Does Private Insurance Adequately Protect Families of Children With Mental Health Disorders?

METHODS

RESULTS

A total of 4918 CSHCN with private insurance coverage reported a need for mental health care in 2005–2006. We compared the health care experience of these children with (1) 2346 privately insured children without SHCN (the referent sample), (2) 16 250 privately insured CSHCN who did not report a need for mental health care, and (3) a subset of group 2 that consists of 7902 privately insured CSHCN who did not report a need for mental health care but did report a need for specialist care.

Children who needed mental health care had greater out-of-pocket costs on average than all 3 comparison groups (Table 1). For example, 61% of children who needed mental health care reported annual out-of-pocket costs greater than $500 compared with only 19% of the referent sample. Less than 1% of the referent sample had annual out-of-pocket costs greater than $5000 compared with 7% of the sample of those who needed mental health care. The 2 groups of CSHCN with no mental health care need (columns 2 and 3) had more families with high out-of-pocket costs than the referent sample but fewer than the CSHCN who needed mental health care. Financial outcomes were worse for children with a need for specialty care compared with children with no need for specialty care.

Results for health plan experience outcomes were similar; children who needed mental health care were more likely to have negative health plan experiences than other children. Regarding labor-market and time outcomes, CSHCN who needed mental health care had caregivers who spent more time arranging and providing care, and these caregivers were more likely to stop work or cut work hours to care for their child.

Examining parent care experience outcomes, parents of children with mental health care needs were more likely than those in the other 3 groups to report that they were dissatisfied with services received. Although almost 14% of parents of CSHCN who needed mental health care were dissatisfied, only 3% of the parents of the referent sample were dissatisfied. Parents of CSHCN who needed mental health care were more than twice as likely as parents of other CSHCN to report dissatisfaction with services (14 vs 5%).

In Table 2 we list the adjusted results. Column 1 reports the odds of each of our outcomes comparing CSHCN with and without mental health care needs. The results were similar to the unadjusted outcomes. For all financial and health plan experience outcomes, CSHCN with mental health care needs faired worse than their counterparts with no mental health care need (column 1), even when comparing them to CSHCN with no mental health care need but a need for specialty care (column 2).

For labor-market and time outcomes, we saw fewer differences than in the unadjusted results. CSHCN with no mental health care needs but with a need for specialty care were less likely than CSHCN with mental health care needs to spend >10 hours/week providing care.

Parents of CSHCN who needed mental health care had lower overall patient satisfaction compared with parents of CSHCN with no need for mental health care (OR: 1.59) and with parents of CSHCN who needed specialty care (OR: 1.54). When considering individual components of patient satisfaction (using measures of family centered care), only 1 component (received specific information from doctors) was significantly different (P < .05) when comparing parents of CSHCN with and without mental health care need.

In columns 3 through 5 of Table 2, we list results for the subset of CSHCN with specific categories of disorders. Generally, we found that children with autism experienced the greatest difference in outcomes.

In Table 3 we compare CSHCN with and without mental health care need within relevant subsamples. In analyses not shown, we also examined these subsamples comparing CSHCN with mental health care need to CSHCN with no mental health care need but with a need for specialty care. In almost all cases, the results were qualitatively similar; we only mention below when results diverged from those listed in Table 3.

Column 1 of Table 3 lists results when limiting the sample to children in 6 states with a broad mental health parity law. Somewhat surprisingly, we found that these families had a greater difference in financial outcomes compared with residents of all states. Otherwise, there were few differences between these analyses and those presented in column 1 of Table 2 (what we refer to below as the full sample). In some cases, the ORs were similar but no longer significant because of the smaller sample size. In column 2, we limited the sample to residents of states with an adequate supply of child psychiatrists. Generally, results were similar to those of the full sample in Table 2. One exception was the patient-satisfaction variables. In this subsample, there were fewer differences in patient satisfaction between those with and without mental health care needs. In all cases, the point estimate suggests that those with no mental health care needs have similar or greater satisfaction.

Column 4 of Table 3 lists the results for the subsample with no prescription drug needs. This sample is much smaller than the full sample in Table 2 and may represent children with different health care needs and health statuses. We detect differences in financial outcomes comparing those with and without mental health care need similar in magnitude to the full sample. However, within this subsample, comparing children with mental health care need to CSHCN with no need for mental health care but with a need for specialty health care (results not shown), differences in financial outcomes were not found. This suggests that, at least among those with no prescription drug needs, there are few differences in the financial burden between those with and without a need for mental health care. Finally, column 5 of Table 3 lists results for the subsample of children whose conditions were usually stable. We found few differences when compared with the full sample.

DISCUSSION

Families of children with mental health care needs with private insurance coverage face significantly greater financial barriers, have more negative health plan experiences, and are more likely to reduce their labor-market participation to care for their child than other families. These families are also somewhat more likely to report dissatisfaction with services than other families. In absolute terms, this burden is substantial. Among the privately insured, 43% spend more than $1000 out-of-pocket on their child's health care, indicating that private insurance coverage does not protect families from the expenses associated with mental health treatment.

A number of factors may explain the increased financial burden and other challenges faced by families of privately insured CSHCN with mental health care needs. Federal parity has long been advocated as a means of eliminating inequities in private insurance coverage for mental health care, and research has indicated that parity can lower the out-of-pocket costs of treating children with mental illness.^17,18 The passage of a comprehensive federal parity law by Congress in the fall of 2008 may have reduced the financial burden on privately insured families of children with mental health disorders, but we did not find that living in a state with a broad state mental health parity law eliminated differences in financial outcomes between children who needed mental health care and other children. Also, federal parity will not address the growth in prescription drug costs for the treatment of mental health conditions and does not directly affect the labor-market and time costs of caring for a mentally ill child. Other policies should be aimed at addressing these significant costs imposed on families.

A number of limitations are important to note. First, information on a child's condition and experiences with health care were reported by the respondent, usually a parent. One concern is that children with mental health care needs may be more likely to have a parent with mental health care needs who may have responded to questions about the child's condition and its consequences differently from other parents. A second concern is that the average disease severity of children with mental health care needs may differ from that of other CSHCN. If children with mental health care needs are sicker, for example, then differences in outcomes may be caused by differences in the underlying severity of the condition rather than the condition itself. The comparison with children with no mental health care need but need for other specialty services mitigates this concern, although differences may still exist. Third, there are limits with state parity laws that we were unable to control for in our study. Most importantly, health insurance obtained by a self-insured firm is not subject to state parity laws. In some states, more than half the workforce is employed by self-insured firms.¹⁹ Another limitation is that we limited our sample to children with private insurance coverage. Children with mental health care needs with public coverage may also face different challenges than other CSHCN, and outcomes for these children would also be interesting to study.

Although we found that, under private insurance, CSHCN with mental health care needs face greater barriers than other CSHCN, we were unable to definitively determine the causes of these differences. Our results do suggest that the shortage of child psychiatrists may have some impact on parent satisfaction and that the out-of-pocket cost of psychotropic medications may play a role in the high financial burden on these families. More research needs to be performed to better understand the cause of these differences and to develop policy solutions that may ameliorate these effects.