“Parity Law” Propelled Both Progress and Challenges in Addiction, Mental Health Care
2023 marks 15th anniversary of historic signing of law aimed at ending discrimination in insurance coverage
By William C. Moyers
NOTE: This was published for the Hazelden Betty Ford Foundation’s monthly Recovery Advocacy Update. If you’d like to receive our advocacy emails, subscribe today.
Not for a moment do I doubt that it was the right thing for Hazelden and the Betty Ford Center to fight to end discrimination by insurance companies against people like me. But nothing has been the same since we and others won that fight. And on the 15th anniversary of that crowning public policy accomplishment, I must admit there are moments I question if the impact on the institution that changed my life went beyond what any of us ever anticipated.
In the fall of 2008, President George W. Bush signed the historic “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Act,” requiring group- and self-insured health plans providing behavioral health benefits to cover treatment for addiction or mental illness fairly — that is, “on par” with their coverage for medical and surgical care. The legislation highlighted the bipartisan effort of Sen. Wellstone, a Democratic from Minnesota, and Sen. Dominici, a Republican from New Mexico. Paul was my friend whose shocking death in a plane crash six years earlier galvanized our efforts. Both he and Dominici had firsthand experience with family members who struggled with behavioral health challenges. Along with Rep. Jim Ramstad, a Republican member of the U.S. House from Minnesota, and Rhode Island Democrat Rep. Patrick Kennedy — both of whom openly shared their intimate stories of addiction and recovery — Congress finally came together to embrace our rallying cry that “addiction is a bipartisan illness that demands a bipartisan solution.”
It took 12 long years and hundreds of thousands of dollars in advocacy investments to make this happen. Hazelden helped lead the charge, along with the Partnership for Recovery we forged with the Betty Ford Center (which later merged with Hazelden to form the Hazelden Betty Ford Foundation) as well as the Valley Hope and Ashley treatment organizations. Scores of other trade and professional associations also joined the fight, and thousands of people from across the nation heard our rallying cry to add their faces and voices to the cause by contacting their members of Congress and the White House. It worked.
Today, more people than ever can get help at Hazelden Betty Ford using their private health insurance. Indeed, about 95% of our patients use their insurance for treatment, compared to about 5% when I was a patient in 1989 and my family paid out of pocket for that stint and my second at Hazelden, two years later. The parity law has expanded access to help and healing for millions of Americans at treatment centers large and small, non-profit and for-profit. In 2010, this law also influenced the Obama Administration’s decision to include addiction and mental illness treatment as an essential health benefit as defined by the Affordable Care Act, opening the doors even wider for millions of other Americans who do not have private insurance.
Candidly, though, I acknowledge that all of us were blindsided by the seismic shift that resulted from our successful push for parity — and the contracts treatment centers subsequently established with insurance companies. All of a sudden, the mission of treatment centers had to be married more closely with the bottom-line focus of payers. One result is that residential treatment stays have declined. At one time, 28 days was famously the standard. Now, at Hazelden Betty Ford, the average length of residential stay is closer to 21 days. To an old-time alum like me, that seems hardly enough time to understand, much less acclimate and start to put into daily practice, a recovery lifestyle. Or to forge meaningful relationships with peers, counselors and housekeepers on the units. Or to appreciate the unique quality of the facilities and the campuses that burnish our brand. I often fear that some of our residential patients have barely cleared their heads of the substances inside before it is time to move on, step down, or step into outpatient treatment under the terms of the contract with the insurers.
The good news is that while residential stays have shortened, many of our Hazelden Betty Ford patients step down to a little less intense level of care called “day treatment” — often while living in a recovery residence — and then into other even lower levels of outpatient care, and they can get mental health care and other recovery supports for themselves and their family members all along the way. As a result, average overall lengths of engagement at our organization have expanded and care is more individualized. It’s not unusual, for example, for patients to be engaged at some level for several months. It’s also easier for people to step into lower-intensity levels of care initially when appropriate. On balance, this all represents a positive trend for the majority we serve and aim to serve at Hazelden Betty Ford. I just didn’t fully realize how big a transformation parity would propel in the design, delivery and resourcing of care. And I’m not sure all treatment providers have been able to transform as quickly and effectively.
Tighter terms for reimbursement across all levels of care — the inevitable result of managed care — have resulted in a tighter bottom line for all care providers. At Hazelden Betty Ford, that has added pressure on an organization with a broader mission that includes a graduate school, robust children’s and family services, educational programing, advocacy, and a research center. Plus, we’re in an inflationary economic environment, with millions of dollars in expenses to maintain or upgrade our sites and campuses across the country and the salaries and benefits for the 1,600 employees who make our mission unique. The adage “no margin, no mission” is true, and even with the generosity of donors at an all-time high, Hazelden Betty Ford’s tug-of-war — like all organizations’ — is between the revenue we produce and the expenses we incur.
Such pressures are not the fault of our insurance partners. But it is the reality we face because of what we asked for all those years ago when I started as a public policy specialist at Hazelden. On my first day at work, my boss sent me to Washington, D.C., to “smash stigma, end discrimination, expand access to treatment and highlight the promise of recovery.” I wasn’t confident where to start. Today, I know we aren’t finished. But we have come a long way.
On the cusp of Hazelden Betty Ford’s 75th anniversary in 2024, and now closer to the end of my career than the beginning, I am grateful that our nonprofit remains strong and healthy amid the changing landscape. I also naturally worry about the challenge of where we are going as an industry and whether greater percentages of people will ultimately recover in the years ahead as behavioral health services become a more integrated part of mainstream healthcare. I know demonstrating outcomes will be key. So, too, will be enhancing parity enforcement, keeping the issue of addiction and recovery centered in the public dialogue, and much more.
As I reflect on the progress and challenges that parity propelled 15 years ago, I’m certain we must continue to adapt and remain focused on what so many need from us: hope. That priority will never change.
William C. Moyers is vice president of public affairs and community relations for the Hazelden Betty Ford Foundation.
