Our findings suggest that the FEHB parity policy did not substantially expand children’s access to MH/SA services. Observed increases in the likelihood of MH/SA service use for 6 of the 7 FEHB plans were on par with that in other large, privately insured plans and not attributable to the parity policy. As was the case for adults in the FEHB plans, the 1 plan (Mid-Atlantic 2) experiencing a statistically significant increase in children’s MH/SA service use beyond that attributable to the secular trend was the only plan that did not carve out MH/SA care to a managed care company.2
Likewise, the findings offer no evidence of MH/SA spending increases attributable to the parity policy. Instead, when secular trends were taken into account, spending by child service users decreased significantly in 2 of 7 plans and showed no statistically significant change in the other 5. Although all 7 of the plans experienced spending growth after implementation of the parity policy, this growth was because of secular trends. A similar spending pattern was found previously for adult FEHB service users.2
Insofar as we found few statistically significant differences in the probability of children’s MH/SA service use or spending that could be attributed to the FEHB parity policy, our results are “negative.” The large sample sizes and small magnitude of estimated differences between FEHB and comparison plan enrollees strongly suggest little or no impact of the parity policy on children’s MH/SA use and spending rather than insufficient statistical power to detect impacts of the policy.
Our findings support the hypothesis that parity can, in some instances, reduce out-of-pocket spending for children using MH/SA services, increasing financial protection. Three of 7 plans showed statistically significant decreases in out-of-pocket costs for child MH/SA service users, and for users in those 3 plans the average dollar amount of savings was sizeable. Although FEHB adult MH/SA service users in 5 of the 7 plans experienced statistically significant decreases in out-of-pocket spending attributable to the parity policy, these decreases were smaller in magnitude than those for children in the same plan.
Our study had several limitations. First, with quasiexperimental studies there is a risk of nonequivalence of intervention and comparison groups, particularly in time trends over a longer period before parity. However, the consistency of key findings across multiple matched sets of plans is reassuring, and plan variations in out-of-pocket spending are interpretable. Second, MH/SA diagnoses may be underreported in claims data yielding an underestimate of MH/SA service use and spending. To address this issue, we used multiple methods of identifying MH/SA use, including an MH/SA-specific procedure code, indication of a face-to-face encounter with an MH/SA provider, and indication of an MH/SA-specific place of service. Third, the analysis involved only 7 of the FEHB plans, all PPOs, potentially limiting the generalizability of the findings. However, these 7 plans used different managed care arrangements and had >3 million FEHB beneficiaries across the United States. Fourth, to avoid confounding the effect of changing enrollment with the effect of the FEHB parity policy, we excluded children who were not enrolled continuously throughout the study period, which may limit the generalizability of our findings. We also excluded children who were >15 years of age at study start (and, thus, not >18 years of age throughout the 4-year study period), so our study may underrepresent older teens. Fifth, for the 6 plans in which FEHB parity implementation was accompanied by adoption of a carve-out arrangement, the design did not permit us to disentangle the effects of parity and carve-out status. Finally, using 2 years of data after parity implementation, we are unable to examine the longer-term effects of parity on spending and use. It is possible, for example, that after the 2-year follow-up period, families would become more familiar with their parity benefits and, consequently, service use by children would increase.
The relatively small proportion (13%–18%) of adolescents comprising our child sample and the exclusion of adolescents over age 15 years at study start may have contributed to the finding of limited impact of the FEHB parity policy on children’s MH/SA use and spending. The literature suggests that adolescents are more likely than younger children to use inpatient and outpatient MH/SA care and so benefit more from the removal of coverage limits.10