69 Patient cost-sharing, mental health care and inequalities INTRODUCTION Mental disorders are the leading cause of disability among adolescents and young adults in high-income countries [1, 2]. Approximately 75% of adult mental disorders have their onset during adolescence, increasing the risk of recurrent mental disorders and disabling physical conditions in adulthood [2, 3]. Adolescents from socioeconomically disadvantaged families are two to three times more likely to develop mental health problems, and more likely to have limited access to mental health services [4-6]. Although awareness of the crucial time period of adolescence for mental health has increased in recent years [7, 8], health care systems still fail to address the transition from children and adolescent mental health services (CAMHS) to adult mental health services (AMHS).[9] This transition is often accompanied by disruptions of care due to several factors – policy, servicerelated, and individual – and can have longlasting consequences on health and development [10, 11]. Health care financing has been mentioned as a potential factor contributing to the treatment gap, in particular when there are changes in financial arrangements from minors to adults, such as the introduction of patient costsharing [12]. Cost-sharing has been introduced widely in response to increasing health care expenditures [13]. By exposing individuals with coverage to a larger proportion of the full prices of services, economic theory predicts a decrease in individual demand [14]. How much individuals react to cost-sharing depends on the price elasticity of health care demand [13]. At the limit, when demand is price inelastic, cost-sharing only shifts the burden of financing to the user. Theory predicts further that price elasticities depend on the value of care, with less valuable care being more price-elastic [15]. However, the RAND Health Insurance Experiment [16], the Oregon Health Insurance Experiment [17] and more recent quasi-experimental work [14, 18, 19] have shown that cost-sharing is a blunt instrument to reduce health care consumption, leading to cuts in appropriate care. The RAND Health Insurance Experiment also found cost-sharing to mostly harm those of low socioeconomic status in poor health [18, 20, 21]. Such differential effects by income can arise for different reasons: out of pocket payments representing a larger share of the total budget for individuals with low income, higher utility losses due to higher marginal utility of low income, and low income individuals having worse health [13]. Earlier work also confirmed that users of mental health services, as compared to “physical” care, are more responsive to cost-sharing [22]. Potential explanations include underestimating the importance of mental wellbeing, stigma around the use of mental health services, the perception that mental health services provide low-quality of care, and uncertainty about the effectiveness of some interventions [22]. Although forgoing necessary mental health care in adolescence and early adulthood might come at higher future costs for patients, health systems and society [7], evidence 3
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