Client-Level Effects of States' Mental Health Agency Expenditures and Mental Health Parity Legislation

Despite federal parity legislation, gaps in access to behavioral health care persist across the United States. Stronger parity implementation has been associated with an improved system-level mental health infrastructure. The authors determined whether parity and higher per capita expenditures lead to better client-level access and outcomes.

This analysis of individual-level data extends previous system-level work by examining client-level outcomes across the top 10 and bottom 10 states for per capita state mental health agency (SMHA) expenditures and parity implementation (comprehensive vs. limited). Five outcomes were assessed: treatment receipt, unmet need, cost-related barriers to care among adults with ≥14 days of mental illness per month, drug overdose mortality, and suicide mortality. Group differences were compared with Mann-Whitney U tests.

Across the two analytic stratifications-top 10 versus bottom 10 states and comprehensive parity versus noncomprehensive parity-few statistically significant differences emerged. States with higher SMHA expenditures and those with comprehensive parity had significantly lower cost-related barriers to care for adults experiencing frequent mentally unhealthy days. No significant differences between the two analytic stratifications were observed for treatment receipt, unmet need, or overdose or suicide mortality rate, although directional trends favored states that had greater expenditures and comprehensive parity.

These findings suggest that parity implementation and mental health spending alone may not meaningfully improve most client-level outcomes. Additional mechanisms, including adequate mental health workforce availability, insurance networks, community-level mental health investment, and parity enforcement, may mediate the relationship between public health policies and individual care experiences.