Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Mental health and substance use disorders affect millions of Americans, leading to substantial health care expenditures, productivity losses, and family disruption. This session examines recent trends in the financing and delivery of mental health treatment and its implications for patient care and access to treatment. The first paper examines the determinants of closures in private and public psychiatric hospitals between 1995 and 2004. The 40 percent decline in private hospitals and 15 percent decline in public hospitals have the potential to reduce access to care and decrease societal welfare if undertaken for the sole purpose of reducing costs. But these closures also create the potential to improve patient care and enhance welfare if resources are shifted appropriately to community-based services. The second paper uses a quasi-experimental difference-in-difference design to examine the impact of a unique managed competition program initiated in 2004-05 on seven Adult and Older Adult Mental Health Services (AOAMHS) outpatient and case management programs located in San Diego County. Using program and person-level analyses, the study determines the extent to which hypothesized cost decreases were achieved through a change in the mix of services, reduced services, or reduced costs per service. The last paper in the session examines out-of-pocket burdens and, uniquely, how these burdens vary across time and the extent to which high spending coincides with dips in income and loss of insurance coverage. Spikes in spending and associated loss of income and insurance coverage are likely to be particularly burdensome for lower-income families who have fewer assets to smooth out shocks.