A new study published in JAMA Open Network looked at the the comprehensiveness of state insurance laws and perceived access to pediatric mental health care.
“Our study investigated the association of the comprehensiveness of state mental and behavioral health insurance laws with caregiver perception of access to mental and behavioral health care for children in the United States,” study author Ashley A. Foster told us. “We also assessed the association of comprehensiveness of state mental and behavioral health insurance laws with caregiver perception of adequacy of mental and behavioral health insurance coverage.”
The research team expected there would be variability in comprehensiveness of state mental and behavioral health insurance laws throughout the country. They also had the hypotheses that less comprehensive state mental and behavioral health insurance laws would be associated with caregiver perception of poor access to care as well as caregiver perception of inadequate mental and behavioral health insurance coverage.
“As a pediatric emergency medicine physician, I often care for children who have difficulty accessing the mental and behavioral health care that they need and present to the emergency department in crisis,” Foster told us. “I therefore wanted to understand if robustness of state mental health insurance laws influence whether children with mental and behavioral health conditions can get the care that they need.”
The research team paired the State Mental Health Insurance Laws Dataset, previously created by co-authors Megan Douglas and Teal Benevides, with the National Survey of Children’s Health. The mental health insurance laws dataset measures comprehensiveness of mental health insurance laws by state using a validated legal coding instrument with six questions across four themes (parity, mandated coverage, mental health condition definition, and enforcement-compliance) that produces a composite score for each state ranging between zero (least comprehensive) to seven (most comprehensive).
“The primary exposure was comprehensiveness of state mental and behavioral health insurance laws with outcome measures of perceived poor access to mental and behavioral health care and perceived inadequate mental and behavioral health insurance coverage,” Foster told us. “We used multivariable regression models to analyze the associations of the state mental health insurance laws dataset scores with the outcome measures.”
Within the study period, there were 3,193 caregivers representing 1,770,492 children (12.4%) who perceived poor access to mental and behavioral health care. In the multivariable model, caregivers of children living in states with the most comprehensive mental and behavioral health insurance legislation (scores 5-7) had decreased odds of perceiving poor access to mental and behavioral health care compared with caregivers of children living in states with the least comprehensive insurance legislation (scores 0-2). Additionally, there were higher odds of perceived poor access to mental and behavioral health care among caregivers of Black and Asian compared with White children. As exposures to adverse childhood experiences (ACEs) increased, the odds of perceived poor access to mental and behavioral health care also increased.
“A total of 3,517 caregivers representing 1,643,260 children (12.5%) perceived that their child or adolescent had inadequate mental and behavioral health insurance coverage,” Foster told us. “In the multivariable model, caregivers of children living in states with moderately comprehensive mental and behavioral health insurance legislation (score 4) had increased odds of perceived inadequate mental and behavioral health insurance coverage compared with caregivers of children living in states with the least comprehensive legislation (score 0-2).”
Caregivers of children with four or more ACEs had higher adjusted odds of perceived inadequate mental and behavioral health insurance coverage compared with caregivers of children and adolescents with no ACEs.
“We were surprised to find that moderate comprehensiveness of state mental and behavioral health insurance legislation was associated with increased odds of perceived inadequate insurance coverage,” Foster told us. “This could be due to a multitude of reasons.”
Some reasons include the differing influence of the components of the comprehensiveness score, unmeasured child-level and state-level confounders, variability in clinicians accepting insurance within a state, significant cost-sharing by families even with insurance, or quality of parity enforcement within a state.
“We believe that our findings have policy implications,” Foster told us. “States can work to enhance their comprehensiveness of mental health insurance laws to enhance child access to mental and behavioral health care.”
Additionally, explained Foster, policies are also needed to work to enhance mental and behavioral health care in other ways that may include access to telehealth, integration of mental and behavioral health in primary care, and expansion of the mental and behavioral health professional workforce.
“This study underscores the importance of state-level policy in shaping health outcomes and the need for ongoing evaluation and advocacy to improve access to mental and behavioral health services for children,” Foster told us.