Abstract
This cross-sectional study examines US household medical spending for children with a mental health condition between 2017 and 2021.
Introduction
The prevalence of pediatric mental health (MH) conditions and the demand for behavioral health services is growing in the US.1,2,3 However, the current contribution of pediatric MH conditions to overall household health care expenditures is unknown. This study assesses medical spending for children with a MH condition between 2017 and 2021. We also investigate the association of a child’s MH condition with their household’s medical spending.
Methods
This cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The WCG institutional review board-Copernicus Group classified the study as exempt from human participant review and informed consent.
This cross-sectional study uses data from the Medical Expenditure Panel Survey, a nationally representative sample of the US population that contains medical spending, use, and household demographic information. MH conditions were identified as diagnoses for any MH condition and also analyzed separately for behavioral disorders, attention-deficit/hyperactivity disorder, anxiety, and depression (eAppendix in Supplement 1).
We estimated the weighted prevalence of MH diagnoses and total medical spend from 2017 to 2021 among children aged 5 to 17 years. We estimated segmented generalized linear regression models with a log link and gamma distribution that compared spending differences between children with and without a MH condition. A separate model was estimated using pooled data to determine spending differences in total health care, inpatient, outpatient, drug, and emergency department costs associated with each MH condition (eAppendix in Supplement 1). A similar procedure was repeated to determine spending differences between household members with a child in the household with a MH condition and households without. All analyses were completed using Stata version 18.0 (StataCorp). All tests were 2-sided, and statistical significance was set at P <.05. Data were analyzed from 2017 to 2021.
Results
There was a yearly weighted mean of 9 046 483 children (unweighted No., 827 children) with an MH condition and 33 922 246 family members (unweighted No., 3093 families). From 2017 to 2021, the weighted prevalence of MH diagnoses among children increased from 21.3% to 25.9%, a 21.6% relative increase (Table 1). Total medical spending for pediatric MH conditions were associated with a 45.2% increase from 2017 to 2021 (Table 1), and spending was higher across all categories in the 2017 to 2021 pooled analysis (Table 2). Pediatric MH conditions were also associated with $2337 higher total medical spending among household members in 2021 (Table 1). Overall, pediatric MH conditions were associated with $31 billion in child spending and $59 billion in household spending and made up 46.6% of all pediatric medical spending in 2021.
Table 1. Prevalence and Difference in Medical Spending of Children With an MH Condition and Household Members Between 2017 and 2021 (Weighted).
| Measure | Participants, % (95% CI) | ||||
|---|---|---|---|---|---|
| 2017 | 2018 | 2019 | 2020 | 2021 | |
| Child prevalence | |||||
| Any MH condition | 21.3 (18.8-23.8) | 23.9 (21.1-26.6) | 22.6 (20-25.2) | 26.6 (23.4-29.8) | 25.9 (22-29.8) |
| Behavioral disorders | 13.3 (11.3-15.3) | 15.5 (13.2-17.8) | 14.7 (12.6-16.8) | 15.7 (13.2-18.2) | 13.5 (10.8-16.1) |
| ADHD | 12.5 (10.7-14.3) | 14.3 (12-16.5) | 13.6 (11.8-15.5) | 14.9 (12.5-17.4) | 13.0 (10.4-15.6) |
| Anxiety | 6.5 (5.3-7.7) | 6.0 (4.6-7.5) | 5.8 (4.6-6.9) | 7.5 (5.8-9.1) | 8.5 (6.3-10.7) |
| Depression | 4.0 (3-5) | 3.6 (2.8-4.3) | 3.4 (2.5-4.4) | 4.0 (3-5) | 4.8 (3.6-6) |
| Household member prevalence | |||||
| Any MH condition | 25.4 (23.1-27.9) | 27.4 (25.1-29.9) | 26.7 (24.4-29.1) | 30.7 (28-33.5) | 31.5 (28.5-34.6) |
| Behavioral disorders | 17.0 (15-19.3) | 18.7 (16.5-21.1) | 17.8 (15.8-20) | 19.0 (16.6-21.7) | 17.4 (14.9-20.2) |
| ADHD | 16.1 (14.2-18.2) | 17.4 (15.2-19.7) | 16.7 (14.8-18.8) | 18.1 (15.7-20.7) | 16.6 (14.2-19.3) |
| Anxiety | 8.0 (6.6-10) | 7.0 (5.6-8.7) | 7.3 (6.1-8.6) | 8.8 (7.2-10.8) | 11.1 (8.9-13.8) |
| Depression | 4.8 (3.8-6) | 4.2 (3.4-5) | 4.4 (3.4-5.6) | 5.1 (4-6.5) | 6.4 (4.9-8.4) |
| Child difference in medical spending, average marginal effect (95% CI), $a | |||||
| Any MH condition | 3004 (2322.0-3686.4) | 3171 (2502.5-3839.4) | 4093 (3227.4-4958.5) | 2754 (1939.6-3567.4) | 4361 (2798.5-5922.9) |
| Behavioral disorders | 2672 (1940.1-3403.4) | 2203 (1572.6-2833.9) | 3427 (2518.3-4336.0) | 1871 (1075.0-2667.2) | 3060 (1457.8-4661.7) |
| ADHD | 2499 (1829.7-3167.8) | 2312 (1655.6-2968.5) | 3405 (2467.0-4343.6) | 1839 (1015.9-2663.0) | 3630 (997.0-6263.3) |
| Anxiety | 2322 (1596.7-3046.3) | 3153 (2195.1-4110.4) | 3592 (2350.5-4833.5) | 1272 (231.9-2312.9) | 3256 (1641.8-4869.3) |
| Depression | 3706 (2646.2-4765.8) | 2604 (1599.4-3608.0) | 3035 (1915.2-4155.3) | 1499 (−16.5-3013.7) | 5979 (3151.9-8806.2) |
| Household member difference in medical spending, average marginal effect (95% CI), $b | |||||
| Any MH condition | 2480 (1833.6-3125.6) | 1625 (1015.9-2233.6) | 1983 (1472.3-2494.1) | 1759 (1082.8-2435.5) | 2337 (1408.8-3265.6) |
| Behavioral disorders | 2106 (1472.4-2739.3) | 1575 (9,12.1-2237.8) | 1771 (1108.9-2433.9) | 2019 (1270.2-2768.4) | 2519 (1464.6-3572.5) |
| ADHD | 1940 (1350.3-2529.1) | 1621 (951.5-2290.2) | 1823 (1141.9-2503.2) | 1810 (1081.3-2538.1) | 2512 (1435.5-3589.1) |
| Anxiety | 1859 (1052.1-2665.6) | 1721 (1008.3-2433.0) | 2276 (1511.8-3040.9) | 1056 (1,79.6-1932.2) | 2416 (802.4-4029.2) |
| Depression | 3337 (2198.9-4475.0) | 1797 (613.8-2981.0) | 2112 (841.8-3382.2) | 2167 (903.8-3431.1) | 3944 (2087.5-5800.5) |
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; MH, mental health.
Controlling for differences in gender, race, geographic region, household income, household size, insurance status, and year.
Controlling for differences in age, education, gender, race, geographic region, household income, household size, insurance status, and year.
Table 2. Difference in Medical Spending Associated With Pediatric MH Conditions From 2017 to 2021 (Weighted).
| Condition | Increased medical spending, average marginal effect (95% CI), $ | |||||
|---|---|---|---|---|---|---|
| Total | Inpatient | Outpatient | Drug | Office | ED | |
| Child spendinga | ||||||
| Any MH condition | 3074.5 (2680.2 to 3468.7) | 408.2 (193.0 to 623.4) | 224.7 (118.3 to 331.1) | 749.0 (599.1 to 898.9) | 1295 (1083.1 to 1506.4) | 25.6 (0.3 to 51.0) |
| Behavioral disorders | 2492.8 (2123.4 to 2862.2) | 240.5 (43.5 to 437.4) | 97.0 (−15.9 to 209.9) | 793.9 (674.0 to 913.8) | 848.6 (698.9 to 998.4) | −18.3 (−47.0 to 10.4) |
| ADHD | 2475.3 (2101.2 to 2849.4) | 260.3 (50.6 to 469.9) | 94.8 (−23.4 to 212.9) | 829.6 (705.4 to 953.9) | 761.8 (618.7 to 904.9) | −18.4 (−48.1 to 11.2) |
| Anxiety | 2311.5 (1708.9 to 2914.0) | 543.6 (255.6 to 831.6) | 247.0 (101.5 to 392.4) | 416.3 (259.1 to 573.5) | 971.3 (775.5 to 1167.1) | 26.9 (−7.3 to 61.0) |
| Depression | 3074.0 (2391.4 to 3756.5) | 686.0 (406.7 to 965.3) | 216.2 (44.3 to 388.1) | 427.5 (287.9 to 567.0) | 1171 (921.2 to 1420.0) | 76.6 (29.3 to 124.0) |
| Household member spendingb | ||||||
| Any MH condition | 1827.7 (1497.5 to 2157.9) | 154 (−40.5 to 348.5) | 113.7 (34.9 to 192.5) | 784.8 (572.8 to 996.8) | 805.8 (669.2 to 942.4) | 28.1 (5.8 to 50.4) |
| Behavioral disorders | 1980.0 (1607.5 to 2352.6) | 196.1 (−22.1 to 414.2) | 150.4 (62.3 to 238.5) | 1095 (850.2 to 1340.1) | 647.8 (499.9 to 795.8) | 17.4 (−7.5 to 42.3) |
| ADHD | 1939.7 (1557.0 to 2322.4) | 218.7 (−5.9 to 443.3) | 108.5 (17.5 to 199.5) | 1057 (813.8 to 1300.0) | 622.1 (473.8 to 770.3) | 18.6 (−6.1 to 43.4) |
| Anxiety | 1702.9 (1275.6 to 2130.3) | 201.7 (−77.4 to 480.9) | 159.0 (60.9 to 257.1) | 445.3 (213.7 to 676.8) | 870.4 (691.4 to 1049.4) | 44.8 (14.5 to 75.0) |
| Depression | 2283.6 (1714.9 to 2852.3) | 636.2 (263.1 to 1009.3) | 112.5 (−11.9 to 237.0) | 642.7 (341.8 to 943.7) | 884.0 (701.6 to 1066.3) | 38.3 (4.1 to 72.5) |
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; ED, emergency department; MH, mental health.
Controlling for differences in gender, race, geographic region, household income, household size, insurance status, and year.
Controlling for differences in age, education, gender, race, geographic region, household income, household size, insurance status, and year.
Discussion
This study supports the literature on the growing prevalence of pediatric MH diagnoses.1,2 Our findings suggested large increases between 2017 and 2021 in total medical spending for households with a pediatric MH condition for both the child and household members. Some sources of spending, such as drug and office costs, may be beneficial if the care is high quality and evidence-based, while others, such as emergency department costs, may reflect the need for improved care.4 Caregiver MH service use may account for increased household medical spending since poor MH among caregivers is associated with child MH disorders.5
This study has limitations. The cross-sectional design limits distinguishing drivers of pediatric MH diagnosis and medical spending, given insurance coverage expansion to behavioral health services.6 Furthermore, we were unable to distinguish between new and existing diagnoses and could not attribute the increase in medical spending as a result of an increase in diagnoses or an increase in use of MH services among existing cases. We also relied on confirmed pediatric mental health diagnoses and are thus unable to account for undiagnosed mental health conditions. Finally, our analysis does not examine differences by insurance type (eg, commercial insurance vs Medicaid).
These results underscore the large financial burden associated with pediatric MH conditions on the US health care system. The associated increase in household member medical spending may warrant family-based approaches to treating pediatric MH conditions.
eAppendix.
Data Sharing Statement
References
- 1.Mental health surveillance among children–United States, 2005-2011. US Centers for Disease Control and Prevention. Accessed October 16, 2023. https://stacks.cdc.gov/view/cdc/13598
- 2.Tkacz J, Brady BL. Increasing rate of diagnosed childhood mental illness in the United States: incidence, prevalence, and costs. Public Health Pract (Oxf). 2021;2:100204. doi: 10.1016/j.puhip.2021.100204 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kalmin MM, Cantor JH, Bravata DM, Ho PC, Whaley C, McBain RK. Utilization and spending on mental health services among children and youths with commercial insurance. JAMA Netw Open. 2023;6(10):e2336979. doi: 10.1001/jamanetworkopen.2023.36979 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lui JHL, Brookman-Frazee L, Vázquez AL, et al. Patterns of child mental health service utilization within a multiple EBP system of care. Adm Policy Ment Health. 2022;49(3):506-520. doi: 10.1007/s10488-021-01179-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Wolicki SB, Bitsko RH, Cree RA, et al. Mental health of parents and primary caregivers by sex and associated child health indicators. Advers Resil Sci. 2021;2(2):125-139. doi: 10.1007/s42844-021-00037-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Expanding access to behavioral health coverage. RTI Health Advance. Accessed October 16, 2023. https://healthcare.rti.org/insights/health-plans-mental-health
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eAppendix.
Data Sharing Statement