 parity effort. By that time, it had become clear that with the failure of President Clinton's efforts to reform health care, any progressive steps would have to be taken on the state level. "It signaled to us that if we were going to take up the parity fight, it was going to have to be a full-scale approach right here in the state capitol," Libertoff said.

The first step toward full parity actually occurred in 1994 with the passage of the Vermont Mental Health Utilization Review Bill, which ad- dressed substance abuse along with mental health coverage and managed-care providers' use of "utilization reviews" to avoid treatment. "It anticipated some of the problems that we all have with managed care, particularly when utilization review can inappropriately be used as a way of cutting off treatment or eliminating treatment," Libertoff said.

The bill took a step that was, and is, highly unusual: It required all managed-care agents to register with the state. It also established a review process and a review panel for people who believe that a managed-care company behaved improperly.

The bill set the stage for the parity debate that came two years later because, Libertoff says, "Our argument is that unless you have some regulation over managed care, the industry may try to gut the utility of the parity bill by relying on inappropriate utilization review to resist expanding coverage. "

Late in 1996, Libertoff began drafting legislation that would call for comprehensive parity. Some states have opted to restrict parity coverage only to those people with specific and severe forms of mental illnesses or only to children. The second feature of Libertoff's proposed legislation was its absence of exemptions and limitations, which are common in the other states offering parity coverage. The SAMHSA report, for instance, found that four states exempt small businesses. In largely rural Vermont, with its high percentage of people who work for small employers, such an exemption would have been "disastrous," Libertoff says.

"The third thing is that very early on I made the decision to include substance abuse, which became a fascinating issue. It ended up becoming a focal point of a lot of very spirited debate. The business community in Vermont focused a lot of their negative positioning on that part of the bill."

According to Libertoff, business' opposition to including substance-abuse treatment in the bill wasn't so much based on economics as on moral beliefs about personal choice. That is, opponents argued, while mental-health problems often are not a person's own fault, drinking too much is a matter of personal choice. It was a position that took much effort to overcome, Libertoff said. "We said that it's time to treat substance abuse for what it is: a disease and a medical condition, and not something that's like a hobby that one chooses to do."

Take Action
Kenneth Libertoff offers four points of advice for advocates who are interested in working for parity legislation in their states:

• Start with a goal of establishing a comprehensive parity system-one that includes coverage for substance abuse as well as mental health, and one that doesn't exempt groups from participation. "The legislative process is one of compromise," Libertoff says. "If you compromise too early by saying, 'We're going to take out substance abuse because it's too controversial,' we think you're selling the issue far short."

• Get sound actuarial analysis on the costs of a parity system because without it, cost uncertainties will be the first area that opponents will attack.

• It's important to establish a broad coalition, including advocates, consumers, family members, and practitioners, but the practitioners should occupy secondary roles. "It's the best strategy to do," Libertoff says, "because when practitioners come forward as leaders on this, they seem very self-serving. In some states, that's been a very serious mistake. Legislators think they're supporting this because they're going to make more money."

• Public testimony from persons whose lives have been personally affected by substance-abuse and mental-health treatment is a powerful tool.

Call 800-789-2647 to receive a copy of the US Dept. HHS report, "The
Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits" or visit the web site of the National Association of Alcoholism and Drug Abuse Counselors at: http://www.nadac.org/legis.htm or call 703-741-7686.

Prepared by Join Together Staff   

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