Advocates for parity legislation for addiction and mental-health disorders need to build their case on solid data, line up bipartisan support, know their enemies, and not be afraid to go for a comprehensive bill, according to Ken Libertoff, Ph.D., executive director of the Vermont Association for Mental Health.
Libertoff compiled a series of “lessons learned” — some painful — from a failed mid-1980s campaign to pass parity legislation in the Vermont legislature, as well as a successful advocacy effort in 1996 and 1997 that led to one of the strongest parity laws in the country. These insights form the basis of Libertoff's book, “Fighting for Parity in an Age of Incremental Health Care Reform,” available from the National Mental Health Association.
Vermont's drive for a comprehensive addiction and mental-health parity law began with a broad-based, well-organized coalition, said Libertoff. Members of the coalition included individual concerned citizens, parents and family members of people with addictions and mental illness, consumers, advocates, and health-care professionals.
Libertoff said that advocates determined early on that seeking partial parity — the prevailing tactic in many other states, and on the federal level — made little sense. “The legislative process naturally works to modify and reduce proposals,” noted Libertoff. “Common sense, therefore, dictates that beginning with the best possible piece of legislation is, in fact, a realistic starting point … For us, the objective was to end discrimination, once and for all.”
That said, Libertoff stressed that winning the battle over parity is no tea party: “The issue triggers powerful opposition, most notably in the business and insurance industry.” In Vermont, for example, Vermont Blue Cross & Blue Shield helped sink parity during the 1985-86 legislative session by testifying that increasing the lifetime cap for mental-health benefits to $250,000 would cause a 300-percent increase in insurance premiums.
“Back in the mid-1980s, advocates for improved mental-health benefits thought of their proposed initiative as a minor bill … [but] the opposite was true,” according to Libertoff. “The parity issue is a lightning rod; it attracts the attention, and usually the opposition, of many of the most powerful forces in the State House. Stigma and discrimination have often framed the debate, as has a general opposition to mandates, fueled by random speculation about the cost of this benefit.”
Addressing the latter point is key, said Libertoff. “One of the most painful lessons of the 1985-86 legislative experience was that promoting the lofty goal of ending discrimination in the treatment of mental-health problems does not win State House battles,” he said. “Meaningful and reliable cost data does.” So, when parity was brought back to the legislature in 1997, advocates were armed with a Coopers & Lybrant study on the actual cost of the bill. The study showed that full parity would only result in a 3.4 percent premium increase — contrary to the alarmist predictions of Blue Cross & Blue Shield, which never did bring in any data to back up its estimates.
Advocates need to know who the likely opponents of parity are; at the same time, however, they must avoid a bunker mentality. During the 1980s campaign, Libertoff noted, Vermont mental-health advocates never even spoke to insurers or businesses prior to the legislative hearings. “In fact, we probably did not want to know their perspective, partly out of fear that they would kill the bill even before it was introduced, and partly because we secretly hoped that industry and employer lobbyists might not notice our legislation,” said Libertoff.
During the successful parity campaign, however, activists made a point of informally meeting with opponents to get their views, provide information, and even solicit their input in designing the legislation. “By assuming a more aggressive and perhaps more risky stance, [advocates] were able to increase the chances of the bill's passage through information-sharing, negotiation, and open-door problem-solving,” said Libertoff.
Libertoff also advised parity advocates to line up bipartisan support for parity legislation. The natural inclination might be to seek out liberal Democrats — as Vermont activists did in the mid-80s — but the passage of the 1997 parity law was accomplished only with strong Republican support. “As advocates, we need to remind ourselves and educate others about the fact that mental illness is not a partisan disease,” he noted. “It afflicts people of all political stripes.”
Strong communications — including written position papers and a “parity platform” — also helped keep the Vermont coalition unified, and contributed to the ultimate success of the legislation, said Libertoff. The parity platform, in particular, provided a clear, concise framework for the legislation and helped bind and anchor coalition members during rough times. The platform also served as a “major educational tool” with lawmakers and the media, according to Libertoff.
The battle for addiction and mental-health parity does not end when the law is passed, stressed Libertoff. Consumer-protection laws aimed at regulating managed care are a critical companion to parity, he noted, ensuring that coverage is worth more than the paper it is written on. And implementation of the law is a major, ongoing challenge for advocates in Vermont and elsewhere.
“Interpreting the law, communicating to purchasers as well as policyholders, and enforcing the legislation are but a few critical issues,” said Libertoff. “To be effective in monitoring the bill's implementation, advocates must quickly assume different roles, acquire new skills, and use them in a totally different environment.”
The Vermont Association for Mental Health: 802-223-6263; firstname.lastname@example.org.