Putting a Price on Child Maltreatment

This summer, three agencies within the US Department of Health and Human Services (HHS) issued a letter to state directors of child welfare, Medicaid, and mental health authorities on the importance of addressing complex trauma among children and youth known to the child welfare system. The letter calls attention to advances in research since the Adverse Childhood Experience Study (ACES)  highlighted the link between multiple traumatic experiences and an increased likelihood of future health problems and provides clarification on the use of federal funding streams like Medicaid to pay for trauma-related needs. Medicaid already covers 43 million children, or half of all low-income children, in conjunction with the Children’s Health Insurance Program (CHIP), and is, therefore, a common type of health insurance coverage for children experiencing trauma, such as child maltreatment.

Whereas studies have attempted to quantify the cost of child maltreatment on health care spending, a recent article in Pediatrics, the official journal of the American Academy of Pediatrics, measures, for the first time, the health care costs in the Medicaid program associated with child maltreatment. Led by researchers across the country, including the Centers for Disease Control and Prevention, the study takes data on child maltreatment from the National Survey of Child and Adolescent Well-Being (NSCAW) and matches it with Medicaid claims data from the Medicaid Analytic Extract (MAX).

Since the NSCAW is only a representative sample of children investigated or assessed for child maltreatment, the authors undertake propensity score matching to create a comparison group using a probit regression model with the MAX data that contains data on children with Medicaid claims regardless of maltreatment. Specifically, they estimate the likelihood that any child in the sample from the two data sets is in the maltreated group, and then match the children in the NSCAW sample with a non-NSCAW child.

This allows the authors to compare total Medicaid expenditures between the groups, as well as expenditures on services thought to be impacted by maltreatment—including psychiatric care, prescription drugs, and targeted case management. They find Medicaid spending among NSCAW children to be much higher, with the difference in mean costs being greater than $2600 per child per year. Computing a rough estimation based on child-related Medicaid spending in 2009 and the prevalence of child maltreatment among Medicaid participants, the authors claim that 9 percent, or $5.9 billion, of all Medicaid expenditures for children are due to excess costs associated with child maltreatment.

Despite these findings, the authors note a few limitations they faced, some of which they were able to account for with adjustments. First, health care expenditure data can be skewed, making means sensitive to extreme values and thus misleading. Second, the NSCAW data presents a sample of investigated cases of maltreated children, not necessarily substantiated ones. The authors note, however, that research has shown that health outcomes between children with investigated cases and substantiated ones are not significantly different. Additionally, the authors were restricted to using only Medicaid claims for children enrolled in Medicaid fee-for-service (FFS) or primary care case management (PCCM) plans, not including children in health maintenance organizations, which provide fixed payments per month. The authors were also not able to observe whether the non-NSCAW children used for creating the comparison group experienced child maltreatment that was not investigated. This could potentially bias the expenditure difference, making it too low because the comparison group didn’t accurately reflect children who had not experienced maltreatment.

Although this study is not a perfect account of the health care costs associated with child maltreatment, it helps illustrate the magnitude of the problem and what could be saved if child maltreatment were prevented. Given the current fiscal climate, cutting health care expenditures is a top priority for many policy makers, and a focus on decreasing child maltreatment may be once place to start.

Feature Photo: cc/(Toni Verdú Carbó)