Parity, child mental health, and substance abuse

最近通过的《2008年Paul Wellstone和Pete Domenici精神健康平等和成瘾平等法案》要求私人健康计划提供平等的行为和医疗/外科服务，也被称为平等，这是扩大获得药物滥用和精神健康治疗的重要一步。新的法律将为行为健康服务提供新的资金，它可能会对私人和公共保险的行为健康治疗范围进行重大重组。事实上，新立法可能会通过对州儿童健康保险计划（SCHIP）的间接影响产生最大的公共卫生影响，该计划为20岁以下不符合收入条件的儿童提供公共健康保险。与享受医疗补助计划的儿童相比，参加SCHIP计划的儿童出现行为健康问题的比例更高。然而，SCHIP计划往往会通过访问/天限制，高共同支付，共同保险和免赔额来限制行为健康治疗的覆盖范围，这是医疗补助计划所没有的。联邦平价立法对许多SCHIP项目尤其重要，因为这些州通过对受新法律直接影响的私人保险计划的行为健康福利进行基准测试来满足联邦SCHIP福利要求。因此，新的立法创造了一个自然的实验，有效地诱导了福利设计的变化，并可能改变一些SCHIP项目中行为健康服务的管理，而其他不以这种方式衡量福利的项目则保持不变。2009年2月，重新授权SCHIP进一步加强了这项立法对获得药物滥用和精神健康服务的影响，因为它扩大了方案的范围，增加了资金，而且它要求平等。我们建议利用新的联邦平价立法带来的变化来实现三个目标。1)研究SCHIP项目如何改变行为健康福利设计和管理方法，以应对平价立法引起的基准计划的变化；2)在实施新的联邦平价立法后，估计受影响州可能参加SCHIP的儿童行为健康服务（目标2）的覆盖面、利用率和自付支出的变化。我们将通过收集法律变更前后各州SCHIP项目的福利设计和管理特征的主要数据来实现这些目标（目标1）。其次，我们将在法律变更生效前和法律变更后12个月对3至17岁儿童的药物滥用和心理健康服务使用情况及其相关结果进行调查（目标2）。我们将使用适当的面板数据方法来分析这些新数据，以解释对个体的重复观察，并使用估计策略，如计数数据的广义泊松或负二项模型和广义线性模型来解决经常高度倾斜的支出数据。

The recent passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which requires private health plans to provide equal coverage of behavioral and medical/surgical services, also known as parity, represents an important step in the expansion of access to substance abuse and mental health treatment. The new law will create an opportunity for new funding for behavioral health services, and it will likely launch a significant restructuring of private and public insurance coverage for behavioral health treatments. In fact, the new legislation may have its largest public health impact through its indirect influence on the State Children’s Health Insurance Program (SCHIP), public health insurance coverage for children under 20 not income-eligible for Medicaid. SCHIP enrollees suffer behavioral health problems at higher rates than in the overall child population, like their counterparts on Medicaid. However, SCHIP programs tend to limit coverage of behavioral health treatment through visit/day limits, high co-payments, coinsurance, and deductibles in ways that Medicaid programs do not. Federal parity legislation is especially significant for many SCHIP programs because these states meet federal SCHIP benefit requirements by benchmarking behavioral health benefits against private insurance plans directly affected by the new law. Thus, the new legislation creates a natural experiment by effectively inducing changes in benefit design, and likely changes in the management of behavioral health services in some SCHIP programs, while leaving other programs that do not benchmark benefits in this way unchanged. The effect of this legislation on access to substance abuse and mental health services was further strengthened by the reauthorization of SCHIP in February of 2009, both because it expands the scope of the program with additional funding, and because it requires parity. We propose to exploit the variation created by new federal parity legislation to pursue three aims. 1) to examine how SCHIP programs change behavioral health benefit design and management approaches in response to changes in benchmark plans induced by parity legislation; and 2) to estimate changes in SCHIP coverage, utilization and out of pocket spending for child behavioral health services (Aim 2) among likely SCHIP enrollees in affected states following the implementation of new federal parity legislation. We will pursue these aims with primary data collection regarding benefit design and management features of state SCHIP programs before and after the law change (Aim 1). Second, we will survey parents regarding substance abuse and mental health service use and related outcomes among children aged 3 to 17 before the law change takes effect and 12 months after the law change (Aim 2). We will analyze these new data using appropriate panel data methods to account for repeated observations on individuals, and using estimation strategies such as generalized Poisson or negative binomial models for count data and generalized linear models to address spending data, which are often highly skewed.