Can Mental Health Parity Help Address the Mental/Behavioral Gap in Child Health?

Children and youth face major gaps in access to mental and behavioral health services. Rates of identification of mental health conditions in the pediatric population continue to lag well behind what we know about the prevalence of these conditions. In addition, most children and youth with identified disorders do not get adequate treatment. Conservative figures place prevalence of diagnosable mental health conditions as at least 20% of the pediatric population, rising with older age. Increasing stress on families also leads to more needs for prevention and mental health promotion. And the separation between mental and physical health ignores much evidence of the substantially higher rates of mental and behavioral health conditions among children and youth with physical health conditions (2–3 times the rates found among pediatric patients without physical health conditions).^1,2 

Some access problems reflect major limitations in the mental health workforce (far too few child psychiatrists, psychologists, developmental-behavioral pediatricians, and other mental health professionals). Workforce limitations in turn reflect the weak financial base for children’s mental health services, providing relatively few incentives for young people to enter the children’s mental health workforce. Low- and moderate-income communities increasingly lack psychiatrists and other treating professionals. The separation of mental and physical health means that many children with asthma, cystic fibrosis, heart disease, and other chronic conditions have limited access to mental health services despite clear evidence that the treatment of comorbid mental health conditions improves the general health and functioning of children.

We all hoped that a mandated parity of mental and physical health services would lower out-of-pocket costs and improve payment, thereby improving workforce and access issues. In the study by Kennedy-Hendricks et al³ in this issue of Pediatrics, the authors carefully examined whether mental health parity in commercial plans lowered out-of-pocket costs for children and youth with mental health diagnoses. In the study, children and youth with mental health conditions had high annual non–mental health expenditures, and the subset of children and youth with particularly high mental health expenditures had twice as much annual non–mental health expenditures, indicating the intermingling of mental and physical health services. Parity findings include less growth in out-of-pocket costs for children in parity plans than that in the comparison group (although these differences were fairly small), with little change in the percent paid out of pocket (both groups still paid ≥30% of the total mental health expenditures out of pocket). But the study revealed dramatic increases (more than doubling) in overall mental health spending and use over the study period not attributable to parity. No explanation for this doubling is offered in the report, although understanding the causes might offer insight into improving access to mental health services. Although several potential explanations for the parity findings exist, the bottom line is that parity has some (but only limited) impact on the access to and costs of mental health services.

Programs that integrate mental health services with physical health services (both in community pediatric practices and in subspecialty programs) help change the paradigm of unmet mental health needs. Indeed, much recent work by the National Academy of Medicine,^4,5 the American Board of Pediatrics,⁶ and the American Academy of Pediatrics,⁷ has supported and advocated for building the children’s mental health workforce and reintegrating mental and behavioral health with the rest of pediatric health care. Resources used to prevent mental health conditions, despite growing evidence of the efficacy of prevention, are particularly sparse.⁸ What still needs to be done? Of course, these workforce and integration efforts should be continued to train children’s health professionals to better address the needs of children and families holistically, but better financing is critical. Can mental health parity help address the mental and behavioral health gap in children’s health and improve access to mental health services? The current study offers some hope, although it also suggests the need to monitor and enforce parity better than what seems to have occurred at least in its early years. Parity seems less likely to improve preventive efforts unless mental health benefits clearly support the many effective preventive interventions. Awareness of the importance of mental and behavioral health is hardly new. Haggerty et al⁹ coined the term “new morbidity” almost half a century ago, noting that “parents indicated much…unhappiness about such problems as behavior disorders in preschoolers, inadequate functioning in schools, and the management of adolescents’ adjustment difficulties.” With a growing emphasis on the importance of mental and behavioral health and their influences on many other aspects of the health of children and adults, it may be time to think more imaginatively about health care financing that can better ensure attention to mental health concerns broadly. New alternative payment models could help, especially if data are collected on process and outcome measures related to mental health, but the current study highlights the need to improve the financing of mental and behavioral health care.