MPHAEA & Marble Cake: Parity & the Forgotten Frame of Federalism

Federal parity laws, and their state equivalents, have been shown to increase access to substance use disorder (SUD) treatment, by decreasing the cost of SUD treatment borne by the insured, and has resulted in little increase in health plan costs. Despite these improvements, the effects of parity on access to SUD treatment have been lower than expected. Recent reports suggest that states have varied in their enforcement parity, failures which may explain why persons surveyed still report having inadequate insurance coverage for SUD treatment despite the parity legislation. While other articles have offered suggestions for improving parity, most have lumped mental health and substance use disorder treatment coverage together in their analysis and recommendations. This paper focuses exclusively on SUD treatment and its distinct institutional history. Aside from focusing exclusively on substance use disorder treatment, this paper contributes to the literature by analyzing parity implementation through the lens of theories of federalism. It argues that in order for parity implementation to be effective, it must account for the current ideological divisions that have characterized intergovernmental relationships for nearly a decade. This paper demonstrates how theories of federalism and intergovernmental relations are particularly useful in analyzing the implementation of health insurance parity reform because they suggest that some of the implementation issues that have arisen were due to the structure of the division of federal/state responsibilities. In doing so, this paper suggests alternate structures for dividing the responsibilities for enforcement