State Legislators’ Support for Behavioral Health Parity Laws: The Influence of Mutable and Fixed Factors at Multiple Levels

Jonathan Purtle, Félice Lê-Scherban, Xi Wang, Paul T. Shattuck, Enola K. Proctor, Ross C. Brownson

Research output: Contribution to journalArticlepeer-review


Policy Points When communicating with state legislators, advocates for state behavioral health parity laws should emphasize that the laws do not increase insurance premiums. Legislators’ opinions about the impacts of state behavioral health parity laws and the effectiveness of behavioral health treatment have more influence on support for the laws than do their political party affiliation or state-level contextual factors. Reducing legislators’ stigma toward people with mental illness could increase their support for state behavioral health parity laws. Context: Comprehensive state behavioral health parity legislation (C-SBHPL) is an evidence-based policy that improves access and adherence to behavioral health treatments. However, adoption of C-SBHPL by state legislators is low. Little is known about how C-SBHPL evidence might be most effectively disseminated to legislators or how legislators’ fixed characteristics (eg, ideology), mutable characteristics (eg, beliefs about the policy's impact), and state-level contextual factors might influence their support for behavioral health policies. The purpose of our study is (1) to describe the associations between legislators’ fixed and mutable characteristics, state-level contextual factors, and support for C-SBHPL; and (2) to identify the mutable characteristics of legislators independently associated with C-SBHPL support. Methods: We conducted a multimodal (post mail, email, telephone) survey of US state legislators in 2017 (N = 475). The dependent variable was strong support for C-SBHPL, and the independent variables included legislators’ fixed and mutable characteristics and state-level contextual factors. We conducted multivariable, multilevel (legislator, state) logistic regression. Findings: Thirty-nine percent of the legislators strongly supported C-SBHPL. After adjustment, the strongest predictors of C-SBHPL support were beliefs that C-SBHPL increases access to behavioral health treatments (aOR = 5.85; 95% CI = 2.41, 14.20) and does not increase insurance premiums (aOR = 2.70; 95% CI = 1.24, 5.90). Stigma toward people with mental illness was inversely associated with support (aOR = 0.86; 95% CI = 0.78, 0.95). After adjustment, ideology was the only fixed characteristic significantly associated with support for C-SBHPL. State-level contextual factors did not moderate associations between mutable characteristics and support for C-SBHPL. Conclusions: Legislators’ mutable characteristics are stronger predictors of C-SBHPL support than are most of their fixed characteristics and all state-level contextual factors, and thus should be targeted by dissemination efforts.

Original languageEnglish (US)
Pages (from-to)1200-1232
Number of pages33
JournalMilbank Quarterly
Issue number4
StatePublished - Dec 1 2019


  • Dissemination
  • behavioral health parity laws
  • legislators

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health


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