A. Bowen Garrett

Changing supply and earning patterns of the mental health workforce.

The authors examine recent trends in the supply and earnings of various mental health providers from 1989 to 1995. The makeup of the mental health workforce is fundamentally different now than a decade ago. The number and earnings of psychiatrists have been relatively flat. The number of psychologists increased by 24%, with their earnings rising rapidly in the 1980s, and remaining level since 1990. The number of clinically trained social workers increased by 87% over the same period, and the number of advanced practice nurses certified in mental health specialties almost doubled, with the earnings of these masters-level providers increasing steadily over the period described. These trends are discussed in the context of major changes in the financing and delivery of mental health care.

Child Outpatient Mental Health Service Use: Why Doesn't Insurance Matter?

BACKGROUND: Several recent studies of child outpatient mental health service use in the US have shown that having private insurance has no effect on the propensity to use services. Some studies also find that public coverage has no beneficial effect relative to no insurance. AIMS: This study explores several potential explanations, including inadequate measurement of mental health status, bandwagon effects, unobservable heterogeneity and public sector substitution for private services, for the lack of an effect of private insurance on service use. METHODS: We use secondary analysis of data from the three mainland US sites of NIMHs 1992 field trial of the Cooperative Agreement for Methodological Research for Multi-Site Surveys of Mental Disorders in Child and Adolescent Populations (MECA) Study. We examine whether or not a subject used any mental health service, school-based mental health services or outpatient mental health services, and the number of outpatient visits among users. We also examine use of general medical services as a check on our results. We conduct regression analysis; instrumental variables analysis, using instruments based on employment and parental history of mental health problems to identify insurance choice, and bivariate probit analysis to examine multiservice use. RESULTS: We find evidence that children with private health insurance have fewer observable (measured) mental health problems. They also appear to have a lower unobservable (latent) propensity to use mental health services than do children without coverage and those with Medicaid coverage. Unobserved differences in mental health status that relate to insurance choice are found to contribute to the absence of a positive effect for private insurance relative to no coverage in service use regressions. We find no evidence to suggest that differences in attitudes or differences in service availability in childrens census tracts of residence explain the non-effect of insurance. Finally, we find that the lack of a difference is not a consequence of substitution of school-based for office-based services. School-based and office-based specialty mental health services are complements rather than substitutes. School-based services are used by the same children who use office-based services, even after controlling for mental health status. DISCUSSION: Our results are consistent with at least two explanations. First, limits on coverage under private insurance may discourage families who anticipate a need for child mental health services from purchasing such insurance. Second, publicly funded services may be readily available substitutes for private services, so that lack of insurance is not a barrier to adequate care. Despite the richness of data in the MECA dataset, cross-sectional data based on epidemiological surveys do not appear to be sufficient to fully understand the surprising result that insurance does not enable access to care. IMPLICATIONS FOR POLICY AND RESEARCH: Limits on coverage under private mental health insurance combined with a relatively extensive system of public mental health coverage have apparently generated a situation where there is no observed advantage to the marginal family of obtaining private mental health insurance coverage. Further research using longitudinal data is needed to better understand the nature of selection in the child mental health insurance market. Further research using better measures of the nature of treatment provided in different settings is needed to better understand how the private and public mental health systems operate.

Measuring Child Mental Health Status for Services Research

Epidemiological studies of the prevalence of mental health disorders typically contain multiple measures of mental health, using different instruments and different informants (child, parent, and interviewer). We used the Methods for the Epidemiology of Child and Adolescents Mental Disorder (MECA) study of U.S. youth to assess the effects of employing a range of these measures in mental health services research. We examined the effect of including various measures of mental health status in regressions of income on mental health service use. The estimated effect of income on service use varied widely, depending on the measure of mental health status used. Some measures of mental health status have little explanatory power in service use regressions. Measures of mental health status based on parental assessment of impairment or need, such as the Columbia Impairment Scale, are less costly to collect and also have good explanatory power, but are more strongly correlated with income. The Non-Clinician Child Global Assessment Scale (NC-CGAS) performs best in terms of explanatory power and correlation with income. Higher income parents appeared to judge behaviors differently from lower income parents, so analyses based on measures derived from parental report may lead to an understatement of the effect of income on service use.

Health Insurance and Labor Markets: Concepts, Open Questions, and Data Needs

This paper reviews the recent economic research on the relationship between health insurance and labor markets in the United States, with an emphasis on research that has emerged since existing major reviews and the aim of identifying the types of data that are needed for this research to progress. We focus on the conceptual and empirical challenges that researchers face in studying these relationships, the data that have allowed this research to proceed, policy-relevant questions that need further study, and the types of data that would help in obtaining better answers to these questions.