Expenditures for Pediatric Behavioral Health Care Over Time and Estimated Family Financial Burden

Abstract

IMPORTANCE

Pediatric behavioral health conditions are common and may confer substantial health care costs and financial strain on families.

OBJECTIVE

To quantify 2022 US pediatric behavioral health care expenditures, evaluate 2011 to 2022 changes in expenditures, and examine the association between child behavioral health spending and family financial burden.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of US children aged 6 to 17 years, using 2011–2022 Medical Expenditure Panel Survey household component files, with analysis performed from January 11, 2024, to October 15, 2025.

EXPOSURE

Expenditure trends analysis included year. Family financial burden analysis included child behavioral health spending.

MAIN OUTCOMES AND MEASURES

Behavioral health care and overall pediatric health care spending was totaled for 2022, using survey-weighted linear regression models to estimate trends. The association between child behavioral health spending and high family financial burden (sliding-scale income-based threshold) and extreme financial burden (>10% of income) was evaluated with weighted logistic regression. Analyses were inflation adjusted.

RESULTS

Pediatric behavioral health care expenditures in 2022 totaled $41.8 billion (95% CI, $17.0-$66.7 billion). The proportion of pediatric care expenditures for behavioral health increased from 22.4% in 2011 to 40.2% in 2022. Simultaneously, pediatric behavioral health out-of-pocket spending increased from $2.1 to $2.9 billion, by 6.4% annually (95% CI, 3.5%−9.0%). For families with at least 1 child with behavioral health spending, 12.5% of out-of-pocket spending among families with high financial burden and 14.4% of out-of-pocket spending among families with extreme financial burden were for child behavioral health care. Having a child with behavioral health spending was associated with high family financial burden (adjusted odds ratio, 1.60; 95% CI, 1.44–1.78) and extreme family financial burden (adjusted odds ratio, 1.42; 95% CI, 1.22–1.65).

CONCLUSIONS AND RELEVANCE

Behavioral health expenditures nearly doubled to 40% of US child health spending by 2022. Behavioral health spending was associated with high family financial burden, which reflects increased demand and cost for services and supports expanding access through insurance coverage and clinician availability.

Although pediatric behavioral health conditions are common in the United States,¹ many children cannot access timely behavioral health care.² Mental health workforce shortages and challenges accessing outpatient care have led to increases in behavioral health emergency department visits and hospitalizations.^3–6 These trends led multiple national pediatric organizations and the surgeon general to declare a national emergency in 2021.^7,8

Historically, expenditures on pediatric behavioral health care have been substantial. In 2012, behavioral health conditions were the highest contributor ($13.9 billion) to overall pediatric health care expenditures compared with all other pediatric conditions.⁹ A more recent study of US children found that in 2021, $31 billion was spent on medical care for children with mental health conditions.¹⁰ However, that study evaluated overall medical spending and not direct medical spending for behavioral health care. A population-level assessment of behavioral health spending clarifies scale of need, identifies venues driving cost, and evaluates whether investments align with population needs, providing evidence to guide policy, advance research on effective care, and support prevention and early intervention efforts.

US children with behavioral health conditions may have difficulty affording care because many mental health professionals do not accept insurance payments; 20% of pediatric outpatient behavioral health visits are paid out of pocket (OOP).¹¹ Additionally, cost-sharing expenses (eg, deductibles, co-payments)¹² may contribute to family financial burden.^13,14 The Mental Health Parity and Addiction Equity Act of 2008 and the Patient Protection and Affordable Care Act of 2010 sought to enhance insurance coverage for behavioral health services.^15,16 These federal regulations mandated that health plans offer behavioral health and substance use benefits equivalent to physical health benefits, aiming to lower OOP costs and expand access to behavioral health care. However, children still face inconsistencies in coverage for specific behavioral health conditions, and the implementation of federal parity laws differs by state.^17,18 Financial strain may cause deferred or forgone care. Forgone care may in turn lead to behavioral health symptom progression and increased costs due to reliance on acute care (eg, emergency department visits, inpatient care). To better characterize the cost of pediatric behavioral health care to the system and families, the objectives of this study were to (1) quantify 2022 health care expenditures for behavioral health care for children in the United States; (2) evaluate changes in US pediatric behavioral health care expenditures and OOP spending for behavioral health care between 2011 and 2022; and (3) examine the association of child behavioral health spending and family financial burden.

Methods

Study Design and Population

We conducted a cross-sectional analysis using the 2011–2022 Medical Expenditure Panel Survey (MEPS) Household Component. The survey is administered by the Agency for Healthcare Research and Quality and provides nationally representative data on health care use, expenditures, insurance, and sociodemographic information for the US civilian noninstitutionalized population. Expenditures are derived from household interviews and validated against clinician- and facility-reported data; survey design and validation procedures have been detailed previously.^19,20

We studied US children aged 6 to 17 years and their families.^21,22 Behavioral health care spending was defined as a medical visit at a care venue with a primary behavioral health diagnosis determined by Clinical Classifications Software codes (eTable 1 in Supplement 1) or a behavioral health prescription. Behavioral health prescriptions were defined as medications with a Cerner Multum therapeutic class of psychotherapeutic agents; central nervous system stimulants; anxiolytics, sedatives, or hypnotics; or antiadrenergic agents, centrally acting, based on prior literature (eTable 2 in Supplement 1).²³ Care venues within MEPS included home health, outpatient telehealth visits (telehealth hospital outpatient or office-based visits), outpatient in-person visits (outpatient on hospital campus or office-based visits), emergency department visits, inpatient stays, other medical expenses (eg, ambulance services, medical equipment), and behavioral health prescriptions. Telehealth was included as a care venue beginning in 2020, when this variable was introduced to MEPS. The institutional review board at the Ann & Robert H. Lurie Children’s Hospital of Chicago determined that analyzing MEPS data did not involve human subjects and therefore was exempt from review. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.²⁴

Outcomes

The primary outcome was total US pediatric behavioral health expenditures from all sources (including OOP and all payers). We also determined the OOP contribution. Expenditures were inflation adjusted using the year-specific gross domestic product, and OOP expenditures were adjusted based on the consumer price index.²⁵ The primary outcome was analyzed at the child level. Secondary outcomes analyzed at the family level included total family OOP spending for families with at least 1 child aged 6 to 17 years, inclusive of all family adult and child OOP spending for behavioral and nonbehavioral health care. From total family OOP spending, we evaluated whether each family had high financial burden from OOP spending, defined based on total family OOP expenditures exceeding a previously validated income-based sliding-scale threshold (eg, OOP spending exceeded 3.45% of income for families with annual income <$20 000 and OOP spending exceeded 8.35% of income for families with annual income of $75 000),^14,15,26 or extreme financial burden, defined as total OOP medical spending exceeding 10% of family income.¹⁵

Study Variables

Child-level demographic variables included age (6–11 and 12–17 years),^21,22 payer (any private, only public, or uninsured), race and ethnicity (Hispanic, non-Hispanic Asian only, non-Hispanic Black only, non-Hispanic White only, and other races or multiracial), US region (Northeast, South, Midwest, and West), and presence of medical complexity. Race and ethnicity were derived directly from the data source. Respondents indicating Hispanic ethnicity were categorized as such; non-Hispanic respondents indicating a single race were categorized as non-Hispanic Asian only, non-Hispanic Black only, and non-Hispanic White only; and those indicating any other or multiple race categories were categorized as other or multiple races. Presence of medical complexity was defined by greater than or equal to 4 positive items on the Children with Special Health Care Needs 5-item screener, included within MEPS.^27,28 Race and ethnicity were included because of their known associations with use of and access to behavioral health resources.²⁹ Family-level demographic and clinical variables included presence of at least 1 child with adolescent age (12–17 years), family payer (any private, only public, or uninsured), family race and ethnicity (Hispanic, non-Hispanic Asian only, non-Hispanic Black only, non-Hispanic White only, and other races or multiracial), number of children in the family, presence of at least 1 child with behavioral health spending, presence of at least 1 child with medical complexity, US region (Midwest, Northeast, South, and West), and family income, reported as a percentage of the federal poverty level (<100%, 100%−124%, 125%−199%, 200%−399%, and ≥400%).

Statistical Analysis

We accounted for MEPS’s complex survey design by incorporating sampling weights, stratification, and clustering. The data were weighted to generate national estimates and CIs.

Analyses of total and OOP US pediatric health care spending and child behavioral health spending were performed at the child-year level. We first reported total and OOP behavioral health spending among children, as well as the proportion of overall health care spending for behavioral health. We used weighted linear regression to estimate trends in overall pediatric behavioral health spending, pediatric behavioral health OOP spending, and pediatric nonbehavioral health medical OOP spending from 2011 to 2022. We reported expenditures and trends overall and stratified by care venue. To generate CIs, we used a bootstrap with 500 replicate samples, resampling primary sampling units within survey strata. For each replicate, we fit a quasi-Poisson regression with the outcome of spending and exposure of year, deriving 95% CI from the 2.5th and 97.5th percentiles of the bootstrap distribution.³⁰ The same procedure was used to evaluate mean spending per visit by care venue, using weighted linear regression with log mean costs as the dependent variable.

Analyses of financial burden were performed at the family-year level, including only families with at least 1 child aged 6 to 17 years. Among families with high and extreme financial burden from OOP spending and at least 1 child with behavioral health care spending, we estimated the percentage of total family OOP spending for child behavioral health care.

We used survey-weighted quasibinomial regression to evaluate the association between having at least 1 child with behavioral health care spending and family financial burden. We adjusted for other family-level factors we hypothesized contribute to family financial burden, including number of children in the family, presence of at least 1 adolescent (12–17 years), presence of at least 1 child with medical complexity, family payer, family income as measured by the percentage of federal poverty level, and US region.^{10,15,22,31–37} We reported effect estimates as adjusted odds ratios (AORs) with 95% CIs. Statistical tests were 2-tailed, and significance was set at α < .05. Data analyses were performed with R, version 4.5.0 (R Foundation for Statistical Computing), from January 11, 2024, to October 15, 2025.

Results

Trends in Pediatric Behavioral Health Expenditures

During the study period, there were 101.9 million child-years with behavioral health spending, 57.9% of adolescents were aged 12 to 17 years, and 58.8% had private insurance (Table 1). A total of 17.9% of the population were Hispanic, 1.3% were non-Hispanic Asian, 10.7% were non-Hispanic Black, 62.4% were non-Hispanic White, and 7.6% were other/multiple races; 56.9% were male and 43.1% were female. Among all US children aged 6 to 17 years with any medical spending, behavioral health expenditures accounted for 22.4% of all health spending in 2011 and 40.2% in 2022. From 2011–2022, there was an annual estimated increase in pediatric behavioral health spending of $1.2 billion per year (95% CI, $0.6-$1.8 billion). In 2022, national pediatric behavioral health care expenditure for children aged 6 to 17 years was $41.8 billion (95% CI, $17.0-$66.7 billion). A mean (SD) of 8.5 (0.7) million children had any behavioral health expenditure per year, with a mean (SD) of 43.1 (7.4) million behavioral health prescriptions per year (34.5% of all prescriptions for children 6–17 years).

Table 1.

Demographic Characteristics of US Children With Behavioral Health Care Spending, 2011–2022

Characteristic	Child-years, millions (%)
Overall	101.9
Age, y
6–11	42.9 (42.1)
12–17	59.0 (57.9)
Sex
Male	58.0 (56.9)
Female	43.9 (43.1)
Payer
Private	59.9 (58.8)
Public	40.3 (39.5)
Uninsured	1.7 (1.7)
Race and ethnicitya
Hispanic	16.9 (17.9)
Non-Hispanic Asian	1.3 (1.3)
Non-Hispanic Black	10.1 (10.7)
Non-Hispanic White	58.8 (62.4)
Other/multiple racesb	7.2 (7.6)
US region
Midwest	24.5 (24.0)
Northeast	19.0 (18.6)
South	36.2 (35.5)
West	22.1 (21.7)
Medical complexity	15.5 (15.2)

^aMissing data: 8.5% of sample.

^bRace and ethnicity were derived directly from the data source. Respondents indicating Hispanic ethnicity were categorized as such; non-Hispanic respondents indicating a single race were categorized as non-Hispanic Asian only, non-Hispanic Black only, and non-Hispanic White only; and those indicating any other or multiple race categories were categorized as other or multiple races.

Changes in Behavioral Health Expenditures by Care Venue

Behavioral health expenditures increased for the following care venues: home health care (24.8% per year; 95% CI, 8.0%−46.7%), outpatient in-person visits (11.0% per year; 95% CI, 8.0%−14.0%), and outpatient telehealth visits (98.8% per year from 2020–2022; 95% CI, 83.5%−120.6%) (Figure 1). Overall cost per visit increased from $219.28 in 2011 to $348.22 in 2022 (3% per year; 95% CI, 1%−4%), with statistically significant increases noted in care venues of home health (8% per year; 95% CI, 5%−11%) and outpatient in-person visits (4% per year; 95% CI, 3%−5%) (eFigure 1 in Supplement 1). There was a decrease in expenditures for behavioral health prescriptions (−3.5% per year; 95% CI, −4.9% to −2.2%) and number of behavioral health prescriptions (from 45.0 million in 2011 to 33.0 million in 2022, −2.3% per year; 95% CI, −3.5% to −1.1%) (Figure 2). Expenditures for behavioral health emergency department visits and inpatient care did not change significantly.

Figure 1.

Total US Pediatric Behavioral Health Care Expenditures by Care Venue, 2011–2022

Figure 2. Pediatric Behavioral Health Prescription Counts and Expenditures, 2011–2022.

Number of behavioral health prescriptions for US children aged 6 to 17 years (left y-axis) and prescription expenditures (right y-axis) from 2011 to 2022.

OOP Spending

US pediatric behavioral health OOP spending increased from $2.1 billion in 2011 to $2.9 billion in 2022, a 6.4% annual increase (95% CI, 3.5%−9.0%). Pediatric nonbehavioral health OOP medical spending increased by 2.7% annually (95% CI, 0.6%−4.8%). The proportion of OOP behavioral health spending was 12.1% in 2011 and 6.9% in 2022 (eFigure 2 in Supplement 1). Behavioral health OOP spending for US children accounted for 23.3% of all child OOP spending in 2011 and 26.2% in 2022. There were significant increases in behavioral health OOP spending for outpatient telehealth visits (112.5% per year; 95% CI, 86.6%−167.0%) and outpatient in-person visits (10.1% per year; 95% CI, 5.8%−14.6%) and significant decreases in OOP spending for behavioral health prescriptions (−5.3% per year; 95% CI −8.7% to −3.0%) (Figure 3).

Figure 3.

Out-of-Pocket Spending for US Pediatric Behavioral Health Care by Care Venue, 2011-2022

Family Financial Burden

Among 363.9 million family-years, 39.2 million (10.8%) had high financial burden, and 17.3 million (4.7%) had extreme financial burden due to total OOP health care costs. For families with at least 1 child with behavioral health spending, 12.5% of OOP spending among families with high financial burden and 14.4% of OOP spending among families with extreme financial burden was for child behavioral health care.

Having a child with behavioral health spending was independently associated with high family financial burden (AOR, 1.60; 95% CI, 1.44–1.78) and extreme family financial burden (AOR, 1.42; 95% CI, 1.22–1.65) (Table 2). Having at least 1 child with medical complexity was also associated with high (AOR, 1.26; 95% CI, 1.06–1.28) and extreme financial burden (AOR, 1.38; 95% CI, 1.08–1.76). Every additional child in the family was associated with a decreased likelihood of high financial burden (AOR, 0.77 per child; 95% CI, 0.73–0.80) and extreme financial burden (AOR, 0.85 per child; 95% CI, 0.79–0.91). Families identifying as Hispanic, non-Hispanic Asian, non-Hispanic Black, and other/multiple race and ethnicities were less likely to have high or extreme financial burden compared with families identifying as non-Hispanic White. Publicly insured families were also less likely to experience high (AOR, 0.56; 95% CI, 0.50–0.64) or extreme (AOR, 0.71; 95% CI, 0.59–0.85) financial burden compared with those with private insurance. Families in all income categories greater than or equal to 100% above the federal poverty level were less likely to experience high or extreme financial burden compared with those at less than 100% of the federal poverty level.

Table 2.

Family-Level Characteristics Associated With Out-of-Pocket Spending Causing High and Extreme Financial Burden, 2011–2022

	Financial burden, adjusted OR (95% CI)
Characteristic	High	Extreme
No. of children	0.77 (0.73–0.80)	0.85 (0.79–0.91)
Presence of ≥1 child with behavioral health spending	1.60 (1.44–1.78)	1.42 (1.22–1.65)
Presence of ≥1 adolescent	1.16 (1.06–1.28)	1.07 (0.93–1.24)
Presence of ≥1 child with medical complexity	1.26 (1.06–1.28)	1.38 (1.08–1.76)
Race and ethnicity
Hispanic	0.49 (0.43–0.55)	0.49 (0.41–0.58)
Non-Hispanic Asian	0.47 (0.36–0.61)	0.55 (0.37–0.82)
Non-Hispanic Black	0.48 (0.43–0.55)	0.45 (0.38–0.54)
Non-Hispanic White	1 [Reference]	1 [Reference]
Other/multiple racesa	0.77 (0.67–0.88)	0.73 (0.61–0.88)
Payer
Private	1 [Reference]	1 [Reference]
Public	0.56 (0.50–0.64)	0.71 (0.59–0.85)
Uninsured	0.89 (0.78–1.02)	1.00 (0.82–1.22)
Federal poverty level, %
<100	1 [Reference]	1 [Reference]
100–124	0.57 (0.49–0.66)	0.22 (0.17–0.28)
125–199	0.38 (0.34–0.43)	0.21 (0.17–0.26)
200–399	0.08 (0.06–0.09)	0.09 (0.08–0.12)
≥400	0.02 (0.01–0.02)	0.04 (0.03–0.05)
US region
Midwest	1.12 (0.95–1.32)	0.98 (0.77–1.25)
Northeast	1 [Reference]	1 [Reference]
South	1.00 (1.00–1.35)	1.16 (0.94–1.44)
West	1.03 (0.88–1.22)	1.09 (0.86–1.38)

Abbreviation: OR, odds ratio.

^aRace and ethnicity were derived directly from the data source. Respondents indicating Hispanic ethnicity were categorized as such; non-Hispanic respondents indicating a single race were categorized as non-Hispanic Asian only, non-Hispanic Black only, and non-Hispanic White only; and those indicating any other or multiple race categories were categorized as other or multiple races.

Discussion

From 2011–2022, pediatric behavioral health spending increased by $1.2 billion per year and by 2022 accounted for $41.8 billion and 40% of all health care spending for US children aged 6 to 17 years. Behavioral health prescription counts and expenditures decreased, whereas home health, telehealth, and outpatient visit spending increased. Emergency department and inpatient spending did not change significantly. US pediatric behavioral health OOP spending increased annually at over twice the rate of nonbehavioral health OOP medical spending. Presence of at least 1 child with behavioral health spending was independently associated with high and extreme family financial burden.

This study’s data build on prior work showing that behavioral health conditions are responsible for the largest burden of US child medical spending.^9,10 Substantial behavioral health care expenditures for children in the United States likely reflect several factors, including increasing prevalence of behavioral health conditions in US children, the rise of community-based care venues, and increasing costs. Prior literature has described the increased prevalence of behavioral health conditions over time.^38–42 The COVID-19 pandemic may have further accelerated this trend due to challenges including school closures, social isolation, increased uncertainty, financial stressors, and death of parents or caregivers.⁴³ Simultaneously, reduced stigma and expansion of outpatient services likely have encouraged families to seek care.^44–46 In addition, there was an overall increase in cost per medical visit, which further contributes to the substantial increase in pediatric behavioral health spending in the United States.

Annual spending increases in home health, telehealth, and outpatient in-person visits reflect new policies and models of care delivery. Telehealth rapidly expanded during the pandemic and is likely to remain a lasting component of behavioral health care delivery in the United States.^21,47 In the past decade, and especially since the pandemic, telehealth use expanded due to social distancing needs; regulatory changes, including reimbursement structures; and advances in technology, increasing the accessibility of outpatient care for many families.^48,49 Like telehealth, home health is a growing care delivery method aimed to increase access to services, especially for children with barriers to leaving home, such as medical complexity and medical technology dependence.^50,51 The American Rescue Plan Act of 2021 expanded Medicaid matching funds for home and community-based services in an effort to increase uptake of this new care delivery model.^52,53

US pediatric behavioral health OOP spending increased at nearly twice the rate of nonbehavioral health OOP expenditures during the study, and by 2022, more than one-quarter of total pediatric OOP spending was for behavioral health care. The increasing share of pediatric OOP spending for behavioral health care may reflect that the supply of in-network clinicians has not kept pace with demand, leading families to rely on out-of-network care and incur higher OOP costs for behavioral health compared with other types of medical care.^11,54 Although cost sharing is meant to balance financial protection with judicious health care use, high OOP spending can lead to cost-related reductions in care and poor health outcomes.^55–57 High OOP burden may also increase disparities in access to behavioral health care because the most vulnerable populations are more susceptible to cost-related underusage or forgone medical care.^55,58,59 Yet the proportion of behavioral health spending that was OOP decreased, suggesting that overall behavioral health spending grew even faster, possibly due to policy expansions or greater coverage through public and safety-net programs. Further study is needed to examine how insurance type and access to behavioral health care resources shape these spending patterns among US children.

On the family level, presence of a child with behavioral health spending was independently associated with high and extreme family financial burden. Although federal parity laws, which mandate equal coverage for behavioral and nonbehavioral health care, have expanded access to behavioral health services, state-level differences in strength and enforcement of these laws may influence how much families pay for behavioral health care.⁶⁰ Parity with medical coverage is associated with increased behavioral health service use; however, consumer-driven and high-deductible plans are associated with greater proportions of OOP behavioral health spending for families compared with preferred provider organizations.⁶¹ Moreover, individuals covered by public insurance may have more complete behavioral health coverage and fewer co-payments, leading to lower OOP behavioral health burden compared with those with private insurance.⁵⁹ Similar to the present study, prior studies have also found higher health care spending and use for White families, which warrants exploration to determine the extent to which this is due to differential access to care.^62,63 Additionally, previous literature supports that financial problems due to medical spending are more prevalent among lower-income families, although families of all income levels remain at risk.⁶⁴

Limitations

The MEPS collects data based on caregiver-reported recall and diary entries, which may lead to recall bias and underestimation or overestimation of child behavioral health care use. Expenditures may be related to more than 1 symptom or condition, including for conditions other than behavioral health. This study included only spending associated with a primary behavioral health diagnosis to minimize this effect but still may have overestimated or underestimated spending specific to behavioral health. Furthermore, OOP costs do not account for families who received reimbursement for care after reporting to MEPS, nor do they cover indirect costs of care, such as transportation and missed work. Finally, MEPS provides no direct information on the clinical effectiveness of care provided.

Conclusions

Pediatric behavioral health expenditures account for a substantial portion of all US pediatric health care spending, representing 40% of total US pediatric medical expenditures in 2022, with statistically significant annual increases from 2011–2022. During this time, US pediatric OOP behavioral health spending increased at more than twice the rate of OOP nonbehavioral health spending. Many US families are experiencing high and extreme financial burden due to OOP health care costs, and having a child with behavioral health expenditures independently increases a family’s risk of financial burden. Additionally, having access to public insurance may be protective against family financial burden. To ensure that growing behavioral health spending delivers value, future policy and research should study relationships between cost and spending, use, and outcomes while advancing equitable, affordable access to needed behavioral health care.

Supplementary Material

Supplemental content

Key Points.

Questions

What are overall and out-of-pocket behavioral health expenditures for US children, and how have they changed over time?

Findings

In this cross-sectional study, US pediatric behavioral health expenditures totaled $41.8 billion, with $2.9 billion in out-of-pocket expenditures in 2022. The proportion of total pediatric medical expenditures directed to behavioral health increased from 22.4% in 2011 to 40.2% in 2022.

Meaning

Behavioral health care accounts for an increasing share of children’s medical expenditures; findings suggest a greater demand and cost for care and underscore the importance of enhancing pediatric behavioral health care access through insurance and clinician capacity.

Data Sharing Statement:

See Supplement 2.