Parity is a concept that has now been enshrined in federal legislation since passage of the Wellstone-Domenci Mental Health Parity and Addiction Equity Act of 2008, and reinforced by the provisions of the Patient Protection and Affordable Care Act (ACA) signed into law in 2010. These acts acknowledge that mental illness is a chronic and relapsing disease, as recognized by the American Medical Association (AMA), American Society of Addiction Medicine (ASAM), and other organizations, and includes such conditions as schizophrenia, bipolar disorder, depression, and substance use disorder/addiction (Smith et al., 2010).
Medicalization of addiction treatment needs to be based on assessment, with the appropriate level of care based on the acuity of the disease, including residential addiction treatment where indicated. However, many of those afflicted do not have access to the treatments and medications that are increasingly available to address their illness. Implementing parity for addictive disease as for other diseases, for examples, diabetes, has produced conflict within the current insurance-based system that bases its criteria on medical necessity, as if addictive disease were an acute disease, such as a time-limited infection, rather than a chronic illness like diabetes.
Governments attempt to balance their budgets by eliminating beds in psychiatric units, health insurance plans have placed limits on numbers of counseling sessions, residential social model programs and therapeutic communities are not considered adequately “medical.” As a result, individuals’ lives can spiral downward, resulting in alcohol and other drug use and a life on the street. There is a trend toward medicalizing such psychosocial programs in order to provide integrated care to bridge this gap in healthcare reform and parity.
The denial of access to comprehensive treatment is costly for communities and frustrating for families (Jervis, 2014). According to the U.S. Department of Housing and Urban Development, more than 20% of the country’s homeless have a severe mental illness (Jervis, 2014). The 2002 Culhane Report showed that New York City’s provision of hospital, jail, and other services to street-based homeless populations cost over $40,000 per person, while individuals placed in supportive housing cost about 40% less, a considerable savings (Culhane et al., 2002).
Much of the resistance to parity for mental health illness and addictive disease lies in their stigmatization, perhaps because of the anti-social behaviors these illnesses induce. Placing limits on the quantity of care received can be seen as “punishment” for these behaviors.
In California, a group called Right2Treatment is advocating for four key changes to the State’s Medi-Cal policies:
- Enforce parity;
- Integrate mental health care with mainstream physical health care as required by the ACA;
- Create uniform standards of care statewide, in all counties; and
- Establish accountability that the standards are being met (Yanello 2014).
Although studies such as the Culhane Report demonstrate the cost benefits of supportive care for those with mental illness, the reality is that government agencies have unique mandates and may not be structured to establish joint programs with other agencies. Supportive housing for those with addictive disease, for example, might require staff in the areas of medicine, psychiatry/psychology, building/construction, nutrition, and employment services. Facilities such as HealthRIGHT 360, formed from the merger of Haight Ashbury Free Clinics and Walden House in 2011 in San Francisco, and Center Point, in San Rafael, California, have developed models that incorporate these varying elements into their programs.
Parity is now the law of the land. Budget-makers and the treatment community must find ways to creatively assure that the services guaranteed by law are available, accessible and effective for the many who need them.
Culhane, D. P., Metraux, S., & Hadley, T. (2002). Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Housing Policy Debate, 13(1), 107–163.
Jervis, R. (2014, August 28). “The cost of not caring: Mental disorders strand thousands on the streets. USA Today, pp. 1A, 7A.
Smith, D. E., Lee, D. R., & Davidson, L. D. (2010). Health care equality and parity for treatment of addictive disease. Journal of Psychoactive Drugs, 42(2), 121–126.
Yannello, A. (2014, August 8). End funding disparity for treatment of mental, physical illnesses. San Francisco Chronicle. Retrieved from https://www.sfgate.com/opinion/article/Disparity-in-funding-results-in-unequal-medical-5677526.php