Research on Child and Adolescent Mental Health

make comprehensive estimates difficult to obtain
(Hoagwood and Rupp, 1994). In addition to private
insurance and public treatment settings, some
mental health services are delivered and paid for by
the education, child welfare, and juvenile justice
sectors. Social services are major sources of services
for children but are not part of the National Health
Accounts (NHA), the best known summary of
annual health care costs
(http://www.hcfa.gov/stats/NHE-Proj/; Levit et al.,
2000).
The 1986 Office of Technology Assessment (OTA)
report on Children’s Mental Health Problems and
Services conjectured that “federal and private
sources currently bear less of a burden” but
warned that there are no data to support a firm
conclusion: “In the case of Medicaid, for example,
the only mental health expenditure known is that
of mental hospitals. Private third-party payers
prefer not to disclose what they pay for mental
health services and the amount actually spent by
clients themselves is not known. The proportion
of costs specifically for children’s mental health
treatment is even more difficult to determine”
(p. 132).
A later OTA report on adolescents (1991) provided
utilization estimates for specific services based on
several different databases (National Ambulatory
Care Survey, National Health Interview Survey,
Inventory of Mental Health Organization, some
secondary sources) but cautioned that “these
estimates from varying sources do not allow an
overall estimate of mental health services
utilization by adolescents” (p.457). An
unpublished background paper by Burns, Taube,
and Taube cited in the report gave total estimates
for U.S. adolescents in 1986 at $3.5 billion (see
also Burns, 1991). Of this, 46 percent was
attributed to hospital inpatient care, 28 percent to
residential treatment centers, and 26 percent to
outpatient care.
BACKGROUND ON HEALTH SPENDING AND
UTILIZATION ESTIMATES
Since 1964, the U.S. Department of Health and
Human Services has published an annual series of
statistics presenting total national health
expenditures during each year. The aim of these
National Health Accounts (NHAs) is to identify all
goods and services that can be characterized as
relating to health care in the nation and
determine the amount of money used for the
purchase of these goods and services. The NHA
framework is a matrix of operational categories
classifying sources of health care dollars and
services purchased with these funds (HCFA,
various years). The NHA recognize several types
of spending, including "personal health care,"
"government public health activity," "program
administration," and "research and construction."
In 1997, national health expenditures were
estimated at $1,092.4 billion (13.5% of GDP and
$3927 per capita) and expected to grow to
$1,316.2 billion (14.3% of GDP and 4,611 per
capita) by 2000. Most of the expenditures are for
personal health care, broken down by type of
expenditure and payer. For the purposes of this
project, we are concerned only with personal
health care, not the other categories, even if they
relate to child mental health, such as NIMH
funded research. The NHA collects information
primarily from larger reporting units (e.g.,
hospitals) instead of trying to aggregate
individual service or patient information. The
NHA contains no information about health care
utilization (e.g., number of physician visits or
hospital days) for specific patient groups.
An ongoing project funded by the Substance Abuse
and Mental Health Services Administration
(SAMHSA) provides national estimates for mental
health and substance abuse expenditures (Mark et
al., 1998; Coffey et al., 2000). The project builds on
earlier work by Frank and Kamlet (1985), Rice et al.
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