The economic burden of child maltreatment in the United States, 2015
Introduction
Child maltreatment includes neglect, physical abuse, psychological maltreatment, and sexual abuse (Leeb, Paulozzi, Melanson, Simon, & Arias, 2008). In 2015, 1670 children died nationwide due to maltreatment and another 683,000 suffered maltreatment that was substantiated by authorities (US Department of Health & Human Services, 2017). Survey data suggests child maltreatment is far more prevalent, affecting an estimated 25% of children and youth age 0–17 years old (Finkelhor, Turner, Shattuck, & Hamby, 2015).
Fang, Brown, Florence, and Mercy (2012) reported in this journal the estimated lifetime per-victim cost of nonfatal and fatal child maltreatment and the associated US population economic burden based on 2008 incidence data (Fang et al., 2012). That study estimated the lifetime per victim cost of nonfatal and fatal child maltreatment to be $210,000 and $1.3 million, respectively, and the annual US economic burden to be $124 billion (all 2010 USD). Since that study, new data and the recent promotion of alternative methodologies for valuing morbidity and mortality have created an opportunity to update those estimates. This study aimed to use the most recent data and recommended methods to update previous estimates of 1) the per-victim lifetime cost, and 2) the annual US population economic burden of child maltreatment.
In this study we applied three updates to the previous study’s methods and data: 1) value per statistical life (VSL) methodology replaced the previous study’s human capital valuation of child maltreatment mortality, 2) monetized quality-adjusted life years (QALY) methodology replaced the previous study’s human capital valuation of child maltreatment morbidity, and 3) updated estimates of the exposed population based on the most recent administrative data.
The two cost methodology updates (VSL and monetized QALYs) were made in consideration of recent US Department of Health and Human Services (USDHHS) guidance on methods for economic evaluation for regulatory impact analysis (Office of the Assistant Secretary for Planning & Evaluation, 2016). That guidance recommended the use of VSL to value mortality and monetized QALYs to value morbidity where appropriate data exists to do so. VSL and monetized QALYs can replace the human capital valuation method used to value mortality and morbidity in many previous cost of illness studies, including the previous child maltreatment cost study (Fang et al., 2012). Both methods for valuing morbidity and mortality—VSL/monetized QALYs and the human capital method—use a societal cost perspective; that is, both methods aim to include all measureable costs attributable to a given health condition, not only those that incur to a particular payer (e.g., health system, employer).
There is a substantial literature on methods to estimate the cost of mortality and morbidity (Office of the Assistant Secretary for Planning & Evaluation, 2016). In brief, VSL mortality valuation and QALY morbidity valuation can be ultimately based on a person’s willingness to pay for a defined change in mortality or morbidity risk, while the human capital method is based on the value of lost work and other productive activities—typically assessed at an observed earnings rate—due to mortality or morbidity. A major criticism of the human capital method is that intangible costs, such as the pain, suffering, and grief experienced by a community when a person dies, are not captured (Corso, Fang, & Mercy, 2011). VSL and QALY methods attempt to capture these intangible costs and typically include mortality and morbidity valuations that are many times greater than corresponding human capital valuations.
Owing to available data, a VSL mortality value is typically applied as a single standard value in cost of illness studies to estimate the cost of one lost life (e.g., $9.6 million as 2014 USD in the recent USDHHS guidance) (Office of the Assistant Secretary for Planning & Evaluation, 2016). A QALY is a measure of the state of health, where 1 QALY is equal to 1 year of life in perfect health (National Institute for Health & Care Excellence, 2017); health conditions with greater impairment are therefore associated with lower number of QALYs. A monetized QALY morbidity value (or, monetized QALY) can be calculated using the number of years of life lived (usually assessed using population survival probabilities; or, a lifetable), a VSL value, and a condition-specific QALY measure. In other words, monetized QALYs represent the cost of reduced quality of life valued at a selected VSL rate. The VSL mortality value selected for a given study therefore has a substantial effect on the study’s corresponding monetary QALY valuation.
VSL is higher for children than for adults, and the VSL value proposed in the recent USDHHS guidance is based on average mortality at 40 years old (Hammitt & Haninger, 2010; Office of the Assistant Secretary for Planning & Evaluation, 2016). VSL also varies based on the characteristics of a given disease, although given the limited number of original studies that have measured VSL, it is relatively uncommon to be able to use a condition-specific VSL in a cost of illness study. However, for child maltreatment there exists a condition-specific VSL estimate based on an original analysis (Corso et al., 2011). In that previous study, a random sample of adults (n = 199) in Georgia was questioned in 2008 on their willingness to pay for a 50% annual reduction in the risk of a child being killed by a parent or caregiver (or, a reduction from 2 per 100,000 to 1 per 100,000 population). Based on mean estimated willingness to pay ($148) among the respondent sample, authors reported a child maltreatment-specific VSL of $14.8 million (2008 USD). This VSL value is consistent with previous original studies indicating that an adult’s willingness to pay for a reduced mortality risk to a child is higher than for oneself; VSL for children has been estimated at $12-15 million compared to $6-10 million for adults (2007 USD) (Hammitt & Haninger, 2010).
It appears just one study has reported child maltreatment preference-based health-related quality of life measures that can be used to calculate monetized QALYs from a VSL value (Corso, Edwards, Fang, & Mercy, 2008). In that study, researchers used data from the Adverse Childhood Experiences Study to assess self-reported health-related quality of life among adults who self-reported childhood maltreatment (n = 2812) anytime during age ≤18 years old compared to adults matched on demographic and economic characteristics who did not report childhood maltreatment (n = 3356). Respondents who reported childhood maltreatment had an average marginal disutility of 0.028 QALY per year during adulthood (age ≥ 19) compared with respondents who reported no childhood maltreatment.
Section snippets
Methods
This study updates the estimated lifetime per-victim cost and the associated population economic burden of child maltreatment reported in Fang et al. (2012). Updates are based on VSL and QALY valuations of mortality and morbidity that replace human capital valuations (commonly referred to as lost productivity values) applied in the previous study. The cost estimates in this study include intangible costs due to pain, suffering, and grief attributable to child maltreatment experienced among
Results
The total estimated per-victim cost of nonfatal child maltreatment increased from $210,012 (2010 USD) as reported in Fang et al. (2012) to $830,928 (2015 USD) (Table 2). This increase is almost entirely due to using monetized QALYs (i.e., includes intangible costs due to pain, suffering, and grief attributable to child maltreatment experienced among victims and communities) in place of the human capital-based lost productivity value applied in Fang et al. (2012). This methodology change
Discussion
Using updated cost methods and data, this study estimated a much higher per-victim lifetime cost of child maltreatment for victims of nonfatal ($831,000) and fatal ($16.6 million) child maltreatment, and a higher estimated annual US population economic burden ($428 billion to $2.0 trillion, depending on data source for nonfatal child maltreatment incidence) (all 2015 USD) than reported in a previous study (Fang et al., 2012) (which reported lifetime costs for nonfatal and fatal child
Funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Financial disclosures
The authors have no financial relationships of interest.
Conflicts of interest
The authors have no conflicts of interest.
Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Contributor statement
Cora Peterson led the study design and interpretation of results, analyzed the data, drafted and edited the manuscript, and approved the final manuscript as submitted.
Curtis Florence led the study design and interpretation of results, edited the manuscript, and approved the final manuscript as submitted.
Joanne Klevens assisted with the study design and interpretation of results, edited the manuscript, and approved the final manuscript as submitted.
Acknowledgements
Authors thank Amber Jessup and Daniel Lawver at Office of the Assistant Secretary for Planning and Evaluation for sharing data and calculations related to value per statistical life estimates published in: Office of the Assistant Secretary for Planning and Evaluation. (2016). Guidelines for regulatory impact analysis. Washington, DC: U.S. Department of Health and Human Services.
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