Effect of the Affordable Care Act's young adult insurance expansions on hospital-based mental health care

Association of Medicaid coverage with emergency department utilization after self-harm in Korea: A nationwide registry-based study

BACKGROUND

Self-harm presents an important public health challenge. It imposes a notable burden on the utilization of emergency department (ED) services and medical expenses from patients and family. The Medicaid system is vital in providing financial support for individuals who struggle with medical expenses. This study explored the association of Medicaid coverage with ED visits following incidents of self-harm, utilizing nationwide ED surveillance data in Korea.

METHODS

Data of all patients older than 14 years who presented to EDs following incidents of self-harm irrespective of intention to end their life, including cases of self-poisoning, were gathered from the National ED Information System (NEDIS). The annual self-harm visit rate (SHVR) per 100,000 people was calculated for each province and a generalized linear model analysis was conducted, with SHVR as a dependent variable and factors related to Medicaid coverage as independent variables.

RESULTS

A 1% increase in Medicaid enrollment rate was linked to a significant decrease of 14% in SHVR. Each additional 1,000 Korean Won of Medicaid spending per enrollee was correlated with a 1% reduction in SHVR. However, an increase in Medicaid visits per enrollee and an extension of Medicaid coverage days were associated with an increase in SHVR. SHVR exhibited a stronger associated with parameters of Medicaid coverage in adolescents and young adults than in older adult population.

CONCLUSION

Expansion of Medicaid coverage coupled with careful monitoring of shifts in Medicaid utilization patterns can mitigate ED overloading by reducing visits related to self-harm.

Effects of the Affordable Care Act Dependent Coverage Mandate on Health Insurance Coverage for Individuals in Same-Sex Couples

A large body of research documents that the 2010 dependent coverage mandate of the U.S. Affordable Care Act was responsible for significantly increasing health insurance coverage among young adults. No prior research has examined whether sexual minority young adults also benefitted from the dependent coverage mandate despite previous studies showing lower health insurance coverage among sexual minorities. Our estimates from the American Community Survey, using difference-in-differences and event study models, show that men in same-sex couples aged 21-25 experienced a significantly greater increase in the likelihood of having any health insurance after 2010 than older, 27- to 31-year-old men in same-sex couples. This increase is concentrated among employer-sponsored insurance, and it is robust to permutations of periods and age groups. Effects for women in same-sex couples and men in different-sex couples are smaller than the associated effects for men in same-sex couples. These findings confirm the broad effects of expanded dependent coverage and suggest that eliminating the federal dependent mandate could reduce health insurance coverage among young adult sexual minorities in same-sex couples.

Women's Coverage, Utilization, Affordability, And Health After The ACA: A Review Of The Literature

Women of working age (ages 19-64) faced specific challenges in obtaining health insurance coverage and health care before the Affordable Care Act. Multiple factors contributed to women's experiencing uninsurance, underinsurance, and increased financial burdens related to obtaining health care. This literature review summarizes evidence on the law's effects on women's health care and health and finds improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes. Despite major progress after the Affordable Care Act's implementation, barriers to coverage, access, and affordability remain, and serious threats to women's health still exist. Highlighting the law's effects on women's health is critical for informing future policies directed toward the continuing improvement of women's health care and health.

Private coverage mandates, business cycles, and provider treatment intensity

The Affordable Care Act (ACA) is the source of multiple large-scale health insurance expansions affecting various segments of the US population. Although much has been done to quantify the first-order effects of these policies, less empirical investigation has been devoted to the effects on the supply-side of health care. We focus on a well-known ACA initiative (the young adult dependent coverage mandate) to offer novel evidence on two fronts: the policy's heterogeneous effect across different labor markets and the potential for the policy-induced shift in payer mix to influence provider treatment decisions. First, we show that the federal mandate's direct effect on young adult private insurance take-up is strongly mitigated by the Great Recession. Second, we demonstrate that providers do not treat young adults more aggressively when more of them hold private coverage. Policymakers should keep these broader considerations and more diffuse risk protection implications in mind when contemplating changes to the law.

Insurance expansions and adolescent use of substance use disorder treatment

OBJECTIVE

To provide evidence on the effects of expansions to private and public insurance programs on adolescent specialty substance use disorder (SUD) treatment use.

DATA SOURCE/STUDY SETTING

The Treatment Episodes Data Set (TEDS), 1996 to 2017.

STUDY DESIGN

A quasi-experimental difference-in-differences design using observational data.

DATA COLLECTION

The TEDS provides administrative data on admissions to specialty SUD treatment.

PRINCIPAL FINDINGS

Expansions of laws that compel private insurers to cover SUD treatment services at parity with general health care increase adolescent admissions by 26% (P < .05). These increases are driven by nonintensive outpatient admissions, the most common treatment episodes, which rise by 30% (P < .05) postparity law. In contrast, increases in income eligibility for public insurance targeting those 6-18 years old are not statistically associated with SUD treatment.

CONCLUSIONS

Private insurance expansions allow more adolescents to receive SUD treatment, while public insurance income eligibility expansions do not appear to influence adolescent SUD treatment.

Association of Follow-Up After an Emergency Department Visit for Mental Illness with Utilization Based Outcomes

Follow-up within 30 days of an emergency department (ED) visit for mental illness is a new and widely-used quality measure. However, no empirical evidence validates associations between follow-up and subsequent utilization based outcomes. Using Massachusetts all payer claims data, we identified insured individuals with an ED visit for mental illness. Multivariate regression analysis estimated associations between follow-up within 30 days after an ED visit for mental illness with costs, hospitalizations, and additional ED visits in 180 days following the index visit. 63,814 index ED visits were included (56.5% female, mean [SD] age 38.0 [12.1] years, 48% Medicaid covered). 31% of index ED principal diagnoses were for major depressive disorder, 3% schizophrenia, 5% bipolar disorder, 34% anxiety disorder, 0.6% post-traumatic stress disorder, 8% other psychoses, and 19% other mental illness diagnoses. Only 33% of patients had a follow-up visit for mental illness within 30 days. Adjusted regression analyses show timely follow-up is associated with increased costs in the 180 days after (average marginal effect = $1622; 95% confidence interval [CI] 1459, 1786), an increased probability of inpatient hospitalization (2.7 percentage points; 95% CI 0.021, 0.032), and a small reduction in the probability of at least one additional ED visit (- 1.7 percentage points; 95% CI - 0.026 to 0.009). Overall follow-up rates are low; follow-up within 30 days of an ED visit for mental illness is associated with increased costs and increased probability of hospitalization in the follow-up period. It is not known whether increased rates of utilization improve patient outcomes, potentially by receiving appropriate more intensive care.

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.

Primary Care Physician Referral Patterns for Behavioral Health Diagnoses

OBJECTIVE

This study examined whether visits to primary care physicians (PCPs) by patients with a primary behavioral health diagnosis were more likely to be associated with referral to another physician and if so, whether the association varied by clinical condition.

METHODS

Using PCP visits (N=577,719,897) from the 2011-2015 National Ambulatory Medical Care Survey, the authors estimated logistic regression models of whether the probability of a referral differed between visits with and without a primary behavioral health diagnosis.

RESULTS

Visits with primary behavioral health diagnoses were 4.3 percentage points (p<0.05) more likely than visits with other primary diagnoses to result in a referral, after the analyses controlled for patient, insurance, physician, and organizational characteristics. The probability of referral varied by behavioral health condition.

CONCLUSIONS

Referral patterns for behavioral health diagnoses are an important component of high-quality primary care. Optimizing referral patterns is a key way to improve coordination of care and resource allocation.

Health Care Reform, Length of Stay, and Readmissions for Child Mental Health Hospitalizations

BACKGROUND

Health care reform may impact inpatient mental health services by increasing access and changing insurer incentives. We examined whether implementation of the 2014 Affordable Care Act (ACA) was associated with changes in psychiatric length of stay (LOS) and 30-day readmissions for pediatric patients.

METHODS

We conducted an interrupted time-series analysis to evaluate LOS and 30-day readmissions during the 30 months before and 24 months after ACA implementation, with a 6-month wash-out period, on patients aged 4 to 17 years who were discharged from the psychiatry unit of a children's hospital. Differences by payer (Medicaid versus non-Medicaid) were examined in moderated interrupted time series. Logistic regression was used to examine the association between psychiatric LOS and 30-day readmissions.

RESULTS

There were 1874 encounters in the pre-ACA period and 2186 encounters in the post-ACA period. Compared with pre-ACA implementation, post-ACA implementation was associated with LOS that was significantly decreasing over time (pre-ACA versus post-ACA slope difference: -0.10 days per encounter per month [95% confidence interval -0.17 to -0.02]; P = .01), especially for Medicaid-insured patients (pre-ACA versus post-ACA slope difference: -0.14 days per encounter per month [95% confidence interval -0.26 to -0.01]; P = .03). The overall proportion of 30-day readmissions increased significantly (pre-ACA 6%, post-ACA 10%; P < .05 for the difference). We found no association between LOS and 30-day readmissions.

CONCLUSIONS

ACA implementation was associated with a decline in psychiatric inpatient LOS over time, especially for those on Medicaid, and an increase in 30-day readmissions. LOS was not associated with 30-day inpatient readmissions. Further investigation to understand the drivers of these patterns is warranted.

The Affordable Care Act and Recent Reforms: Policy Implications for Equitable Mental Health Care Delivery

Controversy exists over how to ethically distribute health care resources and which factors should determine access to health care services. Although the US has traditionally used a market-based private insurance model that does not ensure universal coverage, the Patient Protection and Affordable Care Act (ACA) in the United States aims to increase equitable access to health care by increasing the accessibility, affordability, and quality of health care services. This article evaluates the impact of the ACA on equitable mental health care delivery according to access factors that can hinder or facilitate the delivery of mental health services based on need. The ACA has successfully expanded coverage to millions of Americans and promoted coordination and access to mental health care; however, financial and non-financial access barriers to mental health care and access disparities remain. Reform efforts should not undervalue the gains that the ACA has made but should attempt to balance considerations of cost and increasing free-market mechanisms with decreasing remaining health care disparities.

Did the Affordable Care Act Reach Penetrating Trauma Patients?

BACKGROUND

The benefits of the Affordable Care Act (ACA) for trauma patients have been well established. However, the ACA's impact on penetrating trauma patients (PTPs), a population that is historically young and uninsured, has not been defined. We hypothesized that PTPs in the post-ACA era would have better outcomes.

MATERIAL AND METHODS

The National Trauma Data Bank (NTDB) was queried for all PTPs from 2009 (pre-ACA) and 2011-2014 (post-ACA). Subset analysis was performed in patients aged 19-25 y, as this group was eligible for the ACA's dependent care provision (DCP).

RESULTS

There were 9,714,471 patients in the study, with 2,053,501 (21.1%) pre-ACA and 7,660,970 (78.9%) post-ACA. When compared to pre-ACA, patients in the post-ACA cohort were more likely to have commercial/private insurance, less likely to have Medicaid, and more likely to be uninsured. On logistic regression, the pre-ACA era was associated with mortality (HR: 1.02, 95% CI: 1.01-1.04, P = 0.004). Being uninsured was associated with mortality (HR: 1.89, 95% CI: 1.87-1.92, P < 0.001). On subset analysis of the DCP age group, post-ACA patients were more likely to be uninsured (24.1% versus 17.6%; P < 0.001). In addition, for the DCP age group, pre-ACA era was not associated with mortality (HR: 1.03, 95% CI: 0.99-1.06, P = 0.20).

CONCLUSIONS

Although the ACA provided a survival benefit to PTPs overall, it did not increase insurance coverage for this population. In addition, the DCP of the ACA did not improve insurance access for PTP in the eligible age group. Further efforts are needed to extend insurance access to this population.

Effects of ACA Expansion of Dependent Coverage on Hospital-Based Care of Young Adults With Early Psychosis

OBJECTIVE

Since 2010, the Affordable Care Act has required private health plans to extend dependent coverage to adults up to age 26. Because psychosis often begins in young adulthood, expanded private insurance benefits may affect early psychosis treatment. The authors examined changes in insurance coverage and hospital-based service use among young adults with psychosis before and after this change.

METHODS

The study included a national sample (2006-2013) of discharges and emergency department visits. Using a difference-in-differences study design, the authors compared changes in insurance coverage (measured as payer source), per capita admissions, and 30-day readmissions for psychosis before and after ACA dependent coverage expansion among targeted individuals (ages 20-25) and a comparison group (ages 27-29).

RESULTS

After dependent coverage expansion, hospitalization for psychosis among young adults was 5.8 percentage points more likely to be reimbursed by private insurance among the targeted age group (ages 20-25), compared with the slightly older age group (ages 27-29). Dependent coverage expansion was not associated with changes in overall insurance coverage, per capita admissions, or 30-day readmission for psychosis.

CONCLUSIONS

Although dependent coverage expansion was unrelated to changes in use of hospital-based treatments for psychosis among young adults, care was more likely to be covered by private insurance, and coverage of these hospitalizations by public insurance decreased. This shift from public to private insurance may reduce public spending on young-adult treatments for early-episode psychosis but may leave young adults without coverage for rehabilitation services.

Effects of the Affordable Care Act on Young Women With Gynecologic Cancers

OBJECTIVE

To evaluate the effects of the dependent coverage mandate of the 2010 Affordable Care Act (ACA) on insurance status, stage at diagnosis, and receipt of fertility-sparing treatment among young women with gynecologic cancer.

METHODS

We used a difference-in-differences design to assess insurance status, stage at diagnosis (stage I-II vs III-IV), and receipt of fertility-spearing treatment before and after the 2010 ACA among young women aged 21-26 years vs women aged 27-35 years. We used the National Cancer Database with the 2004-2009 surveys as the pre-ACA years and the 2011-2014 surveys as the post-ACA years. Women with uterine, cervical, ovarian, vulvar, or vaginal cancer were included. We analyzed outcomes for women overall and by cancer and insurance type, adjusting for race, nonrural area, and area-level household income and education level.

RESULTS

A total of 1,912 gynecologic cancer cases pre-ACA and 2,059 post-ACA were identified for women aged 21-26 years vs 9,782 cases pre-ACA and 10,456 post-ACA for women aged 27-35 years. The ACA was associated with increased insurance (difference in differences 2.2%, 95% CI -4.0 to 0.1, P=.04) for young women aged 21-26 years vs women aged 27-35 years and with a significant improvement in early stage at cancer diagnosis (difference in differences 3.6%, 95% CI 0.4-6.9, P=.03) for women aged 21-26 years. Receipt of fertility-sparing treatment increased for women in both age groups post-ACA (P for trend=.004 for women aged 21-26 years and .001 for women aged 27-35 years); there was no significant difference in differences between age groups. Privately insured women were more likely to be diagnosed at an early stage and receive fertility-sparing treatment than publicly insured or uninsured women throughout the study period (P<.001).

CONCLUSIONS

Under the ACA's dependent coverage mandate, young women with gynecologic cancer were more likely to be insured and diagnosed at an early stage of disease.

Higher Benefit for Greater Need: Understanding Changes in Mental Well-being of Young Adults Following the ACA Dependent Coverage Mandate

BACKGROUND

Beginning in late 2010, private health insurance plans were required to allow dependents up to age 26 to remain on a parent's plan. Known as the dependent coverage or young adult mandate, this provision increased coverage substantially within the group of 19-25 year-olds affected by the policy change. Subsequent work evaluating whether increased coverage had a positive effect on mental health found mild improvements in self-reported mental health. This work focused exclusively on average effects among young adults in the years after the policy change, leaving open the question of how young adults fared depending on where they reside in terms of the distribution of risk for mental health issues.

AIMS OF THE STUDY

We assess the effects of the dependent coverage mandate on young adult mental well-being focusing on the distribution of mental health issues. We seek to understand how potential improvements (or degradations) differ across the entire risk profile. Gains among individuals who are at low risk for severe mental health issues may send a far different signal than gains among those with higher risks.

METHODS

Using MEPS data from 2006 through 2013, we use quantile regression within a difference-in-differences design to compare pre/post outcomes across the distribution of risk for young adults ages 23-25 affected by the mandate to 27-29 year-olds not affected by the mandate. Further, we evaluate differences in the effect of the mandate by sex, given well-known disparities in incidence and prevalence of mental illness between men and women. To gauge the effects of the mandate on mental health, we use the Mental Component Score measure within the MEPS, ideal for our quantile regression given the broad range of scores. The key premise in our evaluation is that individuals with higher risks for mental health problems due to biological or socioeconomics factors are more likely to rank at locations of the mental health score distribution indicating worse outcomes.

RESULTS

We find significant improvements in self-reported mental health in the 23-25 year-old group following the mandate. However, the gains were not equal across the risk distribution. For individuals at the 0.1 quantile (worse self-reported mental health), the improvement in MCS scores was significant, a 6.1% increase compared to the pre-mandate baseline at that quantile. Effects were smaller but still significant at the median but there was no apparent effect for those that were at higher levels of self-reported mental health. Our results also suggest improvements for women (+9% relative to baseline at the 0.1 quantile, e.g.) but limited evidence of an effect for men.

IMPLICATIONS FOR FUTURE RESEARCH

The finding that increased insurance coverage led to improved self-reported mental health foremost for young adults with the highest risk of mental health problems is encouraging. However, the mechanism for this effect is unclear and in need of further study. Whether improvements in the mental health status of the population depend more on increased access to services or derive primarily from improved financial security is an important research area.

Impacts of the Dependent Care Expansion on the Allocation of Mental Health Care

We examine the impact of insurance expansion under the Affordable Care Act's Dependent Care Expansion (DCE) on allocation of mental health care across illness severity, types of care and racial/ethnic groups. Evidence suggests that the increase in mental health care utilization resulting from the DCE was restricted to individuals with clinically significant mental health conditions. There is no evidence suggesting that the increase occurred disproportionately in medication-only treatment or that it increased racial/ethnic disparities. The DCE appears to have been successful in increasing utilization of mental health care among a high need group without lowering quality or increasing disparities.

Young Adults' Selection and Use of Dependent Coverage under the Affordable Care Act

The dependent coverage expansion under the Affordable Care Act (ACA) required health insurance policies that cover dependents to offer coverage for policyholder' children up to age 26. It has been well documented that the provision successfully reduced the uninsured rate among the young adults. However, less is known about whether dependent coverage crowded out other insurance types and whether young adults used dependent coverage as a fill-in-the-gap short-term option. Using data from the Survey of Income and Program Participation 2008 Panel, the paper assesses dependent coverage uptake and duration before and after the ACA provision among young adults aged 19-26 versus those aged 27-30. Regressions for additional coverage outcomes were also performed to estimate the crowd-out rate. It was found that the ACA provision had a significant positive impact on dependent coverage uptake and duration. The estimated crowd-out rate ranges from 27 to 42%, depending on the definition. Most dependent coverage enrollees used the coverage for 1 or 2 years. Differences in dependent coverage uptake and duration remained among racial groups. Less healthy individuals were also less likely to make use of dependent coverage.

Access to Health Insurance and Utilization of Substance Use Disorder Treatment: Evidence from the Affordable Care Act Dependent Coverage Provision

The relationship between insurance coverage and use of specialty substance use disorder (SUD) treatment is not well understood. In this study, we add to the literature by examining changes in admissions to SUD treatment following the implementation of a 2010 Affordable Care Act provision requiring health insurers to offer dependent coverage to young adult children of their beneficiaries under age 26. We use national administrative data on admissions to specialty SUD treatment and apply a difference-in-differences design to study effects of the expansion on the rate of treatment utilization among young adults and, among those in treatment, changes in insurance status and payment source. We find that admissions to treatment declined by 11% after the expansion. However, the share of young adults covered by private insurance increased by 5.4 percentage points and the share with private insurance as the payment source increased by 3.7 percentage points. This increase was largely offset by decreased payment from government sources. Copyright © 2017 John Wiley & Sons, Ltd.

Healthcare Access Among Young Adults: Impact of the Affordable Care Act on Young Adults With Hypertension

INTRODUCTION

The Patient Protection and Affordable Care Act provision implemented policies to improve coverage for young adults. It is not known if it affected access to care among young adults with hypertension.

METHODS

National Health Interview Survey data from 2006 to 2009 and 2011 to 2014 were used. Young adults aged 19-25 years were assessed for potential barriers to access to health care. The authors compared the percentage of each indicator of barriers to access to health care among young adults in general, as well as those with hypertension in the two time periods and estimated the AOR. All data were self-reported. The analyses were conducted in 2016.

RESULTS

Among young adults, the frequencies of barrier indicators were significantly lower in 2011-2014 than 2006-2009, except "did not see doctor in the past 12 months." Among those with hypertension, the percentage reporting "no health insurance" (31.3% vs 23.3%, p=0.037); "no place to see a doctor when needed" (30.5% vs 21.6%, p=0.031); or "cannot afford prescribed medicine" (23.0% vs 15.3%, p=0.023) were significantly lower in 2011-2014 compared with that of 2006-2009. The differences maintained statistical significance after adjusting for sex, race/ethnicity, and level of education.

CONCLUSIONS

Significant differences in select access to care measures were found among young adults with hypertension between 2006-2009 and 2011-2014, as was found among young adults generally. Changes in extension of dependent insurance coverage in 2010 may have led to improvements in access to care among this group.

Relative reductions in health care utilization among young adults before aging out of extended dependent coverage

The 2010 Affordable Care Act extended dependent coverage for adult children up to age 26 in the USA. Since then, considerable studies have assessed its various impacts among young adults. However, little is known about whether there is any change in health care use when young adults age out of dependent coverage. This study examines health care consumption changes among young adults prior to their aging out process. I used data from a large insurance claim database and studied health care utilization of young adults under parents' coverage during a 2-year period in a difference-in-difference framework. I found that young adults had relative reductions in health services use, except ER visits, compared with individuals who stayed under parents' coverage. This pattern was the same for both male and females. Individuals with regular medical needs had greater relative reductions compared with those without regular medical needs. The relative reductions in health care use during the aging out process may have an important impact on young adults' health, especially for those with regular medical needs. More efforts could be made to help them maintain regular medical utilization during the transition.

The Affordable Care Act: Disparities in emergency department use for mental health diagnoses in young adults

BACKGROUND

There is little consensus as to the effects of insurance expansion on emergency department (ED) utilization for mental health purposes. We aimed to study the race specific association between the dependent coverage provision of the Affordable Care Act (ACA) and changes in young adults' usage of emergency department services for psychiatric diagnoses.

METHODS

We utilized a Quasi-Experimental analysis of ED use in California from 2009-2011 for behavioral health diagnoses of individuals aged 19 to 31 years. Analysis used a difference-in-differences approach comparing those targeted by the ACA dependent provision (19-25 years) and those who were not (27 to 31 years), evaluating changes in ED visit rates per 1 000 in California. Primary outcomes measured included the quarterly ED visit rates with any psychiatric diagnosis. Subgroups were analyzed for differences based on race and gender.

RESULTS

The ACA dependent provision was associated with 0.05 per 1 000 people fewer psychiatric ED visits among the treatment group (19-25 years) compared to the control group (27-31 years). Hispanics and Asian/Pacific Islanders were the only racial subgroups who did not see this significant reduction and were the only racial subgroups that did not see significant gains in the proportion of psychiatric ED visits covered by private insurance.

CONCLUSION

The ACA dependent provision was associated with a modest reduction in the growth rate of ED use for psychiatric reasons, however, racial disparities in the effect of this provision exist for patients of Hispanic and Asian/Pacific Islander racial groups.

Impact of the Affordable Care Act's Dependent Coverage Expansion on the Health Care and Health Status of Young Adults: What Do We Know So Far?

The dependent coverage expansion (DCE), a component of the Affordable Care Act, required private health insurance policies that cover dependents to offer coverage for policyholders' children through age 25. This review summarizes peer-reviewed research on the impact of the DCE on the chain of consequences through which it could affect public health. Specifically, we examine the impact of the DCE on insurance coverage, access to care, utilization of care, and health status. All studies find that the DCE increased insurance coverage, but evidence regarding downstream impacts is inconsistent. There is evidence that the DCE reduced high out-of-pocket expenditures and frequent emergency room visits and increased behavioral health treatment. Evidence regarding the impact of the DCE on health is sparse but suggestive of positive impacts on self-rated health and health behavior. Inferences regarding the public health impact of the DCE await studies with greater methodological diversity and longer follow-up periods.

The ACA: Impacts on Health, Access, and Employment

On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law. This comprehensive health care reform legislation sought to expand health care coverage to millions of Americans, control health care costs, and improve the overall quality of the health care system. The ACA required that all US citizens and legal residents have qualifying health insurance by 2014. In this paper we give readers a brief overview of the effects of the ACA based on recent research. We then turn our attention to the possibility of using the ACA expansion to answer important underlying questions, such as: To what extent does the holding of insurance lead to improvements in access to care? To what extent does the holding of coverage lead to improvements in health? In mental health? Are there likely general equilibrium effects on labor force participation, hours worked, employment setting, and indeed even the probability of marrying? By necessity, researchers' ability to answer these questions depends on the availability of data, so we discuss current and potential data sources relevant for answering these questions. We also look to what has been studied about the health reform in Massachusetts and early Medicaid expansions to speculate what we can expect to learn about the effects of the ACA on these outcomes in the future.

Key Provisions of the Patient Protection and Affordable Care Act (ACA): A Systematic Review and Presentation of Early Research Findings

OBJECTIVES

To conduct a systematic literature review of selected major provisions of the Affordable Care Act (ACA) pertaining to expanded health insurance coverage. We present and synthesize research findings from the last 5 years regarding both the immediate and long-term effects of the ACA. We conclude with a summary and offer a research agenda for future studies.

STUDY DESIGN

We identified relevant articles from peer-reviewed scholarly journals by performing a comprehensive search of major electronic databases. We also identified reports in the "gray literature" disseminated by government agencies and other organizations.

PRINCIPAL FINDINGS

Overall, research shows that the ACA has substantially decreased the number of uninsured individuals through the dependent coverage provision, Medicaid expansion, health insurance exchanges, availability of subsidies, and other policy changes. Affordability of health insurance continues to be a concern for many people and disparities persist by geography, race/ethnicity, and income. Early evidence also indicates improvements in access to and affordability of health care. All of these changes are certain to ultimately impact state and federal budgets.

CONCLUSIONS

The ACA will either directly or indirectly affect almost all Americans. As new and comprehensive data become available, more rigorous evaluations will provide further insights as to whether the ACA has been successful in achieving its goals.

Reducing Young Adults' Health Care Spending through the ACA Expansion of Dependent Coverage

OBJECTIVE

To estimate health care expenditure trends among young adults ages 19-25 before and after the 2010 implementation of the Affordable Care Act (ACA) provision that extended eligibility for dependent private health insurance coverage.

DATA SOURCES

Nationally representative Medical Expenditure Panel Survey data from 2008 to 2012.

STUDY DESIGN

We conducted repeated cross-sectional analyses and employed a difference-in-differences quantile regression model to estimate health care expenditure trends among young adults ages 19-25 (the treatment group) and ages 27-29 (the control group).

PRINCIPAL FINDINGS

Our results show that the treatment group had 14 percent lower overall health care expenditures and 21 percent lower out-of-pocket payments compared with the control group in 2011-2012. The overall reduction in health care expenditures among young adults ages 19-25 in years 2011-2012 was more significant at the higher end of the health care expenditure distribution. Young adults ages 19-25 had significantly higher emergency department costs at the 10th percentile in 2011-2012. Differences in the trends of costs of private health insurance and doctor visits are not statistically significant.

CONCLUSIONS

Increased health insurance enrollment as a consequence of the ACA provision for dependent coverage has successfully reduced spending and catastrophic expenditures, providing financial protections for young adults.

The ACA's Dependent Coverage Expansion and Out-of-Pocket Spending by Young Adults With Behavioral Health Conditions

OBJECTIVE

Young adults with behavioral health conditions (mental or substance use disorders) often lack access to care. In 2010, the Affordable Care Act (ACA) extended eligibility for dependent coverage under private health insurance, allowing young adults to continue on family plans until age 26. The objective of this study was to analyze out-of-pocket (OOP) spending as a share of total health care expenditures for young adults with behavioral health conditions before and after the implementation of the ACA dependent care provision. The study examined the population of young adults with behavioral health conditions overall and by race and ethnicity.

METHODS

The study analyzed 2008-2009 and 2011-2012 nationally representative data from the Medical Expenditure Panel Survey with zero-or-one inflated beta regression models in a difference-in-differences framework to estimate the impact of the ACA's dependent coverage expansion. OOP spending was examined as a share of total health care expenditures among young adults with behavioral health disorders. The study compared the treatment group of individuals ages 19-25 (unweighted N=1,158) with a group ages 27-29 (unweighted N=668).

RESULTS

Young adults ages 19-25 with behavioral health disorders were significantly less likely than the older group to have high levels of OOP spending after the implementation of the ACA's dependent coverage expansion. The reduction was pronounced among young adults from racial-ethnic minority groups.

CONCLUSIONS

The extension of health insurance coverage to young adults with behavioral health disorders has provided them with additional financial protection, which can be important given the low incomes and high debt burden that characterize the age group.

The Effects of the Affordable Care Act Adult Dependent Coverage Expansion on Mental Health

BACKGROUND

In September 2010, the Affordable Care Act increased the availability of private health insurance for young adult dependents in the United States and prohibited coverage exclusions for their pre-existing conditions. The coverage expansion improved young adults' financial protection from medical expenses and increased their mental health care use. These short-term effects signal the possibility of accompanying changes in mental health through one or more mechanisms: treatment-induced symptom relief or improved function; improved well-being and/or reduced anxiety as financial security increases; or declines in self-reported mental health if treatment results in the discovery of illnesses.

AIMS

In this study, we estimate the effects of this insurance coverage expansion on young adults' mental health outcomes one year after its implementation.

METHODS

We use a difference-in-differences (DD) framework to estimate the effects of the ACA young adult dependent coverage on mental health outcomes for adults ages 23-25 relative to adults ages 27-29 from 2007-2011. Outcome measures include a global measure of self-rated mental health, the SF-12 mental component summary (MCS), the PHQ-2 screen for depression, and the Kessler index for non-specific psychological distress.

RESULTS

The overall pattern of findings suggests that both age groups experienced modest improvements in a range of outcomes that captured both positive and negative mental health following the 2010 implementation of the coverage expansion. The notable exception to this pattern is a 1.4 point relative increase in the SF-12 MCS score among young adults alone, a measure that captures emotional well-being, mental health symptoms (positive and negative), and social role functioning.

DISCUSSION

This study provides the first estimates of a broad range of mental health outcomes that may be responsive to changes in mental health care use and/or the increased financial security that insurance confers. For the population as a whole, there were few short-term changes in young adults' mental health outcome relative to older adults. However, the relative increase in the SF-12 score among young adults, while small, is likely meaningful at a population level given the observed effect sizes for this measure obtained in clinical trials.

IMPLICATIONS

The vast majority of mental illnesses emerge before individuals reach age 24. Public policy designed to expand health insurance coverage to this population has the potential to influence mental health in a relatively short time frame.

Growth in spending on substance use disorder treatment services for the privately insured population

BACKGROUND

Approximately 8% of individuals with private health insurance in the United States have substance use disorders (SUDs), but in 2009 only 0.4% of all private insurance spending was on SUDs. The objective of this study was to determine if changes that occurred between 2009 and 2012 - such as more generous SUD benefits, an epidemic of opioid use disorders, and slow recovery from a recession - were associated with greater use of SUD treatment.

METHODS

Data were from the 2004-2012 Truven Health Analytics MarketScan(®) Commercial Claims and Encounters Database. This database is representative of individuals with private insurance in the United States. Per enrollee use of and spending on SUD treatment was determined and compared with spending on all health care services. Trends were examined for inpatient care, outpatient care, and prescription medications.

RESULTS

During the 2009-2012 time period, use of and spending on SUD services increased compared with all diagnoses. Two-thirds of the increase was driven by higher growth rates in outpatient use and prices. Despite the high growth rates, SUD treatment penetration rates remained low. As of 2012, only 0.6% of individuals with private insurance used SUD outpatient services, 0.2% filled SUD medication prescriptions, and 0.1% used inpatient SUD services. In 2012, SUD services accounted for less than 0.7% of all private insurance spending.

CONCLUSIONS

Despite recent coverage improvements, individuals with private health insurance still may not receive adequate levels of treatment for SUDs, as evidenced by the small proportion of individuals who access treatment.

Impact of the Patient Protection and Affordable Care Act on Emergency Psychiatry

Emergency psychiatry (EP) is an integral component of comprehensive hospital-based emergency care. EP developed and grew into a medical subspecialty in response to deinstitutionalization and other large-scale forces, resulting in large numbers of psychiatric patients presenting to emergency departments. The Affordable Care Act (ACA) of 2010 contains several features and provisions that are likely to impact the practice of EP. This article reviews and examines the impact of the ACA on psychiatric emergency care to date and anticipated in the near future.

Effects of the Affordable Care Act's young adult insurance expansion on prescription drug insurance coverage, utilization, and expenditures

BACKGROUND

The US Affordable Care Act (ACA) extended the age of eligibility for young adults to remain on their parents' health insurance plans in order to address the disproportionate number of uninsured young adults in the United States. Effective September 23, 2010, the ACA has required all private health insurance plans to cover dependents until the age of 26. However, it is unknown whether the ACA dependent coverage expansion had an impact on prescription drug insurance or the use of prescription drugs.

OBJECTIVES

To evaluate short-term changes in prescription health insurance coverage, prescription drug insurance coverage, prescription drug use, and prescription drug expenditures following implementation of the ACA young adult insurance expansion using national data from 2009 and 2011.

RESULTS

Full-year health insurance coverage increased 4.9 percentage points during the study period, which was mainly due to increases in private health insurance among middle- and high-income young adults. In contrast, full-year prescription drug insurance coverage increased 5.5 percentage points and was primarily concentrated among high-income young adults. Although no significant short-term changes in overall prescription drug use were observed, a 30% decrease in out-of-pocket expenditures was seen among young adults.

CONCLUSIONS

While the main goal of the ACA's young adult insurance expansion was to increase health insurance coverage among young adults, it also had the unintended positive effect of increasing coverage for prescription drug insurance. Additionally, young adults experienced substantial decreases in out-of-pocket spending for prescription drugs. It is important for evaluations of health care policies to assess both intended and unintended outcomes to better understand the implications for the broader health system.

The Effects of Medicaid Eligibility on Mental Health Services and Out-of-Pocket Spending for Mental Health Services

OBJECTIVE

Millions of low-income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out-of-pocket spending.

DATA SOURCES

Secondary data from the 1998-2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.

STUDY DESIGN

Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out-of-pocket spending for mental health services.

DATA EXTRACTION METHODS

Person-year files were constructed including adults ages 21-64 under 300 percent of the Federal Poverty Level.

PRINCIPAL FINDINGS

Medicaid expansions significantly increased health insurance coverage and reduced out-of-pocket spending on mental health services for low-income adults. Effects of expanded Medicaid eligibility on out-of-pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.

CONCLUSIONS

Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out-of-pocket mental health care spending.