Are mental health insurance mandates effective? Evidence from suicides

State mental health insurance parity laws and college educational outcomes

We examine the effect of the state-level full parity mental illness law implementation on mental illness among college-aged individuals and human capital accumulation in college. We utilize administrative data on completed suicides and grade point average (GPA) and survey data on reported mental illness days and decisions to disenroll from college between 1998 and 2008 in a difference-in-differences (DD) analysis to uncover the causal effects of state-level parity laws. We find that state-level parity law reduces youth suicide rate and propensity to report any poor mental health day, increases college GPA, and does not change the propensity to disenroll from college.

Creation of a Longitudinal Legal Data Set to Support Legal Epidemiology Studies of Mental Health Insurance Legislation

OBJECTIVE

This article describes policy surveillance methodology used to track changes in the comprehensiveness of state mental health insurance laws over 23 years, resulting in a data set that supports legal epidemiology studies measuring effects of these laws on mental health outcomes.

METHODS

Structured policy surveillance methods, including a coding protocol, blind coding of laws in 10% of states, and consensus meetings, were used to track changes in state laws from 1997 through 2019-2020. The legal database Westlaw was used to identify relevant statutes. The legal coding instrument included six questions across four themes: parity, mandated coverage, definitions of mental health conditions, and enforcement-compliance. Points (range 0-7) were assigned to reflect the laws' comprehensiveness and aid interpretation of changes over time.

RESULTS

The search resulted in 147 coding time periods across 51 jurisdictions (50 states, District of Columbia). Intercoder consensus rates increased from 89% to 100% in the final round of blinded duplicate coding. Since 1997, average comprehensiveness scores increased from 1.31 to 3.82. In 1997, 41% of jurisdictions had a parity law, 28% mandated coverage, 31% defined mental health conditions, and 8% required state agency enforcement. In 2019-2020, 94% of jurisdictions had a parity law, 63% mandated coverage, 75% defined mental health conditions, and 29% required state enforcement efforts.

CONCLUSIONS

Comprehensiveness of state mental health insurance laws increased from 1997 through 2019-2020. The State Mental Health Insurance Laws Dataset will enable evaluation research on effects of comprehensive legislation and cumulative impact.

Impact of Mental Health Insurance Legislation on Mental Health Treatment in a Longitudinal Sample of Adolescents

BACKGROUND

Mental health insurance laws are intended to improve access to needed treatments and prevent discrimination in coverage for mental health conditions and other medical conditions.

OBJECTIVES

The aim was to estimate the impact of these policies on mental health treatment utilization in a nationally representative longitudinal sample of youth followed through adulthood.

METHODS

We used data from the 1997 National Longitudinal Survey of Youth and the Mental Health Insurance Laws data set. We specified a zero-inflated negative binomial regression model to estimate the relationship between mental health treatment utilization and law exposure while controlling for other explanatory variables.

RESULTS

We found that the number of mental health treatment visits declined as cumulative exposure to mental health insurance legislation increased; a 10 unit (or 10.3%) increase in the law exposure strength resulted in a 4% decline in the number of mental health visits. We also found that state mental health insurance laws are associated with reducing mental health treatments and disparities within at-risk subgroups.

CONCLUSIONS

Prolonged exposure to comprehensive mental health laws across a person's childhood and adolescence may reduce the demand for mental health visitations in adulthood, hence, reducing the burden on the payors and consumers. Further, as the exposure to the mental health law strengthened, the gap between at-risk subgroups was narrowed or eliminated at the highest policy exposure levels.

The association between Urban and Rural Resident Basic Medical Insurance and depressive symptoms among Chinese middle-aged and older adults: Evidence from the China Health and Retirement Longitudinal Study

It is unclear that whether Urban and Rural Resident Basic Medical Insurance (URRBMI) is associated with depressive symptoms among middle-aged and older adults. To fulfill this research gap, this study aimed to investigate the association between URRBMI and depressive symptoms among the middle-aged and older adults in China. This data of this study was sourced from the 2018 wave of China Health and Retirement Longitudinal Study (CHARLS). Ordinary least squares (OLS) regression models were used to explore the association between URRBMI and depressive symptoms. Instrumental variable (IV) method was employed to address potential endogeneity problem which is caused by reverse causation and omitted variable bias. Propensity score matching (PSM) and doubly robust estimation were employed to conduct robustness checks. We provide robust evidence indicating that participation of URRBMI was significantly correlated with a reduced depression score. Moreover, we find that improving the utilization of inpatient and outpatient care may be important channels through which URRBMI relieved depressive symptoms.

The impact of mental health parity laws on birth outcomes

Prior studies have found that poor mental health during pregnancy is associated with poor birth outcomes, but little is known about the ability of mental health care access and treatment to counteract these effects. I use a difference-in-differences strategy exploiting the staggered enactment of state mental health parity laws in 25 states from 1995 to 2002 to identify the impact of mental health care access on the probability of an adverse birth outcome. These state mental health parity laws are insurance mandates requiring coverage of mental health care be equivalent to physical health care. Using birth records, I find that, among the group of mothers most likely to have private insurance, introduction of a mental health parity law in a state decreased the probability of an adverse birth outcome. Furthermore, I find that the parity laws decreased the likelihood that a pregnant woman hospitalized for delivery would receive a mental illness diagnosis.

Impacts of anticancer drug parity laws on mortality rates

This study investigates the impacts of anticancer drug parity laws on mortality rates in the United States using a difference-in-differences approach. Using data from 2004 to 2017 Compressed Mortality Files, we show that the anticancer drug parity laws reduce the mortality rate for head/neck malignant cancers but have no impact on malignant cancers of other types. We also rule out an insurance expansion channel that may influence the relationship between anticancer drug parity laws and malignant cancer mortality. Our results are robust to various specifications and falsification tests. Our findings imply that providing equal access to oral anticancer drugs is an effective tool for the prevention of premature mortality.

The Affordable Care Act Young Adult Mandate and Suicidal Behavior

This article aimed to determine the association between the Affordable Care Act young adult mandate and suicidal behavior. From 2007 to 2013, we used the Nationwide/National Inpatient Sample and National Poison Data System to examine suicide attempt, and Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research to examine suicide. We aggregated each outcome by quarter/year and conducted a difference-in-differences linear regression to compare young adults aged 19 to 25 years with those 27 to 29 years before and after implementation. There were not statistically significant associations between the mandate and suicide attempt inpatient hospitalizations (unstandardized beta coefficient [b] = -0.72, p = .12, standard error [SE] = 0.42) and percentage of poisoning cases due to suspected suicidal intent (b = 0.23, p = .19, SE = 0.16). There was a statistically significant association when examining suicide prevalence (b = -0.03, p = .01, SE = 0.001). The results suggest that health insurance may buffer against but is unlikely to reverse the increasing suicide rate.

Autism spectrum disorder, politics, and the generosity of insurance mandates in the United States

The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians–with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America.

Associations of health insurance coverage, mental health problems, and drug use with mental health service use in US adults: an analysis of 2013 National Survey on Drug Use and Health

OBJECTIVE

To estimate the prevalence of mental health service use among US adults, examine the associations of mental health service use with health insurance coverage, mental health problems and drug use, and detect health disparities.

METHODS

This was a cross-sectional study with 5,434 adults receiving mental health service out of 37,424 adult respondents from the 2013 National Survey on Drug Use and Health. Weighted univariate and multiple logistic regression analyses were used to estimate the associations of potential factors with mental health service use.

RESULTS

The overall prevalence of mental health services use was 14.7%. Our results showed that being female, aging, having a major depressive episode, serious psychological distress, and illicit drug or alcohol abuse/dependence were positively associated with mental health service use; whereas being African American, Asian or Hispanic ethnicity, married, and having any form of insurance were negatively associated with mental health service use . Stratified analysis by insurance types showed that Medicaid/CHIP, CHAMPUS, and other insurance were positively associated with mental health service use.

CONCLUSIONS

Health insurance coverage, mental health problems, and drug abuse or dependence were associated with mental health service use in US adults. Furthermore, adults with different insurances had disparities in access of mental health service.

Achieving Mental Health and Substance Use Disorder Treatment Parity: A Quarter Century of Policy Making and Research

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 changed the landscape of mental health and substance use disorder coverage in the United States. The MHPAEA's comprehensiveness compared with past parity laws, including its extension of parity to plan management strategies, the so-called nonquantitative treatment limitations (NQTL), led to significant improvements in mental health care coverage. In this article, we review the history of this landmark legislation and its recent expansions to new populations, describe past research on the effects of this and other mental health/substance use disorder parity laws, and describe some directions for future research, including NQTL compliance issues, effects of parity on individuals with severe mental illness, and measurement of benefits other than mental health care use.

The spillover effects of health insurance benefit mandates on public insurance coverage: Evidence from veterans

This study examines how regulations in private health insurance markets affect coverage of public insurance. We focus on mental health parity laws, which mandate private health insurance to provide equal coverage for mental and physical health services. The implementation of mental health parity laws may improve a quality dimension of private health insurance but at increased costs. We graphically develop a conceptual framework and then empirically examine whether the regulations shift individuals from private to public insurance. We exploit state-by-year variation in policy implementation in 1999-2008 and focus on a sample of veterans, who have better access to public insurance than non-veterans. Using data from the Current Population Survey, we find that the parity laws reduce employer-sponsored insurance (ESI) coverage by 2.1% points. The drop in ESI is largely offset by enrollment gains in public insurance, namely through the Veterans Affairs (VA) benefit and Medicaid/Medicare programs.

The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among "carve-out" enrollees

Interrupted time series with and without controls was used to evaluate whether the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and its Interim Final Rule increased the probability of specialty behavioral health treatment and levels of utilization and expenditures among patients receiving treatment. Linked insurance claims, eligibility, plan and employer data from 2008 to 2013 were used to estimate segmented regression analyses, allowing for level and slope changes during the transition (2010) and post-MHPAEA (2011-2013) periods. The sample included 1,812,541 individuals ages 27-64 (49,968,367 person-months) in 10,010 Optum "carve-out" plans. Two-part regression models with Generalized Estimating Equations were used to estimate expenditures by payer and outpatient, intermediate and inpatient service use. We found little evidence that MHPAEA increased utilization significantly, but somewhat more robust evidence that costs shifted from patients to plans. Thus the primary impact of MHPAEA among carve-out enrollees may have been a reduction in patient financial burden.

THE EFFECT OF STATE INSURANCE MANDATES ON INFANT IMMUNIZATION RATES

While US infant immunization rates have been increasing in the last 20 years, the cost of fully immunizing a child with all recommended vaccines has almost tripled. This is partly not only due to new additions in the list of recommended vaccines but also due to the use of new, safer, but more expensive technologies in vaccine production and distribution. In recent years, many states have mandated that recommended childhood vaccines be covered by private health insurance companies. Currently, there are 33 states with such a mandate. In this paper, I examine whether the introduction of mandates on private insurers affected immunization rates. Using state and time variation, I find that mandates increased the immunization rate for three vaccines--the diphtheria-tetanus-pertussis, polio, and measles-mumps-rubella vaccines--by about 1.8 percentage points. These results may provide a lower bound for the expected effect of the Affordable Care Act, which mandates coverage of childhood vaccines for all private insurers in the USA. I also find evidence that the mandates shifted a significant portion of vaccinations from publicly funded sources to private ones, with a decline in public health clinic visits and an increase in vaccinations at hospitals and doctor's offices.

Colorectal Cancer Screening and State Health Insurance Mandates

Colorectal cancer (CRC) is the third most deadly cancer in the USA. CRC screening is the most effective way to prevent CRC death, but compliance with recommended screenings is very low. In this study, we investigate whether CRC screening behavior changed under state mandated private insurance coverage of CRC screening in a sample of insured adults from the 1997 to 2008 Behavioral Risk Factor Surveillance Survey (BRFSS). We present difference-in-difference-in-differences (DDD) estimates that compare insured individuals age 51 to 64 to Medicare age-eligible individuals (ages 66 to 75) in mandate and non-mandate states over time. Our DDD estimates suggest endoscopic screening among men increased by 2 to 3 percentage points under mandated coverage among 51 to 64 year olds relative to their Medicare age-eligible counterparts. We find no clear evidence of changes in screening behavior among women. DD estimates suggest no evidence of a mandate effect on either type of CRC screening for men or women.

Depression and Political Participation

In this paper, I propose that depression is a political phenomenon insofar as it has political sources and consequences. I then investigate one aspect of this argument-whether depression reduces participation. I hypothesize that individuals with depression lack the motivation and physical capacity to vote and engage in other forms of political participation due to somatic problems and feelings of hopelessness and apathy. Moreover, I examine how depression in adolescence can have downstream consequences for participation in young adulthood. The analyses, using both cross-sectional and longitudinal data, show that voter turnout and other forms of participation decrease as the severity of depressed mood increases. These findings are discussed in light of disability rights and potential efforts to boost participation among this group.

Heterogeneity and the effect of mental health parity mandates on the labor market

Health insurance benefit mandates are believed to have adverse effects on the labor market, but efforts to document such effects for mental health parity mandates have had limited success. I show that one reason for this failure is that the association between parity mandates and labor market outcomes vary with mental distress. Accounting for this heterogeneity, I find adverse labor market effects for non-distressed individuals, but favorable effects for moderately distressed individuals and individuals with a moderately distressed family member. On net, I conclude that the mandates are welfare increasing for moderately distressed workers and their families, but may be welfare decreasing for non-distressed individuals.

Effects of mental health benefits legislation: a community guide systematic review

CONTEXT

Health insurance benefits for mental health services typically have paid less than benefits for physical health services, resulting in potential underutilization or financial burden for people with mental health conditions. Mental health benefits legislation was introduced to improve financial protection (i.e., decrease financial burden) and to increase access to, and use of, mental health services. This systematic review was conducted to determine the effectiveness of mental health benefits legislation, including executive orders, in improving mental health.

EVIDENCE ACQUISITION

Methods developed for the Guide to Community Preventive Services were used to identify, evaluate, and analyze available evidence. The evidence included studies published or reported from 1965 to March 2011 with at least one of the following outcomes: access to care, financial protection, appropriate utilization, quality of care, diagnosis of mental illness, morbidity and mortality, and quality of life. Analyses were conducted in 2012.

EVIDENCE SYNTHESIS

Thirty eligible studies were identified in 37 papers. Implementation of mental health benefits legislation was associated with financial protection (decreased out-of-pocket costs) and appropriate utilization of services. Among studies examining the impact of legislation strength, most found larger positive effects for comprehensive parity legislation or policies than for less-comprehensive ones. Few studies assessed other mental health outcomes.

CONCLUSIONS

Evidence indicates that mental health benefits legislation, particularly comprehensive parity legislation, is effective in improving financial protection and increasing appropriate utilization of mental health services for people with mental health conditions. Evidence was limited for other mental health outcomes.

The impact of mental health insurance laws on state suicide rates

In the 1990s and early 2000s, a number of states passed laws requiring mental health benefits to be included in health insurance coverage. The variation in the characteristics and enactment date of the laws provides an opportunity to measure the impact of increasing access to mental health care on mental health outcomes, as evidenced by state suicide rates. In contrast with previous research, results show that when states enact laws requiring insurance coverage to include mental health benefits at parity with physical health benefits, the suicide rate decreases significantly by 5%. The findings are robust to a number of specifications and falsification tests.

The role of basic health insurance on depression: an epidemiological cohort study of a randomized community sample in northwest China

BACKGROUND

Little research has focused on the relationship between health insurance and mental health in the community. The objective of this study is to determine how the basic health insurance system influences depression in Northwest China.

METHODS

Participants were selected from 32 communities in two northwestern Chinese cities through a three-stage random sampling. Three waves of interviews were completed in April 2006, December 2006, and January 2008. The baseline survey was completed by 4,079 participants. Subsequently, 2,220 participants completed the first follow-up, and 1,888 completed the second follow-up. Depression symptoms were measured by the Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

A total of 40.0% of participants had at least one form of health insurance. The percentages of participants with severe depressive symptoms in the three waves were 21.7%, 22.0%, and 17.6%. Depressive symptoms were found to be more severe among participants without health insurance in the follow-up surveys. After adjusting for confounders, participants without health insurance were found to experience a higher risk of developing severe depressive symptoms than participants with health insurance (7 months: OR, 1.40; 95% CI, 1.09-1.82; p = 0.01; 20 months: OR, 1.89; 95% CI, 1.37-2.61; p < 0.001).

CONCLUSION

A lack of basic health insurance can dramatically increase the risk of depression based on northwestern Chinese community samples.

Mental health parity legislation, cost-sharing and substance-abuse treatment admissions

Treatment is highly cost-effective in reducing an individual's substance abuse (SA) and associated harms. However, data from Treatment Episodes (TEDS) indicate that per capita treatment admissions substantially lagged behind increases in heavy drug use from 1992 to 2007. Only 10% of individuals with clinical SA disorders receive treatment, and almost half who forgo treatment point to accessibility and cost constraints as barriers to care. This study investigates the impact of state mental health and SA parity legislation on treatment admission flows and cost-sharing. Fixed effects specifications indicate that mandating comprehensive parity for mental health and SA disorders raises the probability that a treatment admission is privately insured, lowering costs for the individual. Despite some crowd-out of charity care for private insurance, mandates reduce the uninsured probability by a net 2.4 percentage points. States mandating comprehensive parity also see an increase in treatment admissions. Thus, increasing cost-sharing and reducing financial barriers may aid the at-risk population in obtaining adequate SA treatment. Supply constraints mute effect sizes, suggesting that demand-focused interventions need to be complemented with policies supporting treatment providers. These results have implications for the effectiveness of the 2008 Federal Mental Health Parity and Addiction Equity Act in increasing SA treatment admissions and promoting cost-sharing.

Cohort-specific risk of suicide for different mental disorders in China

BACKGROUND

The effect of gender, age, and urban versus rural residence on suicide risk among people with different mental disorders is unknown.

AIMS

To estimate cohort-specific risk of suicide among people with different types of mental disorders using data from China's National Psychological Autopsy Study.

METHOD

Logistic regression models estimated adjusted odd ratios (OR) in 895 suicides and 701 injury deaths.

RESULTS

The adjusted risk of suicide for mood disorders was highest (OR = 44.2) followed by that for other mental disorders (OR = 10.7), anxiety disorders (OR = 10.2), psychotic disorders (OR = 7.4), substance use disorders (2.7) and organic mental disorders (OR = 1.2). Risk of suicide among urban residents with any mental disorder was more than double that of rural residents (OR = 15.5 v. 7.6, P = 0.008).

CONCLUSIONS

The suicide risk associated with mental illness varies by type of illness and by demographic cohort. Lower risk of suicide among rural residents with mental disorders highlights the importance of non-mental health approaches to the prevention and management of suicidal behaviour in rural areas of low- and middle-income countries.

Risk for suicide among medicaid beneficiaries

Demographic, diagnostic, and service expenditure characteristics of Florida Medicaid enrollees who died by suicide were investigated. Among persons receiving Medicaid and Supplemental Security Income (SSI), findings indicate the most powerful predictors of suicide were involuntary psychiatric examination, mental health hospitalization, and high mental health service use. Among Medicaid enrollees not receiving SSI, strongest suicide predictors were mental health hospitalization, high expenditures for physical health medications, and involuntary psychiatric examination. Findings suggest reducing involuntary psychiatric examinations and mental health hospitalizations while improving physical health may reduce suicide in the Medicaid population. Comprehensive hospital discharge planning, adherence monitoring with follow-up care, training mental health providers in assessing suicide lethality, and providing adequate assessment time are all crucial to achieve these objectives.

New Evidence on the Effects of State Mental Health Mandates

State mental health parity laws improve equity in private insurance coverage for mental and physical health services, but prior research shows no effect on service use. We study whether state parity differentially affects individuals by employer size since large firms are often exempt from state health mandates due to the Employee Retirement Income Security Act. We also examine whether state parity laws differentially affect use among individuals with low incomes or in poor mental health. We find that individuals in smaller firms are more likely to use services post-parity implementation and that this effect is concentrated among low-income individuals.