MHPAEA & Marble Cake: Parity & the Forgotten Frame of Federalism

38 Pages Posted: 5 Nov 2020 Last revised: 16 Aug 2021

See all articles by Taleed El-Sabawi

Taleed El-Sabawi

Florida International University (FIU) - College of Law; Georgetown University - The O'Neill Institute for National and Global Health Law

Date Written: September 16, 2020


Federal parity laws, and their state equivalents, have been shown to increase access to substance use disorder (SUD) treatment, by decreasing the cost of SUD treatment borne by the insured, and has resulted in little increase in health plan costs. Despite these improvements, the effects of parity on access to SUD treatment have been lower than expected. Recent reports suggest that states have varied in their enforcement parity, failures which may explain why persons surveyed still report having inadequate insurance coverage for SUD treatment despite the parity legislation.

While other articles have offered suggestions for improving parity, most have lumped mental health and substance use disorder treatment coverage together in their analysis and recommendations. This paper focuses exclusively on SUD treatment and its distinct institutional history. Aside from focusing exclusively on substance use disorder treatment, this paper contributes to the literature by analyzing parity implementation through the lens of theories of federalism. It argues that in order for parity implementation to be effective, it must account for the current ideological divisions that have characterized intergovernmental relationships for nearly a decade. This paper demonstrates how theories of federalism and intergovernmental relations are particularly useful in analyzing the implementation of health insurance parity reform because they suggest that some of the implementation issues that have arisen were due to the structure of the division of federal/state responsibilities. In doing so, this paper suggests alternate structures for dividing the responsibilities for enforcement.

Keywords: Parity, health insurance, addiction, opioid use disorder, opioid crisis, substance use disorder

Suggested Citation

El-Sabawi, Taleed, MHPAEA & Marble Cake: Parity & the Forgotten Frame of Federalism (September 16, 2020). 124 Dick. L. Rev. 591 (2020), Elon University Law Legal Studies Research Paper, Available at SSRN:

Taleed El-Sabawi (Contact Author)

Florida International University (FIU) - College of Law ( email )

11200 SW 8th St.
RDB Hall 1097
Miami, FL 33199
United States

Georgetown University - The O'Neill Institute for National and Global Health Law ( email )

600 New Jersey Avenue, NW
Washington, DC 20001
United States

HOME PAGE: http://

Do you have negative results from your research you’d like to share?

Paper statistics

Abstract Views
PlumX Metrics