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State Parity Laws and Access to Treatment for Substance Use Disorder in the United States:  Implications for Federal Parity Legislation

Hefei Wen, BA1; Janet R. Cummings, PhD1; Jason M. Hockenberry, PhD1,2; Laura M. Gaydos, PhD1; Benjamin G. Druss, MD, MPH1
[+] Author Affiliations
1Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
2currently with Center for Comprehensive Access and Delivery Research and Evaluation Center, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
JAMA Psychiatry. 2013;70(12):1355-1362. doi:10.1001/jamapsychiatry.2013.2169.
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Importance  The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment.

Objective  To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation.

Design, Setting, and Participants  We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment.

Interventions  State-level SUD parity laws during the study period.

Main Outcomes and Measures  State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance.

Results  The implementation of any SUD parity law increased the treatment rate by 9% (P < .001) in all specialty SUD treatment facilities and by 15% (P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% (P = .02) and 8% (P = .04), respectively, in all facilities and by 21% (P = .03) and 10% (P = .04), respectively, in facilities accepting private insurance.

Conclusions and Relevance  We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

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Trend in Substance Use Disorder (SUD) Treatment Rate by SUD Parity Status

A, Any change in parity compared with no change. B, All changes in parity ranging from none to full. State-aggregate SUD treatment rates reflect the preparity and postparity periods. We centered the year each state started to implement the law at time 0. The vertical line represents the year during which each state started to implement or extend the law, and it corresponds with the period covered in National Survey of Substance Abuse Treatment Services (N-SSATS) from April 2001 to March 2002 (N-SSATS 2002) for Delaware and Michigan; April 2002 to March 2003 (N-SSATS 2003) for Montana and Rhode Island; April 2003 to March 2004 (N-SSATS 2004) for Maine and New Hampshire; April 2004 to March 2005 (N-SSATS 2005) for Wisconsin and West Virginia; and April 2006 to March 2007 (N-SSATS 2007) for Oregon. Kentucky implemented parity during the gap year between N-SSATS 2000 and 2002, so time 0 consisted of 9 data points instead of 10. For the other states with no change in parity, the treatment rates during N-SSAT 2002, 2003, 2004, 2005, and 2007 were weighted by 2/9, 2/9, 2/9, 2/9, and 1/9, respectively, to match the proportions of the states that implemented parity in a given year. Following the same procedure, we determined times −2, −1, 1, 2, and 3 for the states with any change in parity, and then transferred states with no change in parity to the corresponding time in accord with the parity states. Only 7 states with any change in parity were included for time −2 (no data for Kentucky, Deleware, or Michigan), time 2 (no data for Oregon), and time 3 (no data for Oregon).

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