Does Private Insurance
Adequately Protect Families of
Children with
Mental Health Disorders?
Susan Busch
Colleen Barry
Yale Medical School
We gratefully acknowledge support from NIMH (R01 MH080883)
Background
• Prior research has demonstrated that the
challenges faced by families caring for a
sick child are substantial (See Newacheck
2005, Jacobs 1989, Davidoff 2004 as well as
others).
• These challenges may be more severe for
CSHCN with mental illnesses than for
other special needs children.
Background: Mental Health
• Characteristics of mental illness
• Inequities in coverage under private
insurance
• Shortage of child psychiatrists
• Adverse selection
• Prescription drug spending
Objectives
• To determine whether families of privately
insured children needing mental health
care face different burdens than other
families in caring for their children
– We focus on the privately insured since many
of the insurance barriers noted above
specifically pertain to private insurance
Data
• 2005-2006 National Survey of CSHCN
• Large nationally representative sample of
children (N=38,856)
– Limited to children whose parents report the child has
more health care needs than average, and that the
condition is expected to last at least 12 months
– All SHCN children
• Single cross-section
• Restrict sample to privately insured children
ages 6-17.
Methods
• Examine outcomes across four domains:
–
–
–
–
financial burden
health plan experiences
labor market and time effects, and
parent care experiences
• Compare across four groups:
(1) Children with no SHCN (N=2,346)
(2) CSHCN with no mental health care needs
(N=16,250)
(3) CSHCN with no mental health care need but a need
for other specialty services (N=7,902) – a subgroup of
group (2), and
(4) CSHCN with mental health care needs (N=4,918)
Control variables
• Condition Severity
– Severity of child’s condition (minor, moderate, severe)
– How severely the condition has affected the child’s
ability to do things (a great deal; some; very little)
• Demographics
–
–
–
–
–
–
Race and ethnicity
Child’s age and gender
Family income
Mother’s education
Number of adults and children in the household
Whether the interview was conducted in a language
other than English.
• State dummy variables
– controls for state level factors that influence outcomes
Four Subgroup Analyses
• Children residing in states with broad mental
health parity law (6 states)
• Children residing in states with an adequate
supply of child psychiatrists (6 states)
• Children with no ongoing use of prescription
drugs
• Children whose health care needs are stable
Financial Outcomes (%)
(1)
Children
without
SHCNs
(2)
CSHCN
/ No
MH care
need
(3)
CSHCN
/No
MH care
need /
speclty care
(4)
CSHCN
/MH care
need
Comparing
Col (3) &
Col (4)
Odds ratio
OOP costs > $500
19.4
40.1
50.8
61.0
1.31***
OOP costs > $1000
10.3
22.4
30.9
42.5
1.32***
OOP costs > $5000
0.8
2.4
3.7
6.9
1.30
Child’s HC has caused
financial problems
2.5
11.5
15.1
27.0
1.35***
Need additional income
to care for child
3.0
10.5
13.5
22.6
1.22**
Health plan experiences
(1)
Children
without
SHCNs
(2)
CSHCN
/ No
MH care
need
(3)
CSHCN
/No
MH care
need /
speclty
care
(4)
CSHCN
/MH care need
Comparing
Col (3) &
Col (4)
Odds ratio
Health ins meets
child’s needs
(% never, sometimes)
6.8
8.4
9.6
18.0
1.50***
Costs not covered by
ins are reasonable
(% never, sometimes)
24.0
29.0
30.1
40.0
1.30***
Ins allows child to see
provider that child
needs
(% never, sometimes)
4.6
5.7
6.0
15.3
2.12***
Labor market and time outcomes
(1)
Children
without
SHCNs
(2)
CSHCN
/ No
MH care
need
(3)
CSHCN
/No
MH care need /
speclty care
(4)
CSHCN
/MH care
need
Comparing
Col (3) &
Col (4)
Odds ratio
Spent >10 hours
providing care (%)
0.8
2.3
4.1
4.7
.70**
Spent >10 hours
arranging care (%)
0.7
1.6
2.0
3.0
1.33
Stopped work (%)
0.8
5.3
7.6
13.0
1.16
Stopped work or cut
work hours (%)
2.1
12.7
17.4
30.0
1.29***
Care Experiences outcomes
Comparing
Col (3) &
Col (4)
(2)
CSHCN
/ No
MH care
need
(3)
CSHCN
/No
MH care
need /
speclty care
(4)
CSHCN
/MH care
need
2.7
5.4
6.2
13.7
1.54***
Doctors spend enough time
with you
(% never/sometimes)
17.3
16.1
12.6
18.5
1.21**
Received specific
information you needed
from doctors
(% never/sometimes)
12.2
12.6
12.0
20.4
1.37***
(1)
Children
without
SHCNs
Satisfaction with services
child receives
(% Somewhat/very
dissatisfied)
Odds ratio
Subgroup Analyses
States with MH
parity laws
States with adequate
supply of child
psychiatrists
OOP costs > $500 (%)
2.73***
2.12***
Health insurance meets child’s needs
(1=never, sometimes) (%)
1.74 **
1.83**
Stopped work/cut work hours (%)
1.78***
1.86***
1.58
1.37
1.64 **
.98
Satisfaction with services child receives
(1=Somewhat/very dissatisfied) (%)
Received specific information you needed
from doctors
(1= never/sometimes) (%)
Subgroup Analyses (II)
OOP costs > $500 (%)
Health insurance meets child’s needs
(1=never, sometimes) (%)
Stopped work/cut work hours (%)
Satisfaction with services child receives
(1=Somewhat/very dissatisfied) (%)
Received specific information you
needed from doctors
(1= never/sometimes) (%)
No Rx drug needs
Conditions are usually
stable
1.61***
1.81***
1.25
1.65***
1.52***
1.73***
1.15
1.73***
.94
1.29**
Limitations
• Information on a child’s condition and
experiences with health care are selfreport
• Average disease severity of children with
mental health care needs may differ from
other CSHCN
• There are limits with state parity laws we
were unable to control for in our study
– Self Insured firms exempt
Results
• Compared with other families, families of
children with mental health care needs
– 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
• These families are also somewhat more
likely to report dissatisfaction with care
experiences than other families
Federal Parity
• Federal parity may reduce this financial burden
– Yet, we do not find that living in a state with a broad
state mental health parity law reduced differences in
financial outcomes
– Federal parity will not address growth in prescription
drug costs, and does not affect the labor market for
child psychiatrists
• Other policies should be aimed at addressing
these significant costs imposed on families.
Conclusion
• While we find that, under private insurance,
CSHCN with mental health care needs face
greater barriers than other special needs
children, we are unable to definitively determine
the causes of these differences.
• Our results do suggest that:
– Shortage of child psychiatrists may have some impact
on care experiences
– More research needs to be done to better understand
the cause of these differences, and to develop policy
solutions that may ameliorate these effects.