What Do We Expect From Parity?

Two articles in this month’s issue explore the impact of parity laws on different potential outcomes. One looks at access, and the other examines quality of care. Bilaver and Jordan found no impact of parity on access to autism services as measured by service use. Wallace and McConnell found a significant increase in outpatient follow-up after hospital discharge, a quality measure based on utilization. Most studies of the quality and access outcomes of parity have mixed results.

Questions about the impact of parity sometimes remind me of the old saw about the patient who asks a surgeon, “Will I be able to play the violin after my operation?” The surgeon replies, “Yes, of course.” And the patient exclaims, “Wonderful, I always wanted to be able to play a musical instrument!”

The primary purpose of behavioral health insurance parity is to improve financial protection. Parity is intended to reduce out-of-pocket expenses for the treatment of a mental disorder to the point where those expenses are no more burdensome than would be expected for treating a general medical condition. The fundamental reason we have health insurance is to protect us against catastrophic health care expenditures that might be bankrupting. Parity evens the coverage for behavioral health conditions and general medical and surgical care. It is an issue of fairness.

As these two articles in this issue indicate, our expectations for health insurance parity are high. We expect considerably more than fairness in financial protection. For years it has been argued that dropping discriminatory cost-sharing insurance requirements would result in an increase in the probability of service use. But that has not usually been the case. Then, when managed care was introduced to control spending in tandem with parity, some argued that quality would improve with individualized treatment planning. Others were just hopeful that such utilization management would not withhold needed care and reduce quality. For the most part, the improvements in quality attributable to parity have been modest.

As for me, I am gratified that parity means that we enjoy improved insurance protection at no increase in cost—with some hope of improved access and better quality. I may not be able to play the violin, but at least my behavioral health care will not bankrupt me.