A hallmark of a well-functioning insurance market is protection against the risk of catastrophic financial losses. Historically, protection from large losses resulting from mental health/substance abuse (MH/SA) service use has been unavailable in most private health insurance plans because of special benefit limits on MH/SA services. Parity policies aim to protect individuals with severe mental illnesses against the catastrophic costs of seeking treatment, and, in doing so, increase efficiency and fairness in the insurance market. In 2001, all plans participating in the Federal Employees Health Benefits (FEHB) Program were required to offer coverage for MH/SA services on a par with general medical services. The FEHB parity directive represents the most comprehensive parity policy enacted to date. Previous studies of parity have found that, on average, implementation of MH/SA parity did not result in either the large increases in MH/SA spending predicted by opponents or increased access to services anticipated by mental health advocates. Parity has resulted in relatively small reductions in average out-of-pocket spending for service users. It is possible that the relatively small changes in average out-of-pocket spending resulting from parity adoption were driven by the subset of individuals with the highest costs;however, this issue has not been examined. The impact of parity on the sickest individuals and those carrying the greatest financial burden of illness constitutes the central question left unanswered by the existing literature on parity.
The specific aims of this application are to: 1) Compare the effects of comprehensive parity on total and out-of-pocket MH/SA spending across the distribution of expenditures in order to determine whether parity differentially increased financial protection for individuals with high MH/SA expenditures;2) Examine the effect of comprehensive parity on the composition and intensity of the treatment they receive;and 3) Assess the effect of parity on the likelihood of being rehospitalized for an MH/SA condition and the likelihood that patients diagnosed with bipolar disorder or major depression receive appropriate ambulatory treatment. We will use a quasi-experimental design to compare FEHB plan enrollees with a matched comparison group of privately-insured enrollees not subject to the FEHB parity directive to account for secular trends in MH/SA use and spending. We will attempt to disentangle the effects of parity and managed care carve-outs by comparing plans that used carve-outs with those that did not. We will estimate a combination of two-part random-effects models for longitudinal data, latent class random-effects models, logistic regression models, Poisson regression models, and hazard models to address these aims.

Public Health Relevance

Historically, MH/SA coverage has been seen as inefficient because it did not provide the most valuable protection against financial risk - protection against the risk of incurring large losses - due to high cost sharing and benefit limits for MH/SA services. We know from the existing literature on MH/SA parity that parity is affordable in the context of managed care (i.e., does not result in large MH/SA spending increases on average), but we do not yet know the extent to which parity implementation will achieve its primary goal of improving efficiency in the insurance market by increasing financial protection for individuals with severe disorders who have high treatment costs. The results of this study will inform policy makers about the impact of comprehensive parity on these individuals who carry the greatest financial burden of mental illness, and thus whether parity has improved the efficiency of insurance coverage for MH/SA services.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
Project #
Application #
Study Section
Mental Health Services in Non-Specialty Settings (SRNS)
Program Officer
Rupp, Agnes
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Harvard University
Schools of Medicine
United States
Zip Code
Busch, Alisa B; Yoon, Frank; Barry, Colleen L et al. (2013) The effects of mental health parity on spending and utilization for bipolar, major depression, and adjustment disorders. Am J Psychiatry 170:180-7
Busch, Susan H; Meara, Ellen; Huskamp, Haiden A et al. (2013) Characteristics of Adults With Substance Use Disorders Expected to Be Eligible for Medicaid Under the ACA. Psychiatr Serv 64:520-6
Barry, Colleen L; Chien, Alyna T; Normand, Sharon-Lise T et al. (2013) Parity and out-of-pocket spending for children with high mental health or substance abuse expenditures. Pediatrics 131:e903-11
Goldman, Howard H; Barry, Colleen L; Normand, Sharon-Lise T et al. (2012) Economic grand rounds: the price is right? Changes in the quantity of services used and prices paid in response to parity. Psychiatr Serv 63:107-9
Barry, Colleen L; Huskamp, Haiden A (2011) Moving beyond parity--mental health and addiction care under the ACA. N Engl J Med 365:973-5
Neelon, Brian; O'Malley, A James; Normand, Sharon-Lise T (2011) A bayesian two-part latent class model for longitudinal medical expenditure data: assessing the impact of mental health and substance abuse parity. Biometrics 67:280-9
Yoon, Frank B; Huskamp, Haiden A; Busch, Alisa B et al. (2011) Using Multiple Control Groups and Matching to Address Unobserved Biases in Comparative Effectiveness Research: An Observational Study of the Effectiveness of Mental Health Parity. Stat Biosci 3:63-78
Barry, Colleen L; Huskamp, Haiden A; Goldman, Howard H (2010) A political history of federal mental health and addiction insurance parity. Milbank Q 88:404-33
Barry, Colleen L; Goldman, Howard H; Frank, Richard G et al. (2009) Lessons for healthcare reform from the hard-won success of behavioral health insurance parity. Am J Psychiatry 166:969-71