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1.  State Parity Laws and Access to Treatment for Substance Use Disorder in the United States: Implications for Federal Parity Legislation 
JAMA psychiatry  2013;70(12):1355-1362.
Context
The passage of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) and the 2010 Affordable Care Act (ACA) incorporated parity for substance use disorder (SUD) into federal legislation. Yet prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment.
Objective
This study examined the effect of state-level SUD parity laws on state-aggregate SUD treatment rates from 2000 to 2008, to shed light on the impact of the recent federal-level SUD parity legislation.
Design
A quasi-experimental study design using a two-way (state and year) fixed-effect method
Setting and Participants
All known specialty SUD treatment facilities in the United States
Interventions
State-level SUD parity laws between 2000 and 2008
Main Outcome 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 percent (p<0.01) in all specialty SUD treatment facilities and by 15 percent (p<0.05) in facilities accepting private insurance. Full parity and parity-if-offered (i.e., parity only if SUD coverage is offered) increased SUD treatment rate by 13 percent (p<0.05) and 8 percent (p<0.05) in all facilities, and by 21 percent (p<0.05) and 10 percent (p<0.05) in those accepting private insurance.
Conclusions
We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association was 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.
doi:10.1001/jamapsychiatry.2013.2169
PMCID: PMC4047825  PMID: 24154931
2.  Challenges and Opportunities for Integrating Preventive Substance-Use-Care Services in Primary Care through the Affordable Care Act 
Undertreated or untreated substance use disorders (SUD) remain a pervasive, medically-harmful public health problem in the United States, particularly in medically underserved and low-income populations lacking access to appropriate treatment. The need for greater access to SUD treatment was expressed as policy in the Final Rule on standards related to essential health benefits, required to be covered through the 2010 Affordable Care Act (ACA) health insurance exchanges. SUD treatment services have been included as an essential health benefit, in a manner that complies with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Consequently, with the ACA, a vast expansion of SUD-care services in primary care is looming. This commentary discusses challenges and opportunities under the ACA for equipping health care professionals with appropriate workforce training, infrastructure, and resources to support and guide science-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) for SUD in primary care.
doi:10.1353/hpu.2014.0067
PMCID: PMC3984935  PMID: 24583486
Substance use disorders; Affordable Care Act; addiction treatment; drug abuse treatment; primary care; medical settings; electronic health record; health information technology; prevention; medical home; implementation science; health care reform; health services research; patient-centered medical home; electronic medical record
3.  Behavioral Health Parity and the Affordable Care Act 
Prior to the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) and the ACA, about 49 million Americans were uninsured. Among those with employer sponsored health insurance, 2 % had coverage that entirely excluded mental health benefits and 7% had coverage that entirely excluded substance use benefits. The rates of non-coverage for mental and substance use disorder care in the individual health insurance markets are considerably higher. Private health insurance generally limits the extent of these benefits. The combination of MHPEA and ACA extended overall health insurance coverage to more people and expanded the scope of coverage to include mental health and substance abuse benefits.
doi:10.1080/1536710X.2013.870512
PMCID: PMC4334111  PMID: 24483783
co-occurring disorders; disability economics; disability policy; health care; mental health; mental illness; policy; substance abuse
4.  Behavioral Health Insurance Parity: Does Oregon’s Experience Presage the National Experience with the Mental Health Parity and Addiction Equity Act? 
Objective
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act prohibits commercial group health plans from imposing spending and visit limitations for mental health and substance abuse services that are not imposed on medical-surgical benefits. Controversially, the Act also restricts the use of managed care tools that apply to the behavioral health benefit in ways that differ from their application to the medical-surgical benefit. The only precedent for this approach is Oregon’s state parity law, implemented in 2007. The goal of this study is to estimate the effect of Oregon’s parity law on expenditures for mental health and substance abuse treatment services.
Methods
We compared expenditures for individuals in four Oregon commercial plans from 2005 through 2008 to a matched group of commercially insured individuals in Oregon who were exempt from parity. Using a difference-in-differences analysis, we analyzed the effect of comprehensive parity on spending for mental health and substance abuse services.
Results
Increases in spending on mental health and substance abuse services following Oregon’s parity law were due almost entirely to a general trend observed among individuals with and without parity. Expenditures per enrollee for mental health and substance abuse services attributable to parity were positive but did not differ significantly from zero in any of the four plans (range: +$12.15 to +$25.49, p>0.05 for each comparison).
Conclusion
Behavioral health insurance parity that places restrictions on how plans manage mental health and substance abuse services can improve insurance protections without substantial increases in total costs.
doi:10.1176/appi.ajp.2011.11020320
PMCID: PMC3263406  PMID: 21890792
5.  How would mental health parity affect the marginal price of care? 
Health Services Research  2001;35(6):1207-1227.
OBJECTIVE: To determine the impact of parity in mental health benefits on the marginal prices that consumers face for mental health treatment. DATA SOURCES/DATA COLLECTION: We used detailed information on health plan benefits for a nationally representative sample of the privately insured population under age 65 taken from the 1987 National Medical Expenditure Survey (Edwards and Berlin 1989). The survey was carefully aged and reweighted to represent 1995 population and coverage characteristics. STUDY DESIGN: We computed marginal out-of-pocket costs from the cost-sharing benefits described by policy booklets under current coverage and under parity for various mental health treatment expenditure levels using the MEDSIM health care microsimulation model developed by researchers at the Agency for Healthcare Research and Quality. Descriptive analyses and two-limit Tobit regression models are used to examine how insurance generosity varies across individuals by demographic and socioeconomic characteristics. Our analyses are limited to a description of how parity would change the marginal incentives faced by consumers under their existing plan's cost-sharing arrangements for mental and physical health care. We do not attempt to simulate how parity might affect the level of benefits, including whether benefits are offered at all, or the level of managed care that affects the actual benefits that plan members receive. Rather, we focus only on the nominal benefits described in their policy booklets. PRINCIPAL FINDINGS: Our results show that as of 1995 parity coverage would substantially reduce the share of mental health expenditures that consumers would pay at the margin under their existing plan's cost-sharing provisions, with larger changes for outpatient care than for inpatient care. Because current mental health coverage generally becomes less generous as expenditures rise, while coverage for other medical care becomes more generous (due to stop-loss provisions), the difference in incentives between current mental health coverage and the assumed parity coverage widens as total expenditure grows. We also find that the impact of parity on marginal incentives would vary greatly across the privately insured population. CONCLUSIONS: Based on the large variation in the impact of parity on marginal incentives across the population under current plan cost-sharing arrangements, changes in the demand for mental health treatment will likely also vary across the population.
PMCID: PMC1089187  PMID: 11221816
6.  Childhood Cancer Survivors' Familiarity With and Opinions of the Patient Protection and Affordable Care Act 
Journal of Oncology Practice  2013;9(5):246-250.
Childhood cancer survivors have a low level of familiarity with the Patient Protection and Affordable Care Act (ACA) and are unaware of how it may affect them given their cancer history. These survivors require targeted education to increase knowledge about the ACA.
Purpose:
The Patient Protection and Affordable Care Act (ACA) offers avenues to increase insurance options and access to care; however, it is unknown whether populations with pre-existing conditions, such as cancer survivors, will benefit from the expanded coverage options. We explored childhood cancer survivors' familiarity with and opinion of the ACA to understand how survivors' insurance coverage may be affected.
Materials and Methods:
From April to July 2012 we conducted in-depth, semistructured telephone interviews with 53 adult survivors recruited from the Utah Cancer SEER Registry. Participants were randomly selected from sex, age, and rural/urban strata and were younger than 21 years at time of diagnosis. Interviews were recorded, transcribed, and analyzed with NVivo 9 by two coders (kappa = 0.94). We report on the 49 participants who had heard of the ACA.
Results:
Most survivors were unaware of ACA provisions beyond the insurance mandate. Few knew about coverage for children up to age 26 or pre-existing insurance options. Although one third believed the ACA could potentially benefit them via expanded insurance coverage, many were concerned that the ACA would lead to rising health care costs and decreasing quality of care. Survivors had concerns specific to their cancer history, including fears of future health care rationing if they developed subsequent health problems.
Conclusion:
Childhood cancer survivors have a low level of familiarity with the ACA and are unaware of how it may affect them given their cancer history. These survivors require targeted education to increase knowledge about the ACA.
doi:10.1200/JOP.2013.000919
PMCID: PMC3770506  PMID: 23943900
7.  The Effects of Parity on Mental Health and Substance Use Disorder Spending and Utilization: Does Diagnosis Matter? 
The American journal of psychiatry  2013;170(2):180-187.
Objective
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires insurance parity for mental health/substance use disorder (MH/SUD) and general medical services. Prior research found that parity did not increase MH/SUD spending and lowered out-of-pocket spending. Whether parity’s effects differ by diagnosis is unknown. We examine this question in the context of parity implementation in the Federal Employees Health Benefit (FEHB) Program.
Methods
Using administrative data and a difference-in-difference design, we compared MH/SUD treatment use and spending before (2000) and after (2002) parity for FEHB enrollees diagnosed in 1999 with bipolar disorder, major depression, or adjustment disorder (N=19,094) to that for a national sample of privately-insured individuals unaffected by the policy (N=10,521). Separate models were fit for each diagnostic group.
Results
The parity directive resulted in total spending that was unchanged among MH/SUD users with bipolar disorder and major depression but decreased for adjustment disorder (−$114 [95% CI:−$193,−$41]). Out-of-pocket spending decreased by a comparable amount for all three diagnoses (range: −$78 to −$86). Total annual utilization (e.g., medication management visits, psychotropic prescriptions, and MH/SUD hospitalization bed days) remained unchanged across all diagnoses. Annual psychotherapy visits decreased significantly only for individuals with adjustment disorders (−12%[−17.0%,−6.1%]).
Conclusions
While parity implemented in the context of managed care improved financial protection for individuals in all three diagnostic groups, the policy differentially affected spending and psychotherapy utilization across groups. There was some evidence that resources were preferentially preserved for diagnoses typically more severe/chronic and reduced for diagnoses that are expected to be less so.
doi:10.1176/appi.ajp.2012.12030392
PMCID: PMC4169195  PMID: 23377639
8.  What Oregon's Parity Law Can Tell Us about the Federal Mental Health Parity and Addiction Equity Act and Spending on Substance Abuse Treatment Servicesb 
Drug and Alcohol Dependence  2012;124(3):340-346.
Background
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires commercial group health plans offering coverage for mental health and substance abuse services to offer those services at a level that is no more restrictive than for medical-surgical services. The MHPAEA is notable in restricting the extent to which health plans can use managed care tools on the behavioral health benefit. The only precedent for this approach is Oregon's 2007 state parity law. This study aims to provide evidence on the effect of comprehensive parity on utilization and expenditures for substance abuse treatment services.
Methods
A difference-in-difference analysis compared individuals in five Oregon commercial plans (n=103,820) from 2005–2008 to comparison groups exempt from parity in Oregon (n=19,633) and Washington (n=39,447). The primary outcome measures were annual use and total expenditures.
Results
Spending for alcohol treatment services demonstrated statistically significant increase in comparison to the Oregon and Washington comparison groups. Spending on other drug abuse treatment services was not associated with statistically significant spending increases, and the effect of parity on overall spending (alcohol plus other drug abuse treatment services) was positive but not statistically significant from zero.
Conclusions
Oregon's experience suggests that behavioral health insurance parity that places restrictions on how plans manage the benefit may lead to increases in expenditures for alcohol treatment services but is unlikely to lead to increases in spending for other drug abuse treatment services.
doi:10.1016/j.drugalcdep.2012.02.006
PMCID: PMC3380182  PMID: 22382046
Parity; Health Economics; Health Policy; Alcohol Treatment; Substance Abuse Treatment; Managed Care
9.  The Effects of Federal Parity on Substance Use Disorder Treatment Running title: Federal Parity 
Objective:
In 2008, the U.S. Congress enacted the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) requiring insurers equalize private insurance coverage for mental health and substance use disorder services with coverage for general medical services. Our objective was to examine the effects of the MHPAEA on substance use disorder treatment.
Study design:
We used a difference-in-differences design to compare changes in outcomes among plan enrollees in the years before and after implementation of federal parity (2009-2010) with changes in outcomes among a comparison group of enrollees previously covered by state substance use disorder parity laws.
Methods:
Insurance claims data from Aetna Inc. health plans in ten states with state parity laws were used to compare outcomes for plan enrollees in fully insured and self-insured health plans (N=298,339).
Results:
In the first year of implementation, we find that federal parity did not lead to changes in the proportion of enrollees using substance use disorder treatment. We did find a modest increase in spending on substance use disorder treatment per enrollee ($9.99, 95% CI: 2.54, 18.21), but no significant change in identification, treatment initiation or treatment engagement.
Conclusions:
Inclusion of substance use disorder services in the federal parity law did not result in substantial increases in health plan spending. It will be critical to study results for year 2 after regulations affecting the management of care (e.g., utilization review, network access) took effect.
PMCID: PMC3987861  PMID: 24512166
(3-5): parity; substance-related disorders; substance abuse treatment centers; health policy; Insurance
10.  A Political History of Federal Mental Health and Addiction Insurance Parity 
The Milbank quarterly  2010;88(3):404-433.
Context
This article chronicles the political history of efforts by the U.S. Congress to enact a law requiring “parity” for mental health and addiction benefits and medical/surgical benefits in private health insurance. The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity (MHPAE) Act of 2008 is to eliminate differences in insurance coverage for behavioral health. Mental health and addiction treatment advocates have long viewed parity as a means of increasing fairness in the insurance market, whereas employers and insurers have opposed it because of concerns about its cost. The passage of this law is viewed as a legislative success by both consumer and provider advocates and the employer and insurance groups that fought against it for decades.
Methods
Twenty-nine structured interviews were conducted with key informants in the federal parity debate, including members of Congress and their staff; lobbyists for consumer, provider, employer, and insurance groups; and other key contacts. Historical documentation, academic research on the effects of parity regulations, and public comment letters submitted to the U.S. Departments of Labor, Health and Human Services, and Treasury before the release of federal guidance also were examined.
Findings
Three factors were instrumental to the passage of this law: the emergence of new evidence regarding the costs of parity, personal experience with mental illness and addiction, and the political strategies adopted by congressional champions in the Senate and House of Representatives.
Conclusions
Challenges to implementing the federal parity policy warrant further consideration. This law raises new questions about the future direction of federal policymaking on behavioral health.
doi:10.1111/j.1468-0009.2010.00605.x
PMCID: PMC2950754  PMID: 20860577
parity; insurance; mental health; substance abuse
11.  Do State Parity Laws Reduce the Financial Burden on Families of Children with Mental Health Care Needs? 
Health Services Research  2007;42(3 Pt 1):1061-1084.
Objective
To study the financial impact of state parity laws on families of children in need of mental health services.
Data Source
Privately insured families in the 2000 State and Local Area Integrated Telephone Survey National Survey of Children with Special Health Care Needs (CSHCN) (N=38,856).
Study Design
We examine whether state parity laws reduce the financial burden on families of children with mental health conditions. We use instrumental variable estimation controlling for detailed information on a child's health and functional impairment. We compare those in parity and nonparity states and those needing mental health care with other CSHCN.
Principle Findings
Multivariate regression results indicate that living in a parity state significantly reduced the financial burden on families of children with mental health care needs. Specifically, the likelihood of a child's annual out-of-pocket (OOP) health care spending exceeding $1,000 was significantly lower among families of children needing mental health care living in parity states compared with those in nonparity states. Families with children needing mental health care in parity states were also more likely to view OOP spending as reasonable compared with those in nonparity states. Likewise, living in a parity state significantly lowered the likelihood of a family reporting that a child's health needs caused financial problems. The likelihood of reports that additional income was needed to finance a child's care was also lower among families with mentally ill children living in parity states. However, we detect no significant difference among residents of parity and nonparity states in receipt of needed mental health care.
Conclusion
These results indicate that state parity laws are providing important economic benefits to families of mentally ill children undetected in prior research.
doi:10.1111/j.1475-6773.2006.00650.x
PMCID: PMC1955255  PMID: 17489904
Parity; mental health; CSHCN; economic burden
12.  The Effects of State Mental Health Parity Legislation on Perceived Quality of Insurance Coverage, Perceived Access to Care, and Use of Mental Health Specialty Care 
Health Services Research  2004;39(5):1361-1378.
Objective
To assess the impacts of recent state mental health parity legislation on perceived quality of health insurance coverage, perceived access to needed health care, and use of mental health specialty services by individuals with likely need for mental health care.
Data Sources
The study sample came from two waves of a national household survey first fielded in 1997–1998 and then in 2000–2001. The analysis used a subset of the sample.
Study Design
The study took the Difference-in-Difference-in-Difference approach to investigate changes in self-perceived quality of health insurance coverage and access to needed health care, and use of mental health specialty care by the group with mental disorders (relative to those without) in states with parity legislation of different comprehensiveness (relative to the nonparity states) in the years after the law (relative to before the law).
Principal Findings
Overall, there were no significant or consistent effects of the parity legislation. Descriptive statistics showed significant changes in some (but not all) outcome variables, but these results disappeared in detailed statistical analyses by controlling for important covariates.
Conclusions
The null findings of the effects of state mental health parity mandates suggest that under ERISA (Employee Retirement Income Security Act), the scope of state parity legislation may have been restricted because of large proportion of self-insured employers. Furthermore, comprehensiveness of state legislation appears to be related to the traditional level of use of mental health specialty care, which becomes another confounder for the potential policy effects.
doi:10.1111/j.1475-6773.2004.00294.x
PMCID: PMC1361074  PMID: 15333113
Mental health parity legislation; health care access; insurance coverage; mental health specialty care
13.  Parity and Out-of-Pocket Spending for Children With High Mental Health or Substance Abuse Expenditures 
Pediatrics  2013;131(3):e903-e911.
OBJECTIVE:
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act required health plans to provide mental health and substance use disorder (MH/SUD) benefits on par with medical benefits beginning in 2010. Previous research found that parity significantly lowered average out-of-pocket (OOP) spending on MH/SUD treatment of children. No evidence is available on how parity affects OOP spending by families of children with the highest MH/SUD treatment expenditures.
METHODS:
We used a difference-in-differences study design to examine whether parity reduced families’ (1) share of total MH/SUD treatment expenditures paid OOP or (2) average OOP spending among children whose total MH/SUD expenditures met or exceeded the 90th percentile. By using claims data, we compared changes 2 years before (1999–2000) and 2 years after (2001–2002) the Federal Employees Health Benefits Program implemented parity to a contemporaneous group of health plans that did not implement parity over the same 4-year period. We examined those enrolled in the Federal Employees Health Benefits Program because their parity directive is similar to and served as a model for the new federal parity law.
RESULTS:
Parity led to statistically significant annual declines in the share of total MH/SUD treatment expenditures paid OOP (−5%, 95% confidence interval: −6% to −4%) and average OOP spending on MH/SUD treatment (−$178, 95% confidence interval: −257 to −97).
CONCLUSIONS:
This study provides the first empirical evidence that parity reduces the share and level of OOP spending by families of children with the highest MH/SUD treatment expenditures; however, these spending reductions were smaller than anticipated and unlikely to meaningfully improve families’ financial protection.
doi:10.1542/peds.2012-1491
PMCID: PMC3581843  PMID: 23420919
mental health; substance use disorder; parity; insurance
14.  The Effect of Comprehensive Behavioral Health Parity on Choice of Provider 
Medical Care  2012;50(6):527-533.
Background
“Parity” laws remove treatment limitations for mental health and substance-abuse services covered by commercial health plans. A number of studies of parity implementations have suggested that parity does not lead to large increases in utilization or expenditures for behavioral health services. However, less is known about how parity might affect changes in patients' choice of providers for behavioral health treatment.
Research Design
We compared initiation and provider choice among 46,470 Oregonians who were affected by Oregon's 2007 parity law. Oregon is the only state to have enacted a parity law that places restrictions on how plans manage behavioral health services. This approach has been adopted federally in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). In one set of analyses, we assess initiation and provider choice using a difference-in-difference approach, with a matched group of commercially insured Oregonians who were exempt from parity. In a second set of analyses, we assess the impact of distance on provider choice.
Results
Overall, parity in Oregon was associated with a slight increase (0.5% to 0.8%) in initiations with masters-level specialists, and relatively little change for generalist physicians, psychiatrists and psychologists. Patients are particularly sensitive to distance for nonphysician specialists.
Conclusions
Our results suggest that the MHPAEA may lead to a shift in the use of nonphysician specialists and away from generalist physicians. The extent to which these changes occur is likely to be contingent on the ease and accessibility of nonphysician specialists.
doi:10.1097/MLR.0b013e318245a60f
PMCID: PMC3353151  PMID: 22584888
15.  Impact of Full Mental Health and Substance Abuse Parity for Children in the Federal Employees Health Benefits Program 
Pediatrics  2007;119(2):e452-e459.
OBJECTIVE
The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries’ financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children.
METHODS
Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending.
RESULTS
The apparent increase in the rate of children’s mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children’s mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant.
CONCLUSIONS
Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services.
doi:10.1542/peds.2006-0673
PMCID: PMC1995034  PMID: 17272607
health care costs; health insurance; mental health; substance abuse/use; managed care
16.  Harm reduction, methadone maintenance treatment and the root causes of health and social inequities: An intersectional lens in the Canadian context 
Background
Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment (MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT, particularly how Harm Reduction and MMT are experienced differently by people dependent on how they are positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of domination and oppression;
Methods
A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients accessing mainstream mental health and addictions care and primary health care settings and healthcare providers;
Results
All client-participants had profound histories of abuse and violence, most often connected to the legacy of colonialism (e.g., residential schooling) and ongoing colonial practices (e.g., stigma & everyday racism). Participants lived with co-occurring illness (e.g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday experiences both within and outside the system that further marginalize them. In this paper, we focus on three intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing enactment of peoples' agency, and homelessness;
Conclusions
Harm reduction must move beyond a narrow concern with the harms directly related to drugs and drug use practices to address the harms associated with the determinants of drug use and drug and health policy. An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of and commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.
doi:10.1186/1477-7517-8-17
PMCID: PMC3146821  PMID: 21718531
17.  Institutions, Politics, and Mental Health Parity 
Society and mental health  2012;2(3):10.1177/2156869312455436.
Mental health parity laws require insurers to extend comparable benefits for mental and physical health care. Proponents argue that by placing mental health services alongside physical health services, such laws can help ensure needed treatment and destigmatize mental illness. Opponents counter that such mandates are costly or unnecessary. The authors offer a sociological account of the diffusion and spatial distribution of state mental health parity laws. An event history analysis identifies four factors as especially important: diffusion of law, political ideology, the stability of mental health advocacy organizations and the relative health of state economies. Mental health parity is least likely to be established during times of high state unemployment and under the leadership of conservative state legislatures.
doi:10.1177/2156869312455436
PMCID: PMC3864046  PMID: 24353902
mental health; mental health policy; mental health services
18.  Mental health parity legislation: much ado about nothing? 
Health Services Research  2000;35(1 Pt 2):263-275.
OBJECTIVE: To determine whether state-level parity legislation has led to an increase in utilization of mental health services. DATA SOURCES: Healthcare For Communities (HCC), a multi-site nationally representative study sponsored by the Robert Wood Johnson Foundation that tracks health care system changes for mental health and substance abuse treatment. Information on state-level parity legislation was provided by state offices of the National Alliance for the Mentally Ill (NAMI); local and state market data come from the Area Resource File; information on other health mandates from Blue Cross/Blue Shield. STUDY DESIGN: Two-stage regressions are used to estimate the effect of state parity legislation on use of any mental health services, use of specialty mental health services, and number of specialty visits in the past year. In the first stage, we predicted the probability that a state decides to pass parity legislation as a function of state health care market indicators and previous legislative activity. The fitted probability is used in the second stage to determine the effect of this legislation on access and utilization. PRINCIPAL FINDINGS: State parity legislation is not associated with a significant increase in any of our measures of mental health services utilization. These results are robust to various specifications of the models. CONCLUSIONS: Those states that are able to pass parity legislation do not experience significant increases in the utilization of mental health services. This may be due in part to a loss of coverage for those people most at risk for mental health disorders. The results could be very different, however, if strong federal legislation were passed.
PMCID: PMC1089100  PMID: 10778814
19.  Navigating the mental health and addictions maze: a community-based pilot project of a new role in primary mental health care 
Problem being addressed In a medically under-served rural Canadian community where overburdened family physicians provide most of the cae for patients with mental illness and substance use problems, providing access to timely and effective help for all citizens is a challenge. The care burden of unmet mental health needs is experienced throughout the larger community by diverse community service providers.
Supporting a shared understanding of the needs and challenges, and ensuring effective connection and clear communication between diverse disciplines in primary care, community services and the formal mental health system requires models of service organisation and delivery that go beyond traditional clinical roles.
In cancer care a navigator model has previously been used to address information and service gaps and improve patient experience. We wished to evaluate whether a community-supported navigator model could help solve some of the challenges for clients and service providers in our community, while at the same time allowing data collection that offers a clearer understanding of actual service needs.
Pre-programme activities Community members formed an interdisciplinary community steering committee which met monthly for two years to develop and adapt a service and collaborative research model, generate support, secure ethical approval and raise funds.
Programme description The navigator service was embedded in a local family service organisation, the steering committee met monthly, and along with the researchers met regularly with programme staff and provided support, oversight and development of ethical data collection.
Navigators provided low barrier access, comprehensive assessment, collaborative service planning, and linkage and referral facilitation for any individual or family who requested assistance with a mental health or substance use concern. Navigators also serve as an information resource for any community service provider or family physician needing to assist a client, and collected data on local service needs.
Conclusions Analysis of quantitative administrative data, consented research data, and qualitative interview and survey data demonstrated that this community supported navigator service model was effective in improving service access, assessment and linkage for citizens with mental health and addictions concerns, and connecting a range of community services into a more effective network of care. Connecting unattached clients with a primary care provider and supporting needs assessment and service planning for patients of local family physicians were key navigator functions.
PMCID: PMC2777588  PMID: 22477883
community based participator research; mental health navigation; navigator model; primary mental health care
20.  Perceived Impacts of Health Care Reform on Large Urban Health Departments 
This study aimed at the recognition that the Patient Protection and Affordable Care Act could potentially greatly impact how local health departments function in providing public health services.
Context:
The Patient Protection and Affordable Care Act (ACA) is changing the landscape of health systems across the United States, as well as the functioning of governmental public health departments. As a result, local health departments are reevaluating their roles, objectives, and the services they provide.
Objective:
We gathered perspectives on the current and future impact of the ACA on governmental public health departments from leaders of local health departments in the Big Cities Health Coalition, which represents some of the largest local health departments in the country.
Design:
We conducted interviews with 45 public health officials in 16 participating Big Cities Health Coalition departments. We analyzed data reflecting participants' perspectives on potential changes in programs and services, as well as on challenges and opportunities created by the ACA.
Results:
Respondents uniformly indicated that they expected ACA to have a positive impact on population health. Most participants expected to conduct more population-oriented activities because of the ACA, but there was no consensus about how the ACA would impact the clinical services that their departments could offer. Local health department leaders suggested that the ACA might create a broad range of opportunities that would support public health as a whole, including expanded insurance coverage for the community, greater opportunity to collaborate with Accountable Care Organizations, increased focus on core public health issues, and increased integration with health care and social services.
Conclusions:
Leaders of some of the largest health departments in the United States uniformly acknowledged that realignments in funding prompted by the ACA are changing the roles that their offices can play in controlling infectious diseases, providing robust maternal and child health services, and more generally providing a social safety net for health care services in their communities. Health departments will continue to need strong leaders to strengthen and maintain their critical role in protecting and promoting the health of the public they serve.
doi:10.1097/PHH.0000000000000145
PMCID: PMC4243798  PMID: 25423059
Big City Health Coalition; health care reform; Affordable Care Act; public health practice; urban health
21.  Plastic Surgeons’ Perceptions of the Affordable Care Act: Results of a National Survey 
Background:
The Affordable Care Act (ACA) aims to expand coverage to the uninsured, improve quality, and contain costs. The goal of this study was to ascertain how plastic surgeons perceive the ACA.
Methods:
An electronic questionnaire was e-mailed to members of the American Society of Plastic Surgeons between May and June 2014. The survey was anonymous and voluntary and included questions to assess understanding and opinions of the ACA.
Results:
The survey was sent to 3070 members of the American Society of Plastic Surgeons, and the response rate was 17%. Sixty-eight percent agree or strongly agree that they understand the basic concepts of the ACA. The majority of respondents disagree (38% strongly disagree, 31% disagree) with the notion that the ACA will positively affect their practice, and 51% agree with the statement, “I do not support the ACA, and I believe it did too much.” Two thirds (66%) believe that the ACA deserves a grade of D or F. When answers were analyzed across demographics, 42% of respondents with “Academic” practice background identify with the statement, “I support the ACA but I think it needs more work,” compared to 15% of those who selected “Solo Practice” (p <0.001).
Conclusions:
The ACA will affect all specialties, including plastic surgery. The results of this survey suggest that many plastic surgeons believe that they have a baseline understanding of current health-care reform. The majority of surveyed surgeons do not support the Act. It is imperative that plastic surgeons possess the knowledge of the ACA; its changes, both current and impending, will likely affect patient mix, coverage of procedures, and reimbursement.
doi:10.1097/GOX.0000000000000265
PMCID: PMC4323397
22.  Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults 
Health Services Research  2012;47(5):1773-1790.
Research Objective
To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent's private health plan. Nearly one-in-three young adults lacked coverage before the ACA.
Study Design, Methods, and Data
Data from the Current Population Survey 2005–2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws.
Principal Findings
This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law.
Conclusions and Implications
ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.
doi:10.1111/j.1475-6773.2012.01458.x
PMCID: PMC3513605  PMID: 22924684
Health care reform; health insurance regulation; health policy; health economics
23.  The Effect of Parity on Expenditures for Individuals with Severe Mental Illness 
Health services research  2013;48(5):1634-1652.
Objective
To determine whether comprehensive behavioral health parity leads to changes in expenditures for individuals with severe mental illness (SMI), who are likely to be in greatest need for services that could be outside of health plans’ traditional limitations on behavioral health care.
Data sources/study setting
We studied the effects of a comprehensive parity law enacted by Oregon in 2007. Using claims data, we compared expenditures for individuals in four Oregon commercial plans from 2005 through 2008 to a group of commercially insured individuals in Oregon who were exempt from parity.
Study design
We used difference-in-differences and difference-in-difference-in-differences analyses to estimate changes in spending, and quantile regression methods to assess changes in the distribution of expenditures associated with parity.
Principal findings
Among 2,195 individuals with SMI, parity was associated with increased expenditures for behavioral health services of $333 (95% CI $67, $615), without corresponding increases in out-of-pocket spending. The increase in expenditures was primarily attributable to shifts in the right tail of the distribution.
Conclusions
Oregon’s parity law led to higher average expenditures for individuals with SMI. Parity may allow individuals with high mental health needs to receive services that may have been limited without parity regulations.
doi:10.1111/1475-6773.12058
PMCID: PMC3720714  PMID: 23557191
Health economics; Health Care Costs; Health Care Financing/Insurance/Premiums; Mental Health; Substance Abuse: Alcohol Dependency/Tobacco
24.  On Medicaid and the Affordable Care Act in Connecticut 
Background: Medicaid is the federal program, administered by states, for health care for the poor. The Affordable Care Act (ACA) has added a large number of new recipients to this program.
Hypothesis: Medicaid programs in some, if not many, states do not provide patients uniform access to subspecialty care guaranteed by the federal statutes. Insofar as the ACA does not address this pre-existing “sub-specialty gap” and more patients are now covered by Medicaid under the ACA, the gap is likely to increase and may contribute to disparities of health care access and outcomes.
Methods: A brief description of previous studies demonstrating or suggesting a subspecialty gap in Medicaid services is accompanied by perspectives of the authors, using published literature — most notably the Denver, Colorado health care system — to propose various solutions that may be deployed to address gaps in subspecialty coverage.
Results: All published studies describing the Medicaid subspecialty gap are qualitative, survey designs. There are no authoritative objective data regarding the exact prevalence of gaps for each subspecialty in each state. However, surveys of caregivers suggest that gaps were prevalent in the United States prior to initiation of the ACA. Even fewer papers have addressed solutions (in light of the paucity of data describing the magnitude of the problem), and proposed solutions remain speculative and not grounded in objective data.
Conclusions: There is reason to believe that a substantial proportion of U.S. citizens — those who are guaranteed a full complement of health services through Medicaid — have difficult or no access to some subspecialty services, many of which other citizens take for granted. This problem deserves greater attention to verify its existence, quantify its magnitude, and develop solutions.
PMCID: PMC4257043  PMID: 25506291
Medicaid; health care; insurance; subspecialty care; justice
25.  Characteristics of Adults With Substance Use Disorders Expected to Be Eligible for Medicaid Under the ACA 
Objectives
Provisions in the Affordable Care Act (ACA) are likely to expand access to substance use disorder treatment for low-income individuals. The aim of the study was to provide information on the need for substance use disorder treatment among individuals who may be eligible for Medicaid under the ACA.
Methods
The 2008 and 2009 National Survey on Drug Use and Health provided data on demographic characteristics, health status, and substance use disorders for comparison of current low-income Medicaid enrollees (N=3,809) with currently uninsured individuals with household incomes that may qualify them for Medicaid coverage beginning in 2014 (N=5,049). The incomes of the groups compared were 138% of the federal poverty level (133% provided in the ACA plus a 5% income “disregard” allowed by the law).
Results
The rate of substance use disorders among currently uninsured income-eligible individuals was slightly higher than the rate among current Medicaid enrollees (14.6% versus 11.5%, p=.03). Although both groups had significant unmet need for substance use disorder treatment, the treatment rate among those who needed treatment was significantly lower in the income-eligible group than in the currently enrolled group (31.3% versus 46.8%, p<.01). When the analysis excluded informal care received outside the medical sector, treatment rates among those with treatment needs were much lower in both groups (12.8% in the income-eligible group and 30.7% among current enrollees).
Conclusions
Findings suggest that Medicaid insurance expansions under the ACA will reduce unmet need for substance use disorder treatment.
doi:10.1176/appi.ps.201200011
PMCID: PMC3672321  PMID: 23450343

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