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Finance & Value

Changes In Mental Health Financing Since 1971: Implications For Policymakers And Patients

Abstract

 
The aggregate share that total mental health spending claims of national income has been stable over the past thirty-five years. This stability is a consequence of immense change—new organizational technologies, new treatment technologies, and a growing supply of providers. Aggregate spending stability has been accompanied by major shifts in the composition of financing, which have tended to spread the costs of mental illness more broadly but also have led to fragmentation in public responsibility for people with mental illnesses. Recent developments suggest that financing could be further constrained in the future, even as fragmentation continues to increase.

We anticipate that shifts in financing will continue, which may contribute to even more policy fragmentation, a continuing lack of stewardship for mental health policy, and constraints on aggregate spending that could reduce the well-being of people with mental illnesses.

Spending On Mental Health Services

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According to recent estimates, the United States spent about $85.4 billion on mental health care in 2001.² That spending constituted about 6 percent of the nation’s total health spending and accounted for about 0.84 percent of U.S. gross domestic product (GDP). Tami Mark and colleagues recently showed that mental health spending grew more slowly than general health spending over the 1991–2001 period.³

The relatively slow growth rate of mental health spending since the mid-1990s is a continuation of a trend that has been evident since the 1970s. A useful point of comparison is a comprehensive set of estimates of mental health spending made in 1971. This comparison is complicated, because the range of diagnoses treated as mental health–related and the scope of services included in the estimates have changed over time.⁴ We adjusted the 1971 estimates to make them more comparable to the current figures.⁵ Using these adjusted estimates, we found that in 1971 the country spent an estimated $8.96 billion on mental health care and that mental health care accounted for nearly twice as large a share of overall health spending as in 2001, 11.1 percent.⁶ Total mental health spending made up about 0.84 percent of GDP in 1971. In contrast to the rising share of overall health care in national income, mental health spending’s share of GDP has remained virtually constant.⁷ Indeed, U.S. spending on mental health care as a share of national income is consistent with the pattern in Canada and lower than the corresponding share in the United Kingdom—a sharp contrast to U.S. general health care spending.⁸

This stability in aggregate spending as a share of income contrasts sharply with three key trends. First, the rate of use of mental health services in the noninstitutionalized population has risen: The number of Americans receiving some type of mental health care has increased by about 50 percent since 1977.⁹ Second, consistent with this increase, noninstitutional spending on mental health services has also increased.¹⁰ Third, state and federal policymakers point to out-of-control mental health spending as a critical factor in their budget woes. The differences between the aggregate data, patterns of service use, and policymakers’ perceptions reflect the way in which mental health care’s unchanging share of GDP masks profound changes in the nature of mental health service delivery and the composition of mental health care financing throughout this period.

The Dog That Didn’t Bark

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Rising general health care costs generate intense policy attention, but, as several researchers have argued, cost increases are driven by improvements in technology that have made Americans, on balance, better off.¹¹ It is therefore natural to ask: Does the flat GDP share of mental health spending over thirty years signify an absolute or relative deterioration in the well-being of people with mental health problems? That depends on how the lower rates of spending growth have been achieved. In this case, stability reflects the introduction of new forms of social insurance, organizational technologies, and treatment technologies.

New forms of social insurance. The 1971 mental health system continued to rely heavily on institutional care. An estimated 433,000 people with mental illnesses were hospitalized that year.¹² These institutions provided total care—health, mental health, room, and board. The mental health system today is mainly community-based. In 2000, only 170,000 people with mental illnesses were in such institutions.¹³

As has been widely documented, moving people out of institutions reduced some mental health service costs and shifted others from state mental health authorities (SMHAs) to insurance-financing mechanisms. This shift, however, depended not only on the availability of financing for community-based care, but also on the availability of financing for community-based living. The introduction of the Supplemental Security Income (SSI) program in 1972 and expansions of the Social Security Disability Insurance (SSDI) program in the 1970s provided this new source of financing. By 1999, we estimate that about 1.3 million people with serious mental illnesses were enrolled in each of these programs.¹⁴

The shift to community-based care altered the institutions that served people with mental illnesses, changed how we paid for different components of care, and affected how mental health spending is defined and measured. Community-based housing and other services do not appear in our estimates of national mental health spending. The decline in institutionalization of people with severe mental illnesses changed the financing for non–mental health resources devoted to people with serious mental illnesses. It shifted a set of services, which were previously bundled into the costs of long-term institutional care (housing and board) and counted as part of health care spending, into a class of services that were now outside the health accounts framework and thus no longer counted as mental health spending. This change in measured mental health spending, however, might reflect a decline neither in public spending and services purchased on behalf of this group nor the well-being of people with severe mental disorders.

New organizational technologies. The development and spread of the behavioral health carve-outs in the early 1990s created a new rationing mechanism in mental health. MBHOs have become the dominant institution in controlling use of and spending on mental health services in the private sector, as well as in some Medicaid programs. These organizations have retained many of the features of managed care in the 1990s that contributed to slow general health cost growth during that decade: selective contracting with aggressive price negotiations, widespread utilization review, and prior authorization for costly services.

In the private sector, MBHOs substitute nonprice rationing for the high copayments typical of traditional mental health insurance contracts. This reduction in copayments led to an increase in the use of services among people with less serious mental illnesses. There is less consensus about the effects of MBHO rationing on the well-being of people with serious mental illnesses.¹⁵

Whatever their effects on utilization, MBHOs, like managed care in the general health sector, negotiated aggressively with providers to keep prices down. In the area of price negotiation, MBHOs had a substantial advantage over general managed care firms. Unlike the case in general health, nonphysician providers—psychologists, psychiatric nurses, and social workers—constitute an important part of the mental health workforce. Although the physician-to-population ratio has been relatively stable (even declining in some areas) over time, the supply of mental health providers has greatly increased.¹⁶ The increase in supply gives MBHOs great leverage in negotiations. Indeed, mental health care providers’ incomes fell since 1969.¹⁷

Despite the increase in the supply of mental health care providers generally, the supply of psychiatrists (who can prescribe medications) has remained relatively stable. Nonetheless, this period also saw psychiatrists’ incomes under strain.¹⁸ Changes in treatment technologies have made it easier for generalist physicians to prescribe psychotropic medications. The rate of diagnosis and treatment of mental health problems in primary care thus increased steadily through the 1990s, which in turn reduced psychiatrists’ bargaining power. The use of nonprice rationing allowed MBHOs to expand access and control use. At the same time, the decline in providers’ negotiating power allowed MBHOs to provide this extra access without spending much more.

New treatment technologies. The third factor contributing to this stable share in spending has been a change in the nature of mental health treatment technologies. Recent research shows that quality-adjusted prices for treatment of depression, schizophrenia, and bipolar disorder—three large areas of spending—have been declining.¹⁹ For example, the amount of spending required to gain a full remission for major depression was roughly 20 percent lower in 1996 than in 1991.²⁰ Moreover, in mental health care, unlike in general health care, treatments that were displaced by new technologies were generally not only less effective but often more expensive as well.

The price index literature suggests that stable mental health spending represents an increase in the value of real services being delivered to the U.S. population. In fact, there is evidence to suggest that growth in productivity in mental health care during the late 1980s and 1990s was greater than in general medical care.²¹ Such evidence suggests that the differences in spending growth between general health and mental health services could be overstating the differences in the quality-adjusted growth of services in the two sectors.

The Changing Structure Of Mental Health Service Financing

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The stable GDP share of mental health does not translate into a stable burden of mental health spending across payers. Rather, this stability in the aggregate has been accompanied by very large changes in the composition of financing.

The early part of this history is well known. Following its introduction in 1965, Medicaid rapidly began to dominate mental health spending, taking over the role held before 1970 by state or county mental health authorities. Between 1970 and 1980, the number of inpatient psychiatric beds in state and county hospitals fell by more than half, as cases and costs were shifted to Medicaid-reimbursable settings and consumers of care enrolled in Medicaid.²² Concurrent with the expansion of Medicaid, private insurance coverage for mental health care began to expand, prodded by state mandates. The financing of care shifted away from the venerable state and county authorities and from out-of-pocket spending by individuals, toward more broadly shared forms of financing: the public Medicaid program and private insurance.

These changes toward third-party payment and away from mental health–specific financing mechanisms have intensified and accelerated since 1980. Medicaid’s role continues to grow, but over the past two decades, Medicare has also taken on a much greater role. State and county authorities’ contributions to mental health services, by contrast, have not kept up with national income growth.

Principal financing sources for mental health. People with mental health problems mainly make use of the same financing arrangements as do those with other health problems. Medicare provides coverage to people age sixty-five and older and those with disabilities, including people disabled by mental illnesses and other beneficiaries with mental health problems. About one-fifth of noninstitutionalized people who used mental health services in 2002 held Medicare coverage. Just under one-quarter of this group were under age sixty-five and were covered by Medicare because they had a disabling mental illness that had forced them to stop working and hence qualify for SSDI. An estimated 27.4 percent of SSDI recipients are disabled by a mental illness.²³ By definition, most members of this group have severe illnesses. About one-fifth of those with mental health problems who hold Medicare coverage also hold Medicaid coverage as a supplement.

Despite the importance of Medicaid in financing mental health services, it covers a relatively small number of people who use these services. About 10 percent of people with mental health problems in 2002 reported Medicaid as their primary source of coverage. More than one-third of this group is eligible because of a disability. Medicaid provides coverage for low-income children and mothers and for people eligible because they receive SSI payments due to a disability. An estimated 35 percent of adult SSI enrollees are disabled because of a mental health problem.²⁴

Private insurance covers just over half of those with a mental health diagnosis. Most in this group are not too disabled to work. Finally, about 20 percent of people with mental health problems are uninsured or hold other forms of coverage, a proportion that has held steady since 1996.

Mental health financing also includes direct funding of services, where state funds flow to providers rather than through insurance provided to individuals.²⁵ States have historically paid a large share of mental health spending through the budgeted SMHA system. These budgets, which place binding annual constraints on spending, accounted for 30 percent of all mental health spending in 1971.

Trends in the composition of financing, 1971–2001. Two key trends about the changing sources of payment are our focus here. First is the continued expansion of public spending’s share of total mental health spending, with Medicaid rising to 27.4 percent in 2001 from 16.2 percent in 1971 and Medicare rising from 2.6 percent to 7.3 percent (Exhibit 1). Second is the diminished relative role of direct state spending through SMHAs, which fell from nearly 30 percent of spending in 1971 to about 23 percent in 2001. These figures reflect substantial changes in the levels of spending by the various payers, after overall economic growth is adjusted for. Between 1971 and 1991, Medicare and private payers greatly increased their spending on mental health services, measured as a share of national income, while state and out-of-pocket spending fell sharply and Medicaid remained relatively flat (Exhibit 2). Between 1991 and 2001, Medicaid spending rose very rapidly, consistent with the dire reports of state budget officials; Medicare spending grew about 10 percent relative to income; private spending was stable; and state and out-of-pocket spending fell sharply again.

View larger version (23K): [in this window] [in a new window] EXHIBIT 2 Spending On Mental Health, By Source, As A Share Of Gross Domestic Product (GDP), 1971, 1991, And 2001

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The expansion of social insurance, which, as noted earlier, affected aggregate estimates of spending, also contributed to these compositional changes. The increase in Medicare-covered service users (and the smaller concurrent increase in the share of Medicaid-covered service users) stems from massive increases in the size of the disabled population receiving public income support over this period. Sharp increases in SSI enrollment during the late 1980s and through 1995 translated into increases in the Medicaid share of spending over this period (Exhibit 3). The analogous increases in SSDI enrollment since 1990, continuing through 2003, have led to greater Medicare enrollment of people with mental health problems and contributed to Medicare’s growing share in overall financing.

View larger version (25K): [in this window] [in a new window] EXHIBIT 3 Growth In Supplemental Security Income (SSI) And Social Security Disability Income (SSDI) Enrollment And The U.S. Population, 1975–2003

Looking Forward: Fragmentation, Prioritization, And State Cost Constraints

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Growing Medicare and Medicaid spending both imply a greater federal role in the financing of health services, directly in the case of Medicare and through federal match contributions in Medicaid. This pattern has the positive consequence that the costs of mental health care are being spread very broadly, through the federal payroll and income taxes that finance federal spending.

On the other hand, the federal government has no institutional expertise in addressing the needs of people with mental health problems. Medicare, for example, does not provide coverage for innovative and effective forms of mental health treatment, such as assertive community treatment.²⁹ Medicare’s general lack of benefit flexibility makes it a poor fit for mental health treatment, where innovation often requires collaboration among and financing of many different types of providers and modalities of care.³⁰

The most dramatic change has been the phenomenal growth in Medicaid’s share of mental health spending since 1991 (Exhibit 1), an increase echoed by the data on hospital spending in Exhibit 4. This growth cannot be attributed entirely to an increase in the number of people with serious mental illnesses enrolled in SSI. The share of mental health service users increased just one percentage point between 1996 and 2002, the same amount by which overall Medicaid coverage increased. Nor can it be attributed to MBHOs, which exist in both the private and public sectors. Finally, the change in Medicaid’s spending does not reflect changes in treatment technologies. Rather, the marked shift in Medicaid’s share primarily reflects strategic use of the program by state policymakers, particularly in a few states.

The increasing dominance of Medicaid as the driver of spending increases for the public mental health system holds consequences that are similar to those associated with the growth of Medicare. The increase in Medicaid spending has constrained state mental health policymakers’ flexibility to allocate resources to serve the full range of mental health needs in poor and disadvantaged populations, in terms of both the populations that may be served and the services that may be reimbursed. The reliance on Medicaid funding has shifted the focus of state mental health authorities toward Medicaid-eligible populations: poor women and children and those disabled by mental illnesses (SSI recipients). This could displace states’ resources that might otherwise be directed toward the sizable number of people with severe mental disorders who do not qualify for SSI or Temporary Assistance for Needy Families (TANF) and the even larger number of people with other disabling mental health problems.³¹

Cost constraint through state budget control. The increase in Medicaid’s share of mental health spending since 1991 primarily reflects strategic decisions that have led to a great change in the method of financing a relatively constant mix of services delivered to a relatively stable population. These strategic decisions echo earlier efforts to manipulate Medicaid spending and exploit legislative loopholes in both the mental health and general health sectors.³² Most recently, however, strategic efforts in financing mental health services have put major constraints on the overall growth of the system. Although our evaluation of the stability of mental health spending in the past suggests that it has been accompanied by improvements in the well-being of people with mental illnesses, the most recent shifts leave us less sanguine about future spending growth.

Medicaid spent $23.4 billion on mental health services in 2001. Mental health services financed through Medicaid dollars include the familiar general hospitals, physicians’ offices, private psychiatric hospitals, and prescription drugs. This spending accounts for a little less than two-thirds of total Medicaid mental health spending, and these funds, like most other Medicaid spending, are typically controlled and disbursed under the auspices of state Medicaid programs.

But Medicaid also finances care provided to its beneficiaries through each state’s public mental health system. The state funds used to finance this Medicaid care are tied to the SMHA. The National Association of State Mental Health Program Directors (NASMHPD) reports that about $9.6 billion of Medicaid spending in 2002—about 38 percent of all Medicaid mental health spending that year—was spent on services controlled by SMHAs.³³

State Medicaid spending—and the federal-match dollars that accompany it—channeled through the SMHA, supplements general revenues allocated to the authorities. Exhibit 5 reports data on SMHA spending of Medicaid and state general revenue funds (the two main sources of SMHA spending).³⁴ The composition of SMHA budgets has increasingly shifted toward Medicaid spending. In nominal terms, state general fund allocations to SMHAs rose 22.7 percent from 1997 to 2002, while Medicaid spending through the authorities rose 95.9 percent.

At least that was the story to date. The latest change in mental health financing, however, places major controls on that growth. State governments have increasingly adopted rules requiring that the state match for Medicaid services delivered by specialty mental health providers that participate in the public mental health system be counted as part of the SMHA budget. This formulation means that Medicaid increasingly substitutes for SMHA funds, instead of supplementing them as in the past. As state budget pressures from Medicaid spending have risen, some states have even adopted policies where the only increases in general-fund allocations are those arising from matching requirements (for example, Missouri’s budget).³⁵

To date, these negative consequences have largely existed in theory and not in reality. The availability of Medicaid has led states to spend more on mental health care in aggregate—more on services outside the purview of the SMHA as well as more on services managed by the authority. The availability of federal matching funds has effectively reduced the price of state mental health services and encouraged states to expand their availability.

Future spending patterns. This pattern might not hold in the future. If, over the next five years, mental health spending in Medicaid continues to grow relative to overall Medicaid spending as it has for the for the past five years, SMHAs could see their general funds disappear and their budgets increasingly absorbed by general-fund allocations for the state Medicaid match. Exhibit 6 reports some simple projections based on a Medicaid mental health spending growth rate that is two percentage points above the overall Medicaid spending growth rate (lower than the rate estimated for 1996–2001).³⁶ These projections show an expected 46.6 percent rise in Medicaid mental health spending to nearly $36 billion, and a 47.4 percent increase in matching obligations for SMHA budgets. This growth in matching obligations exceeds the growth rate in general fund allocations to SMHAs for all purposes (39.7 percent) and for non-Medicaid activities (22.8 percent) during 1997–2002. The likely implication is that the response to this growing obligation is to further constrain the growth in general funds for SMHAs for purposes other than the Medicaid match. Other states are likely to follow Missouri’s lead and constrain SMHA budgets to the growth in matching rates.

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Editor's Notes

 
Richard Frank is the Margaret T. Morris Professor of Health Economics in the Department of Health Care Policy, Harvard University, in Cambridge, Massachusetts. Sherry Glied (Sag1{at}columbia.edu) is professor and chair, Department of Health Policy and Management, at Columbia University in New York City.

The authors are grateful to the John D. and Catherine T. MacArthur Foundation for financial supportof this research.

NOTES

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1. R. Frank and S. Glied, Better but Not Well: Mental Health Policy in the United States since 1950 (Baltimore, Md.: Johns Hopkins University Press, forthcoming).
2. Substance Abuse and Mental Health Services Administration, National Estimates of Expenditures for Mental Health and Substance Abuse Treatment, 1991–2001, Pub. no. SMA 05-3999 (Rockville, Md.: SAMHSA, 2005).
3. T.L. Mark et al., "U.S. Spending for Mental Health and Substance Abuse Treatment, 1991–2001," Health Affairs 24 (2005): w133–w142 (published online 29 March 2005; 10.1377/hlthaff.w5.133).[CrossRef]
4. U.S. Department of Health and Human Services, The Cost of Mental Illness—1971, Pub. no. 76–265 (Washington: U.S. Government Printing Office, 1975).
5. See Appendix 1, available online at http://content.healthaffairs.org/cgi/content/full/25/3/601/DC1.
6. DHHS, The Cost of Mental Illness—1971.
7. Bureau of Economic Analysis, "Interactive Access to National Income and Product Accounts Tables," January 2006, http://www.bea.gov/bea/dn/nipaweb/index.asp (accessed 27 January 2006).
8. J.E. Triplett, "What’s Different about Health? Human Repair and Car Repair in National Accounts and National Health Accounts," in Medical Care Output and Productivity, ed. D.M. Cutler and E.R. Berndt (Chicago: University of Chicago Press, 2001), 15–94.
9. Frank and Glied, Better but Not Well.
10. S.H. Zuvekas, "Trends in Mental Health Services Use and Spending, 1987–1996," Health Affairs 20, no. 2 (2001): 214–224.[Free Full Text]
11. D.M. Cutler and M. McClellan, "Is Technological Change in Medicine Worth It?" Health Affairs 20, no. 5 (2001): 11–29.[Abstract/Free Full Text]
12. See Appendix 2, online at http://content.healthaffairs.org/cgi/content/full/25/3/601/DC1.
13. Ibid.
14. Social Security Administration, Annual Statistical Supplement, 2000, Table 7.F1, December 2000, http://www.ssa.gov/policy/docs/statcomps/supplement/2000/7f.pdf (accessed 26 January 2006); and Annual Statistical Report on the Social Security Disability Insurance Program, 2003, Table 21, August 2004, http://www.ssa.gov/policy/docs/statcomps/di_asr/2003/sect01c.pdf (accessed 26 January 2006).
15. R.G. Frank and J.R. Lave, "Economics," in Managed Behavioral Health Services, ed. S. Feldman (Springfield, Ill.: Charles C. Thomas Publisher, 2003), 146–165.
16. R.M. Scheffler and P.B. Kirby, "The Occupational Transformation of the Mental Health System," Health Affairs 22, no. 5 (2003): 177–188.[Abstract/Free Full Text]
17. Frank and Glied, Better but Not Well.
18. R.M. Scheffler, S.L. Ivey, and A.B. Garrett, "Changing Supply and Earning Patterns of the Mental Health Workforce," Administration and Policy in Mental Health 26, no. 2 (1998): 85–99.[CrossRef][Web of Science][Medline]
19. E.R. Berndt et al., "Real Output in Mental Health Care during the 1990s," NBER Working Paper no. 11557 (Cambridge, Mass.: National Bureau of Economic Research, 2005).
20. E.R. Berndt et al., "The Medical Treatment of Depression, 1991–1996: Productive Inefficiency, Expected Outcome Variations, and Price Indexes," Journal of Health Economics 21, no. 3 (2002): 373–396.[CrossRef][Web of Science][Medline]
21. Berndt et al., "Real Output in Mental Health Care."
22. SAMHSA , Mental Health, United States, 2002, Pub. no. SMA 3938 (Rockville, Md.: SAMHSA, 2004), Chap. 18, Table 2.
23. SSA, Annual Statistical Supplement, 2001, Table 5.D1, December 2001, http://www.ssa.gov/policy/docs/statcomps/supplement/2001/5d.pdf (accessed 26 January 2006).
24. Ibid., Table 7.F1, http://www.ssa.gov/policy/docs/statcomps/supplement/2001/7f.pdf (accessed 26 January 2006).
25. See R.G. Frank and T.G. McGuire, "Economics and Mental Health," in The Handbook of Health Economics, ed. A.J. Culyer and J.P. Newhouse (Amsterdam: North Holland, 2000), 893–954.
26. U.S. Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2004, Pub. no. P60–229 (Washington: U.S. GPO, 2005), Table C-1.
27. Tabulations from the Medical Expenditure Panel Survey (MEPS), 1996 and 2002.
28. J.R. Lave, "Developing a Medicare Prospective Payment System for Inpatient Psychiatric Care," Health Affairs 22, no. 5 (2003): 97–109.[Abstract/Free Full Text]
29. S.M. Foote and C. Hogan, "Disability Profile and Health Care Costs of Medicare Beneficiaries under Age Sixty-five," Health Affairs 20, no. 6 (2001): 242–253.[Abstract/Free Full Text]
30. L.D. Brown and M.S. Sparer, "Poor Program’s Progress: The Unanticipated Politics of Medicaid Policy," Health Affairs 22, no. 1 (2003): 31–44.[Abstract/Free Full Text]
31. See R.G. Frank, H.H. Goldman, and M. Hogan, "Medicaid and Mental Health: Be Careful What You Ask For," Health Affairs 22, no. 1 (2003): 101–113.[Abstract/Free Full Text]
32. Brown and Sparer, "Poor Program’s Progress."
33. This estimate was made by applying the average annual growth rate in mental health spending for 1996–2001 to the 2001 estimates to obtain an estimate for 2002.
34. For example, the $15 billion reported in Exhibit 5 for 1997 represents 89.3 percent of SMHA spending.
35. SAMHSA, National Estimates; and Ted Lutterman, director of data analysis, National Association of State Mental Health Program Directors (NASMHPD) Research Institute, personal communication, October 2005.
36. SAMHSA, National Estimates.

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