Office of Health Care Affordability staff on Wednesday presented new estimates of behavioral‑health spending paid entirely out of pocket in California and urged caution in interpreting the results.

Mathematica researchers used the Medical Expenditure Panel Survey (MEPS) household component for 2019–2022 to identify behavioral‑health events and to classify expenses as “out of plan” when they were paid entirely by the respondent or occurred after an individual deductible was met. Their pooled estimate across the four years put out‑of‑plan behavioral‑health spending at roughly 10% of total behavioral‑health expenditures.

The office and its analysts repeatedly stressed limits to the data. “The unweighted sample of respondents reporting out‑of‑plan behavioral‑health expenses was 41 to 45 per year,” Andrew Fair of OCA said during the presentation, and he noted AHRQ guidance that advises against publishing estimates based on fewer than 60 unweighted respondents. For example, the 2019 point estimate for out‑of‑plan spending was $918 million, but Fair said the confidence interval could be as low as $260 million or as high as $1.6 billion.

Board members pressed staff on how the MEPS results compare with the OCA Health Care Payments Data program (HPD) and other administrative sources. “Given that the MEPS estimates for in‑plan behavioral‑health spending conflict with administrative data, this certainly gives us pause in trying to use MEPS to estimate out‑of‑plan trends,” Fair said. HPD administrative totals showed in‑plan behavioral‑health spending rising steadily from about $9.1 billion in 2019 to about $11.6 billion in 2022, while MEPS suggested a larger fluctuation.

Several board members and public commenters pointed to potential under‑reporting in household surveys and to the exclusion of institutional settings (residential treatment, long‑term care) from MEPS. Director Landsberg and staff said OCA would continue to pursue additional data partnerships, including follow‑up with the California Health Care Foundation and other organizations, and explore adding behavioral‑health files to HPD to better capture outpatient trends.

Public health advocates urged the office to keep the patient impact front and center. “Out‑of‑pocket costs can drive people to delay or forgo care,” Adam Zarin of Blood Cancer United said during public comment, calling for stronger measures to control high prices and consolidation that raise patient costs.

OCA did not announce new policy actions tied to the MEPS estimates; instead, staff described the work as an exploratory step that highlights data gaps and next steps for improved measurement and partnerships.