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Parity: How We Got There, Where We Go Next

November 1, 2008
by Daniel Guarnera
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The new law's success will rest on educating the public about treatment
Rep. jim ramstad (r-minn.) speaks at a parity rally organized by rep. patrick kennedy (d-r.i.) on september 17 in washington, d.c.
Rep. Jim Ramstad (R-Minn.) speaks at a parity rally organized by Rep. Patrick Kennedy (D-R.I.) on September 17 in Washington, D.C. Charles Votaw Photography

By late September, addiction treatment advocates were more than a little anxious. Eighteen months of historic progress on a congressional bill to end insurance discrimination against mental health and addiction were in danger of going for naught.

An intractable dispute between the House of Representatives and the Senate over how to pay for parity's expected cost of less than $4 billion over 10 years (the House wanted to offset that cost with spending cuts or tax increases, the Senate did not) was putting parity's future in jeopardy. This was occurring despite the bill's support from Democratic and Republican leadership, both chambers, the business community, the insurance industry, and addiction and mental health treatment advocates. Congress's scheduled adjournment date already had passed, and if parity was not approved before members went home, it might not have another chance—the entire process would have to start from scratch in January.

There is a political maxim that says if you cannot find a solution to a given problem, make the problem bigger. In parity's case, the “bigger” problem that ultimately broke the stalemate was the economic crisis that led to the collapse of firms such as AIG and Lehman Brothers.

The House failed to pass a $700 billion economic rescue package on September 29, and the stock market continued to plunge. Congress came under intense pressure to do something.

The House's failure to pass a rescue package gave the Senate a chance to act. On October 1, the Senate passed (by a 74-25 vote) its own economic stabilization package. It took the opportunity to include in the bill a variety of popular tax cuts, alternative energy incentives, and parity, all of which the House had objected to for months because their costs had not been offset. But now, forced to vote up or down on the Senate proposal as a whole, the House was backed into a corner and voted 262-170 to pass the economic rescue package, including the Senate's add-ons. The president signed the bill, with parity included, into law on October 3.

Parity's passage marked the culmination of more than a decade of advocacy by the addiction community. Addiction had been dropped altogether from a partial mental health parity bill that Congress adopted in 1996, and some early drafts of the current legislation did not consistently include substance use disorders on the same level as mental disorders. However, the final parity bill—officially the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act—is far more comprehensive than the 1996 law both in defining parity and including addiction.

Key provisions

The new parity law requires insurance plans that cover more than 50 employees to cover mental health and substance use disorders under the same terms for which they provide medical/surgical coverage. This means that both cost-sharing (copayments, deductibles, etc.) and treatment limitations (lifetime or annual limits, caps on inpatient days or outpatient visits) must be the same for addiction and mental health as they are for medical conditions. Out-of-network coverage must be the same as well, and state parity laws that are stronger than the federal “floor” will be protected. Insurance plans are free to use medical management techniques to determine what treatment is appropriate for a given diagnosis, as they are for other medical care.

Although an early proposal to require all disorders in the DSM-IV to be covered specifically in the law was ultimately rejected, plans now will be required to be transparent about the medical necessity criteria that are used and about reasons for coverage denials. The government will study and report on patterns of coverage under parity, to ensure that the bill is having its intended effect.

Next steps

Parity, as enacted, will go into effect on the first new plan year after October 3, 2009. It is estimated that more than 100 million people will be better able to access treatment as a result. However, access does not help close the treatment gap if people who need addiction services do not seek them.

Parity supporters believe that the law will help people think of addiction treatment in the same way they think of other medical care, thereby reducing stigma and making services more affordable. But the promise of parity depends in large part on educating the public, informing people about their new coverage, and teaching them to identify substance use that requires treatment. Advocates are now starting to look beyond parity to find ways to use the new law to engage the public about the dangers of addiction and the importance of treatment.

While parity's passage marks a historic achievement for the addiction community, in many ways our work is just beginning.

Daniel Guarnera is the Government Relations Liaison for NAADAC, The Association for Addiction Professionals and the National Association of Addiction Treatment Providers (NAATP), which operate a joint public policy department. His e-mail address is


For more of Daniel Guarnera's perspectives on public policy and advocacy topics of importance to addiction professionals, read his blog on the Addiction Professional Web site, at

Addiction Professional 2008 November;6(6):14-16