Medicaid Spending Differences for Child/Youth Community-Based Care in California’s Decentralized Public Mental Health System

Abstract

This study evaluated spending differences across counties during the decade after California decentralized its public mental health system. Medicaid data for 0–25 year olds using mental health services were collapsed to the county-year level (n = 627). Multivariate models with county fixed effects were used to predict per capita spending for community-based mental health care. While counties increased their spending over time, those with relatively low initial expenditures per user continued to spend less than counties with historically higher spending levels. Spending differences per user were most noticeable in counties with larger racial/ethnic minority populations that also had historically lower spending levels.

Appendix: Sensitivity Analysis

To test whether the model was sensitive to the definition of a diverse population in counties, a different cut point for the variable “diverse” was chosen. Figure 5 below shows a histogram of the fraction of the population that is a racial/ethnic minority in each county, averaged over the 11 years of this study. A roughly bimodal distribution was observed. A 50 % cut point for “more diverse” was used in the main analysis of this study because that indicates that the majority of the population was a racial/ethnic minority. For the other cut point, those with a fraction of racial/ethnic minority population above 35 % were in the “more diverse” group, and those below 35 % racial/ethnic minority population were considered “less diverse.” At this cut point, there were: 19 low baseline spending counties that were less diverse, 15 low baseline spending counties that were more diverse, 9 high baseline spending counties that were less diverse, and 14 high baseline spending counties that were more diverse. A cut point higher than 50 % could not be analyzed because it resulted in very small samples for the more diverse groups of counties.

Fig. 5

Histogram of fraction of racial/ethnic minority population, all counties

The patterns experienced by these new groups of counties (with the lower diversity cut point) (Fig. 6) are somewhat similar to the patterns experienced by those at the higher diversity cut point (Fig. 2). There is considerable overlap in both cases between the spending levels for baseline high counties whether or not they have more or less diversity. There is also considerable overlap in both cases between the spending levels for baseline low counties whether or not they have more or less diversity.

Differences between the two diversity cut points are illuminated by the regression analyses. As we expected, the trends experienced by the four county groups over time were more similar with the lower diversity cut point (Table 4) than with the higher diversity cut point (Table 2). At the 35 % cut point level, holding all else constant (Table 4), each additional year was associated with approximately

Fig. 6

Community-based expenditures per user (in 2013 dollars), counties in groups, 0–25 year olds, FY1993-94 to FY2003-04

Table 4 Effect of time, historical expenditures, racial/ethnic diversity (35 % cut point), county mental health system characteristics, and county socio-demographic characteristics on expenditures for community-based Medi-Cal specialty mental health care per child/youth user, fixed effects (FE) models

• $256 more spending per user in more diverse counties with high baseline spending.

• $363 more spending per user in less diverse counties with low baseline spending.

• $284 more spending per user in more diverse counties with low baseline spending.

• $206 more spending per user in less diverse counties with high baseline spending.