Pete Domenici Mental Health Parity Research Articles

Eating Disorders and Our Youth: Aggressive Action Must be Taken to Ensure Parity.

Eating disorders are one of the most common chronic illnesses among adolescents. Yet, our current framework for mental health care provides limited education, access to care, and support for adolescents suffering from this disease. The enactment of key legislation and federal guidance such as thePaul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is evidence that there are steps being taken to ensure the removal of barriers to care. However, eating disorders are often overlooked as a category of behavioral disorders. This paper analyzes the current legal and social framework for providing care and support to adolescents suffering from eating disorders. In doing so, it offers recommendations to develop stronger protective and responsive measures to ensure access, support, and care to these individuals.

Mitigating the Impact of Coronavirus Disease-2019 on Child and Family Behavioral Health: Suggested Policy Approaches

Mitigating the Impact of Coronavirus Disease-2019 on Child and Family Behavioral Health: Suggested Policy Approaches

Health plans, insurers failing in delivering parity in MH, SUD benefits

A new report from the U.S. Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury finds that health plans and insurance companies are out of compliance with the federal parity law. The 2022 report on the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA), issued to Congress last week, suggests health plans and health insurance issuers are failing to provide the proper mental health (MH) and substance use disorder (SUD) benefits to those under coverage.

Parity for MH/SUD still falling short

Almost 15 years after the law passed requiring that substance use disorders and mental illness be covered by insurance on par with other disorders, it's still not happening. Last week, the federal Departments of Labor, Health and Human Services (HHS) and the Treasury issued their 2022 Report to Congress on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. The report says that insurance companies are still failing to meet the requirements of the law and the agencies' implementing regulations requiring that mental health and substance use disorder benefits be covered at parity with medical and surgical benefits.

Mental Health Parity and Addiction Equity Act and the Use of Outpatient Behavioral Health Services in the United States, 2005-2016.

Objectives. To assess the impact of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) on mental and substance use disorder services in the private, large group employer-sponsored insurance market in the United States. Methods. We analyzed data from the IBM MarketScan Commercial Database from January 2005 through September 2015 by using population-level interrupted time series regressions to determine whether parity implementation was associated with utilization and spending outcomes. Results. MHPAEA had significant positive associations with utilization of mental and substance use disorder outpatient services. A spending decomposition analysis indicated that increases in utilization were the primary drivers of increases in spending associated with MHPAEA. Analyses of opioid use disorder and nonopioid substance use disorder services found that associations with utilization and spending were not attributable only to increases in treatment of opioid use disorder. Conclusions. MHPAEA is positively associated with utilization of outpatient mental and substance use disorder services for Americans covered by large group employer-sponsored insurance. Public Health Implications. These trends continued over the 5-year post-MHPAEA period, underscoring the long-term relationship between this policy change and utilization of behavioral health services.

PUBLIC POLICY Session 4: TEN YEARS SINCE THE FEDERAL PARITY LAW: WHAT NEXT IS NEEDED: Session 315

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (the Federal Parity Law) requires that insurers treat illnesses of the brain the same way that they treat illnesses of the body. However, ten years later many individuals, including older adults, are needing to pay more out of pocket to obtain treatment for illnesses of the brain. The Carter Center Mental Health Program in collaboration with The Morehouse School of Medicine/ Kennedy-Satcher Center for Mental Health Equity and The Kennedy Forum are taking action aimed at improving regulatory and enforcement activity in order to advance the goals of parity.

Targeted Reforms in Health Care Financing to Improve the Care of Adolescents and Young Adults

Significant changes have occurred in the commercial and government insurance marketplace after the passage of 2 federal legislation acts, the Patient Protection and Affordable Care Act of 2010 and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Despite the potential these 2 acts held to improve the health care of adolescents and young adults (AYAs), including the financing of care, there are barriers to achieving this goal. In the first quarter of 2016, 13.7% of individuals 18 to 24 years of age still lacked health insurance. Limitations in the scope of benefits coverage and inadequate provider payment can curtail access to health care for AYAs, particularly care related to sexual and reproductive health and mental and behavioral health. Some health plans impose financial barriers to access because they require families to absorb high cost-sharing expenses (eg, deductibles, copayments, and coinsurance). Finally, challenges of confidentiality inherent in the billing and insurance claim practices of some health insurance plans can discourage access to health care in the absence of other obstacles and interfere with provision of confidential care. This policy statement summarizes the current state of impediments that AYA, including those with special health care needs, face in accessing timely and appropriate health care and that providers face in serving these patients. These impediments include limited scope of benefits, high cost sharing, inadequate provider payment, and insufficient confidentiality protections. With this statement, we aim to improve both access to health care by AYAs and providers' delivery of developmentally appropriate health care for these patients through the presentation of an overview of the issues, specific recommendations for reform of health care financing for AYAs, and practical actions that pediatricians and other providers can take to advocate for appropriate payments for providing health care to AYAs.

Mental Health News: How Frames Influence Support for Policy and Civic Engagement Intentions

Depression accounts for nearly 400 million disability days per year, and has been identified as the definitive public health priority in the decades to come (Greenberg et al., 2015). Despite the passage of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which requires coverage of mental health services, behavioral health and substance-use disorders to be equal to physical health coverage, individuals face numerous barriers when seeking help for depression. This research tests whether changing the way stories frame depression affects how audience members attribute responsibility for depression and their intentions to participate in civic engagement activities supporting policy solutions. Findings from this study contradict earlier scholarship and have implications for how information about depression and policy solutions are framed for the public including how to develop health policy messaging when working with the news media. Suggestions for future research are included.

The Devil Is in the Details: Contracting With Managed Care

The Devil Is in the Details: Contracting With Managed Care

Was federal parity associated with changes in Out-of-network mental health care use and spending?

BackgroundThe goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act is to eliminate differences in insurance coverage between behavioral health and general medical care. The law requires out-of-network mental health benefits be equivalent to out-of-network medical/surgical benefits. Insurers were concerned this provision would lead to unsustainable increases in out-of-network related expenditures. We examined whether federal parity implementation was associated with significant increases in out-of-network mental health care use and spending.MethodsWe conducted an interrupted time series analysis using health insurance claims from self-insured employers (2007–2012). We examined changes in the probability of using out-of-network mental health services and, conditional on out-of-network mental health service use, changes in the number of outpatient out-of-network mental health visits and total out-of-network mental health spending associated with the implementation of federal parity in 2010.ResultsFrom 2007 to 2012, the proportion of individuals receiving any out-of-network mental health services each month declined dramatically from 18 to 12%, with a one-time drop of 3 percentage points at parity implementation (p < .01). Among out-of-network mental health service users, there was an increase in the number of visits per month (.12 visits; p < .01) and total spending per month ($49; p < .01) at parity implementation. Although there was a one-time increase in spending at parity implementation, this increase was accompanied by an attenuation of a trend toward increased spending growth, such that spending was back to original predictions by the end of our study period.ConclusionsDespite concerns expressed by the health insurance industry when federal parity was enacted, out-of-network mental health spending did not substantially increase after parity implementation. In addition, use of out-of-network mental health services appears to have contracted rather than expanded, suggesting insurers may have implemented other policies to curb out-of-network use, such as increasing access to in-network providers.

Increased Service Use Among Children With Autism Spectrum Disorder Associated With Mental Health Parity Law.

Health care services for children with autism spectrum disorder are often expensive and frequently not covered under private health insurance. The 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was viewed as a possible means of improving access by eliminating differences between behavioral health and medical/surgical benefits. We examined whether the legislation was associated with increased use of and spending on mental health care and functional services for children with autism spectrum disorder compared to the period prior to implementation of the law. We used nationwide health insurance commercial group claims data to examine trends in service use and spending among children with autism spectrum disorder before and after implementation of the law. For such children, implementation was associated with increased use of both mental health and non-mental health services. These increases in use were not associated with higher out-of-pocket spending, which suggests that the law improved financial protection for families.

Addiction And RedemptionA Common Struggle: A Personal Journey Through The Past And Future Of Mental Illness And Addiction By Kennedy Patrick J. Fried Stephen New York (NY) : Blue Rider Press , 2015 432 pp., $28.95

I agreed to review former congressman Patrick Kennedy’s new book, A Common Struggle (with coauthor Stephen Fried), out of respect for his many contributions to the field of behavioral health. I expected to browse the major sections and provide some respectful comments. I did not expect to be so engaged, informed, andmoved by the story. I ended up reading it cover to cover. The book reads very much like one of those movies that examines the same important event from several different perspectives. In this case, events in the former congressman’s life are examined simultaneously from three unique perspectives: a patient who has continuously suffered from physical illness (chronic pain and asthma), mental illness (attention deficit hyperactivity disorder and bipolar disorder), and substance use disorders (alcohol, cocaine, and opioids) since his early teens; a scientific historianpresenting an informed and detailed history of the major research discoveries in the behavioral health field over the past quarter-century and their impact (or lack of it) on health care; and a political insider describing thebehind-the-scenes intrigues associated with the major policy changes associated with mental illness and substance use disorder. The subject matter and the unique perspectives of the book alone make it worthwhile reading. But, in addition, the text was truly engaging and at times dramatic. Yes, part of the interest was because the protagonist is a Kennedy, but the book offers no titillating revelations. What held my interest were the remarkable and continuing contrasts and ironies throughout the book. An inescapable irony for me was the fact that Kennedy had unlimited access to the “best” doctors and medical teams to treat his illnesses—yet even the best available carewas almost never integrated or even coordinated to adequately address his mental, physical, and substance use illnesses. In the end, he has gottenbetternotbecauseof, butdespite, the care he received. The famous2006automobile accident that led to the congressman’s admission that he had long battled bipolar disorder and addiction was also a study in incongruities. First, this accident was one of the few he had that did not involve alcohol or illicit drug use but was instead caused by a serious interaction of two medications prescribed to treat his illnesses. Second, Kennedy’s public admission pierced the “secret” of his substance use that had been considered necessary to preserve his career—and the family name. Instead, revealing that secret was critical to the preservation (although not immediately) of Kennedy’s health, important legislative successes, and stable recovery with a fulfilling marital and family life. The ironic crescendo was the recounting of the period surrounding the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. This act that ultimately created far greater access to behavioral health care for Americans was created and coaxed into law by Kennedy and his father, Sen. Ted Kennedy, during a time marked by very serious episodes of mental and substance use illnesses for both of them. The resulting act might be the most important personal rights legislation since the Americans with Disabilities Act of 1990. The behind-the-scenes father-son struggle between the Kennedys over the breadth of coverage of the lawmade this part of the book particularly dramatic. There are a lot of lessons here. The first involves the limits on the prognostic ability of the field of mental health and substance use treatment.Howmany clinicians would have bet on a favorable prognosis for an early-onset case ofmultiple, chronic substance use disorders, complicated by serious physical and mental illnesses? How many employers would risk hiring a youngman with this background? How many families would want their daughter to marry a person with such a history? The second lesson is heartening for clinicians and families alike. Even severely affected individuals can triumph over daunting obstacles and potentially debilitating conditions. At this writing, Patrick Kennedy has several years of solid, stable recovery from these myriad health problems. He was and remains the youngest congressman ever “hired” (repeatedly) by the citizens of Rhode Island (he was just twenty-one when elected to the Rhode Island House of Representatives). And he is a very happily married father of four children and continues his long history of public service through the Kennedy Forum, founded in2013 andaimedat improving the lives of people living with mental illness and addiction. And the final lesson for this reader was that, yes, there are significant benefits to being born a Kennedy—but it’s not for the faint of spirit. ▪

Federal Parity In The Evolving Mental Health And Addiction Care Landscape.

The intent of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 is to eliminate differences between health insurance coverage of mental health and substance use disorder benefits and coverage of medical or surgical benefits. The Affordable Care Act significantly extended the reach of the Wellstone-Domenici law by applying it to new insurance markets. We summarize the evolution of legislative and regulatory actions to bring about federal insurance parity. We also summarize available evidence on how the Wellstone-Domenici law has contributed to addressing insurance discrimination; rectifying market inefficiencies due to adverse selection; and altering utilization, spending, and health outcomes for people with mental health and substance use disorders. In addition, we highlight important gaps in knowledge about how parity has been implemented, describe the groups still lacking parity-level coverage, and make recommendations on steps to improve the likelihood that the Wellstone-Domenici law will fulfill the aims of its architects.

Improving Access To Care And Reducing Involvement In The Criminal Justice System For People With Mental Illness.

People with mental illness make up a disproportionate share of the criminal justice-involved population. The passage of critical new reforms affecting health care for vulnerable populations under the Affordable Care Act and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 presents unique opportunities to transform systems of care and avert criminal justice involvement. In addition, state and local jurisdictions have implemented a number of strategies to divert people with mental illness from the criminal justice system and reduce recidivism. In this article we summarize current knowledge about the involvement of people with mental illness in the criminal justice system and consider the recent opportunities presented by national and local policies that aim to lower the proportion of such people who are incarcerated.

Federal parity law associated with increased probability of using out-of-network substance use disorder treatment services.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires commercial insurers providing group coverage for substance use disorder services to offer benefits for those services at a level equal to those for medical or surgical benefits. Unlike previous parity policies instituted for federal employees and in individual states, the law extends parity to out-of-network services. We conducted an interrupted time-series analysis using insurance claims from large self-insured employers to evaluate whether federal parity was associated with changes in out-of-network treatment for 525,620 users of substance use disorder services. Federal parity was associated with an increased probability of using out-of-network services, an increased average number of out-of-network outpatient visits, and increased average total spending on out-of-network services among users of those services. Our findings were broadly consistent with the contention of federal parity proponents that extending parity to out-of-network services would broaden access to substance use disorder care obtained outside of plan networks.

Brain disease model of addiction: why is it so controversial?

The “Personal View” by Hall, Carter, and Forlini1 questions the value of the BDMA (brain disease model of addiction) and claims that it is not supported by animal or neuroimaging evidence, that it has not helped deliver more effective treatments and that its impact on public policy have been modest. However, these claims are not supported by the evidence. First, preclinical and clinical studies have consistently delineated specific molecular and functional neuroplastic changes at the synaptic and circuitry level that are triggered by repeated drug exposure. These findings, along with ongoing research, are helping us understand the neurobiological processes associated with the loss of control, compulsive drug taking, inflexible behavior, and negative emotional states associated with addiction (Figure 1). Second, uncovering the molecular targets and circuits underlying addiction has already resulted in several effective medications (naloxone and acamprosate for alcoholism, buprenorphine-naloxone for opioid addiction; varenicline for tobacco addiction) and ongoing clinical trials are taking advantage of this knowledge to test new targets 2, 3. For the approved medications the effect sizes are similar to those associated with standard anti-depressant pharmacotherapies. This knowledge had also provided the basis for the use of stimulation techniques such as transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS) and its variants, to strengthen circuits impaired by addiction with promising results 4, 5. It has also provided clinicians with a framework to guide targeted interventions to strengthen the impaired circuits (i.e., behavioral interventions to enhance self-control, reduce stress reactivity, improve mood). Finally, the statement that the effects of the BDMA framework on public policy are modest negates some major achievements, such as the passage in 2008 of the parity law (the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, driven by the BDMA model) that requires medical insurance for the first time in the USA to cover costs associated with the treatment of addiction6. Finally, the mere framework of BDMA has benefits in treatment as it significantly diminishes the stigma attached with addiction and gives hope for recovery to those fighting this devastating disease. Figure 1 Conceptual Framework for Neurobiological Bases of the Transition to Substance Use Disorders We agree that in addiction, as is the case for any other medical condition, there is a severity dimension (incorporated into the recently revised classification of substance use disorders in the diagnostic statistical manual or DSM 5; 7), and that only a small percentage of those with a substance use disorder fall in the most severe category. However, we don’t understand the argument of why this fact should negate the value of the disease model in addiction. It is basic research that is helping us understand this severity dimension and the mechanisms underlying the transition from mild to severe addiction that one day might enable us to develop interventions to revert and/or revert those changes and to identify those who are at most risk when exposed to drugs to transition into a severe phenotype. In the meantime, research is already providing evidence that is guiding therapeutic interventions on the basis of the levels of severity8. Similarly, as for any other disease the largest impact at the population level is derived from interventions that prevent the emergence of the disease process in the first place. In the case of cancer this would entail, for example, the prevention of smoking, which connotes prevention of nicotine addiction. Translational research is a powerful engine of effective prevention: Understanding how genetic, developmental and environmental (including social) factors influence the vulnerability for substance use disorders helps develop better prevention strategies; particularly for those at highest risk for whom universal prevention strategies are not as effective. This can be well illustrated by the case of the very successful smoking prevention campaign that resulted in >50% reduction in smoking but has failed to prevent smoking in 18-20% of the population, presumably those who are the most vulnerable. So why is it that despite all the scientific evidence the BDMA is so frequently singled out for criticism as in the piece by Hall, Carter, and Forlini? We think it reflects in part our expectations that science should immediately translate into transforming solutions, which have not materialized for addiction nor for most of the other brain diseases. Yet, the value of basic research in diseases such as Alzheimer’s or schizophrenia has never been questioned, which leads us to ponder whether the difficulty relies in accepting as a bona fide disease one that erodes the neuronal circuits that enable us to exert free-will. Addiction is a complex disease of a complex brain; ignoring this fact will only hamper our efforts to find effective solutions through a comprehensive and systematic understanding of the underlying phenomena.

A tale of two states: do consumers see mental health insurance parity when shopping on state exchanges?

All insurance products sold on the health insurance exchanges established by the Affordable Care Act are required to offer mental health and substance use disorder benefits in compliance with requirements of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). This column identifies two dimensions of parity compliance that consumers observe while shopping for insurance products offered on two state-run exchanges. The authors discuss a number of apparent discrepancies with the requirements of MHPAEA in these observable dimensions, emphasizing the potential impact of these factors on consumers' decisions about plan enrollment. The analysis reveals a nuanced picture of how insurance issuers are presenting behavioral health benefits to potential enrollees and illustrates broader concerns about parity compliance and the potential for selection on the exchanges. Four specific discrepancies are highlighted as areas for further evaluation.

In name only? Mental health parity or illusory reform.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act mandate significant insurance and patient protection reforms. Despite these safeguards, lax regulatory enforcement and lack of consumer and provider sophistication have failed to remedy ongoing insurer abuses resulting in deprivation of crucial mental health and substance abuse treatment. Even with persistent and informed advocacy, including strategies outlined herein, any potential parity gains are negated by unreasonably low reimbursement benchmarks already used by insurers in many ACA (∗) -exchange plans. The need for legislative remediation is therefore urgent.

APA Holds Press Conference on Key Mental Health Issues

Back to table of contents Previous article Next article Government NewsFull AccessAPA Holds Press Conference on Key Mental Health IssuesJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:25 Jun 2013https://doi.org/10.1176/appi.pn.2013.7a5AbstractTwo continuing struggles—to combat stigma and get federal officials to issue a rule implementing the parity law—dominate the agenda.On June 3, President Obama and Vice-President Biden hosted a White House conference on mental health to which several APA leaders were invited.They included Jeffrey Lieberman, M.D., president of APA and chair of psychiatry at Columbia University; Paul Summergrad, M.D., APA president-elect and chair of psychiatry at Tufts University; and Jeffrey Borenstein, M.D., editor in chief of Psychiatric News, host of the television series “Healthy Minds,” and president and CEO of the Brain & Behavior Research Foundation. Also attending was Patrick Kennedy, a former member of Congress who cosponsored the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act in the House of Representatives and worked hard to ensure its passage. Today he serves as a senior strategic advisor for APA.Former member of Congress Patrick Kennedy addresses the media at the National Press Club in Washington, D.C., after a White House conference on mental health last month. Kennedy is leading the charge for issuance of a long-overdue final rule implementing the Mental Health Parity and Addiction Equity Act of 2008. At left is APA President Jeffrey Lieberman, M.D.David HathcoxAfter the conference, these participants, along with APA Medical Director and CEO James H. Scully Jr., M.D., held a press conference at the National Press Club in Washington, D.C., to discuss some of the key issues in mental health care and how mental illness is perceived by the public.One of those issues concerns the federal parity law that was passed five years ago but still does not have a final rule to ensure that insurance companies follow the law’s provisions as the law was intended. “We want a rule to be released by the White House” that says that treatment for illnesses of the brain as well as the body should be covered by insurance policies, Kennedy declared, and disclosure of the names of insurance companies that do not “comply with parity” should be part of the final rule. Summergrad concurred, emphasizing that it has been five years since the parity act was signed and that a final rule is critical.Another critical issue is how to dissuade the American public from believing that all people who commit violence are mentally ill. “Gun control and violence have been conflated with mental illness,” Lieberman said. Yet only 4 percent of violent crimes are committed by mentally ill individuals, he emphasized.Yet a third pressing issue is how to combat the stigma often attached to mental illness and its treatment. The speakers agreed that the best solution is to change how the media portray mental illness. An example of how reporters propagate stigma is when they write, “A politician has a schizophrenic attitude,” Borenstein noted. Reporters would certainly never write, “A politician has a diabetic attitude.” An example of how popular films foster stigma can be found in the new psychological thriller “Side Effects,” Lieberman pointed out. The film is entertaining, but it undermines the psychiatric profession by reinforcing myths that have often been promulgated about this field, he said.The increasing integration of mental health care with primary care is also high on the national mental health agenda. Scully reported that APA is working with private insurance companies and Medicare officials to ensure that they provide equitable payment for care provided through such initiatives.Finally, the health insurance exchanges that are being set up under the Affordable Care Act will influence how mental illness is covered. “We need a voice in these health exchanges…and APA needs to convene that discussion,” Kennedy asserted. ■To watch a video of APA’s press conference following the White House Conference on Mental Health, go to http://vimeo.com/67656759. ISSUES NewArchived

Parity and Out-of-Pocket Spending for Children With High Mental Health or Substance Abuse Expenditures

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act required health plans to provide mental health and substance use disorder (MH/SUD) benefits on par with medical benefits beginning in 2010. Previous research found that parity significantly lowered average out-of-pocket (OOP) spending on MH/SUD treatment of children. No evidence is available on how parity affects OOP spending by families of children with the highest MH/SUD treatment expenditures. We used a difference-in-differences study design to examine whether parity reduced families' (1) share of total MH/SUD treatment expenditures paid OOP or (2) average OOP spending among children whose total MH/SUD expenditures met or exceeded the 90th percentile. By using claims data, we compared changes 2 years before (1999-2000) and 2 years after (2001-2002) the Federal Employees Health Benefits Program implemented parity to a contemporaneous group of health plans that did not implement parity over the same 4-year period. We examined those enrolled in the Federal Employees Health Benefits Program because their parity directive is similar to and served as a model for the new federal parity law. Parity led to statistically significant annual declines in the share of total MH/SUD treatment expenditures paid OOP (-5%, 95% confidence interval: -6% to -4%) and average OOP spending on MH/SUD treatment (-$178, 95% confidence interval: -257 to -97). This study provides the first empirical evidence that parity reduces the share and level of OOP spending by families of children with the highest MH/SUD treatment expenditures; however, these spending reductions were smaller than anticipated and unlikely to meaningfully improve families' financial protection.