The Glass is Half Full: Reflecting on Mental Health Parity
February 2020

Atyya Chaudhry
AMCHP Senior Program Manager, Health Systems Transformation


The start of a new decade is often a time of reflecting on past successes, challenges, and putting plans in place for the coming years. This last decade has seen the passage of historic laws to improve health care coverage, including the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). The MHPAEA became law in October 2008 and took full effect on January 1, 2010. This law mandates that group insurance plans, Medicaid, and the Children’s Health Insurance Program (CHIP) ensure coverage parity between benefits for mental health and substance use disorders (MH/SUDs) and benefits for medical and surgical services. Essentially, the law mandates that mental health/substance use disorders coverage cannot be more restrictive or more expensive than medical/surgical coverage in a plan, as it relates to coverage in inpatient and outpatient networks; emergency care services; co-pays; deductibles; prescription drugs; provider reimbursement rates; residential treatment; and other benefits. The MHPAEA was bolstered by the passage of the Affordable Care Act (ACA), because the ACA required that MH/SUDs services are covered as an essential health benefit. The ACA also extended MHPAEA’s benefits to individual and small-group insurance plans as well as the population covered by the expansion of Medicaid.

How well are we faring by the current law?

The law is a step in the right direction in improving awareness, coverage, and parity for MH/SUDs treatment and services. Since the law has been implemented, modest improvements have been demonstrated. Authors of a study evaluating the effects of MHPAEA on children found that the law helped bring about reductions in out-of-pocket spending on average for children with mental health conditions. However, the authors of the study also noted that out-of-pocket expenses for children with mental health conditions with high spending was minimal. According to the literature, overall gains from introducing the law vary greatly. These gains are often determined by the degree to which states enforce the Parity Act.

Although the law’s intent is positive, the glass remains half full. The most significant challenges relate to the adequacy of the network and the overall lack of ability to enforce the law. In a study conducted by the Bowman Family Foundation, researchers found that out-of-network utilization rates were higher for those seeking MH/SUDs services compared to other medical services. With limited in-network mental health or substance use treatment providers, families may be required to seek out-of-network services, which may be subject to higher out-of-pocket costs, which include co-pays and deductibles. In addition, this study found that provider reimbursement rates were lower for mental health treatment services, which may reduce the number of participating providers in network.

Although the law established the parity requirement for health insurance plans, compliance and enforcement are the cornerstone to optimize the provisions of the law and to benefit MCH populations.

What resources are Title V programs and other organizations providing to educate on the law?

Mental health and substance use disorders remain a priority issue for many Title V programs.  Although it has been 12 years since the passage of MHPAEA, much work remains to be done. Although state health insurance commissioners have sole authority to enforce compliance of MHPAEA, there are many opportunities to educate maternal and child health (MCH) populations about the parity law. Several consumer-focused resources are available, as follows:

In addition, several national advocacy organizations conduct research and produce reports and resources on parity:

  • To learn more about state-level legislation, the Kennedy Forum has an interactive map that analyzes current legislation and regulatory actions by state.
  • The National Alliance for Mental Illness (NAMI) continues to monitor parity enforcement and has developed various reports and consumer materials, and collects stories from a consumer. NAMI has a presence in all 50 states and Title V can connect with their efforts in mental health/substance use disorders parity.
  • The National Council for Behavioral Health is also monitoring this issue closely and has developed resources on improving access to MH/SUDs treatment in state Medicaid contracts, tips for providers on negotiating managed care contracts, and model parity legislation.
  • Several state departments of mental/behavioral health and human services are members of the National Council for Behavioral Health. Colleagues in your state may be members, which provides an opportunity for you to talk about the parity law and learn more about how your Title V program can help MCH populations understand and access provisions of this law.

AMCHP as an organization is prioritizing the topic of mental health/substance use disorders.  AMCHP’s most recent strategic plan includes a commitment to Reduce the Burden of Substance Use Disorder and Unmet Mental Needs on Women, Children, Families, and Communities. We lean on our members to join us on this challenging path in promoting access and adequate coverage for MH/SUDs treatment and services for maternal and child health populations.