State Enforcement of the Federal Mental Health Parity and Addiction Equity Act

Until passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008, there was no comprehensive federal policy prohibiting health insurers from treating mental health and substance use benefits differently than medical/surgical benefits. Enforcement of the MHPAEA is divided between state insurance departments, the U.S. Department of Labor, and the U.S. Department of Health and Human services depending on insurance type. The goals of this dissertation are to (1) explore state insurance offices’ statutory capacity to enforce the MHPAEA, (2) understand factors that influence variation in state enforcement strategies, and (3) examine the role of the state attorney general in enforcement of the MHPAEA. Manuscript 1 explores states’ statutory capacity to enforce the MHPAEA using a comprehensive legal mapping study of the powers and responsibilities of state insurance departments as they relate to parity oversight and enforcement in the 46 states enforcing the MHPAEA. This study finds that statutory capacity to enforce the MHPAEA is similar across all 46 states, indicating that it is not a primary source of enforcement variation across states. Manuscript 2 is a multiple-case study of four states investigating what other factors may contribute to state-level variation in insurance office enforcement approaches. Findings in this study indicate that sources of variability in state-level enforcement of the federal MHPAEA include insurance office relationships with other state offices, insurers, and advocates; the complex nature of the federal parity law; and the political priority government actors place on parity enforcement. Manuscript 3 uses the same qualitative data used in Manuscript 2 to explore the role of the state attorney general in the enforcement of the MHPAEA. Results from this study suggest that whether state attorneys general (SAG) engage in enforcement is influenced by factors including the office’s perception of its role with regard to enforcement of the MHPAEA, its relationship with the state insurance office, how the SAG’s office interprets the complexities of the federal policy, and the political priorities of the individual SAGs. In combination, the results of this dissertation identify several challenges for state-level enforcement of the MHPAEA and suggest it is unlikely that state enforcement can be uniform. However, the findings also indicate that states with an insurance commissioner or SAG who prioritizes MH/SUD parity have multiple avenues available for investigatory and enforcement activities