An ACA provision increased treatment for young adults with possible mental illnesses relative to comparison group

The impact of the 2014 Medicaid expansion on the health, health care access, and financial well-being of low-income young adults

Prior to the 2014 Affordable Care Act (ACA) expansion, 37% of young adults ages 19-25 in the United States were low-income and a third lacked health insurance coverage-both the highest rates for any age group in the population. The ACA's Medicaid eligibility expansion, therefore, would have been significantly beneficial to low-income young adults. This study evaluates the effect of the ACA Medicaid expansion on the health, health care access and utilization, and financial well-being of low-income young adults ages 19-25. Using 2010-2017 National Health Interview Survey data, I estimate policy effects by applying a difference-in-differences design leveraging the variation in state implementation of the expansion policy. I show that Medicaid expansion improved health insurance coverage, health care access, and financial well-being for low-income young adults in expansion states, but had no effect on their health status and health care utilization. I also find that the policy was associated with larger gains in health coverage for racial minorities relative to their Non-Hispanic White counterparts. With the continued health policy reform debates at the state and federal levels, the empirical evidence from this study can help inform policy decisions that aim to improve health care access and utilization among disadvantaged groups.

Interruptions in Insurance Coverage and Prescription Drug Utilization: Evidence from Kentucky

This study examined how interruptions in insurance coverage affect purchases of prescription drugs for young adults. It used data spanning 2014 to 2018 from Kentucky's prescription drug monitoring program, which tracked the universe of federally-regulated (Schedule II-V) prescription drugs dispensed in the state. The study employed a regression discontinuity design based on the age limit at 26 for dependent insurance coverage for children. At age 26, the probability of purchasing a prescription decreased by 5%, with all subcategories of prescriptions affected. The share of generic prescriptions increased for stimulants (the only category observed with substantial branded prescriptions). By age 27, prescription purchases returned to levels observed at 25, but the share purchased with public insurance and the generic share for stimulants remained higher. The findings suggest that interruptions in insurance coverage decrease prescription drug utilization by young adults and that public insurance programs such as Medicaid are important for resuming treatment.

Impacts of the Affordable Care Act Medicaid Expansion on Mental Health Treatment Among Low-income Adults Across Racial/Ethnic Subgroups, 2010-2017

This study examines whether the Affordable Care Act (ACA) Medicaid expansion (ME) was associated with changes in racial/ethnic disparities in insurance coverage, utilization, and quality of mental health care among low-income adults with probable mental illness using the National Survey on Drug Use and Health with state identifiers. This study employed difference-in-difference models to compare ME states to non-expansion states before (2010-2013) and after (2014-2017) expansion and triple difference models to examine these changes across non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic/Latino racial/ethnic subgroups. Insurance coverage increased significantly for all racial/ethnic groups in expansion states relative to non-expansion states (DD: 9.69; 95% CI: 5.17, 14.21). The proportion low-income adults that received treatment but still had unmet need decreased (DD: -3.06; 95% CI: -5.92, -0.21) and the proportion with unmet need and no mental health treatment increased (DD: 2.38; 95% CI: 0.03, 4.73). ME was not associated with reduced disparities.

The highs and the lows: Recreational marijuana laws and mental health treatment

Recreational marijuana laws (RMLs) continue to grow in popularity, but the effects on mental health treatment are unclear. This paper uses an event-study within a difference-in-differences framework to study the short-run impact of state RMLs on admissions into mental health treatment facilities. The results indicate that shortly after a state adopts an RML, they experience a decrease in the average number of mental health treatment admissions. The findings are driven by white, Black, and Medicaid-funded admissions and are consistent for both male and female admissions. The results are robust to alternative specifications and sensitivity analysis.

Medicaid Expansion and mental health treatment: Evidence from the Affordable Care Act

This study uses a difference-in-differences design within an event-study framework to examine how state decisions to expand Medicaid following the passage of the Affordable Care Act (ACA) affected mental health treatment. The findings suggest that expansion states experienced increased admissions to mental health treatment facilities and Medicaid-reimbursed prescriptions for medications used to treat common forms of mental illness. The results also indicate an increase in admissions with trauma, anxiety, conduct, and depression disorders. There is also suggestive evidence of an increase in the number of mental health treatment facilities accepting Medicaid as a form of payment. Lastly, as with previous studies, I find weak evidence of a decrease in suicides in Medicaid expansion states. These findings highlight the vital role of the ACA in providing access to mental health treatment for low-income Americans.

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.

Trends in Alcohol Use Disorder Treatment Utilization and Setting From 2008 to 2017

OBJECTIVE

Little is known about recent trends in treatment for alcohol use disorder. The authors used national data to examine treatment trends among individuals with alcohol use disorder.

METHODS

A sample of nonelderly adults (ages 18-64 years, N=36,707) with alcohol use disorder was identified from the National Survey on Drug Use and Health. Multinomial logistic regression analysis was conducted to examine trends in treatment for alcohol use disorder in 2008-2010, 2011-2013, and 2014-2017 in any medical setting (hospitals, rehabilitation centers, mental health centers, emergency departments, and private doctors' offices), self-help groups only (no medical setting), and no setting (i.e., no treatment). Additional analyses investigated trends in mental health treatment. Regression models adjusted for predisposing, enabling, and need-related characteristics.

RESULTS

Among those with an alcohol use disorder, the percentage who received any treatment was significantly lower in 2011-2013 (5.6%) than in 2008-2010 (6.9%) (p<0.05). In adjusted analyses, the probability of receiving no treatment increased by 1.5 percentage points in 2014-2017 (95% CI=0.5-2.5) compared with the 2008-2010 baseline. Significant declines were observed in the receipt of any treatment in a medical setting (marginal effect [ME]=-1.0%, 95% CI=-2.0 to -0.0) and self-help treatment only (ME=-0.5%, 95% CI=-0.8 to -0.1) in 2014-2017 compared with the baseline period. The probability of receiving any mental health treatment did not change during the study period.

CONCLUSIONS

Among persons with an alcohol use disorder, treatment declined from 2008 to 2017. Future studies should examine the mechanisms that may be responsible for this decline.

The Affordable Care Act's young adult mandate was associated with a reduction in pain prevalence

ABSTRACT

Pain is a major health problem among U.S. young adults. The passage of the Affordable Care Act's young adult mandate in 2010 allowed individuals to remain on their parents' health insurance until age 26. Although studies have documented the positive effects of this mandate on various health outcomes, less is known about its association with self-reported pain among young adults. Using the 2002 to 2018 National Health Interview Survey (N = 48,053) and a difference-in-differences approach, we compared the probabilities of reporting pain at 5 sites (low back, joint, neck, headache/migraine, and facial/jaw) and the number of pain sites between mandate eligible (ages 20-25) and ineligible (ages 26-30) adults before and after the mandate. In fully adjusted models, the mandate was associated with a decline of 2 percentage points in the probability of reporting pain at any site (marginal effect, -0.02; 95% confidence interval [CI], -0.05 to -0.002; weighted sample proportion, 0.37) and in the number of pain sites (coefficient, -0.07; 95% CI, -0.11 to -0.01; weighted sample average, 0.62). These results were primarily driven by the association between the mandate and the probability of reporting low back pain (marginal effect, -0.03; 95% CI, -0.05 to -0.01; weighted sample proportion, 0.20). Additional analyses revealed that the mandate was associated with improvements in access to care and reductions in risk factors for pain-including chronic conditions and risky health behaviors. To the extent that the results are generalizable to other health insurance programs, removing financial barriers to medical care may help reduce pain prevalence.

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.

Effective Partnership Care Models with Advanced Practice Psychiatric Nurses

The unmet behavioral health treatment needs of children and adolescents have become a public health crisis in the United States, with only 20% of youths obtaining assessment and intervention when indicated. Workforce shortages, including mental health professionals who can provide pharmacologic intervention within an appropriate biopsychosocial context, directly impede our ability to address this crisis. The authors examine the history, education, regulation, and practice of advanced practice psychiatric nurses and consider models of collaborative practice that can be beneficial across treatment settings in order to provide better care of vulnerable youth in ways that foster partnership rather than competition.

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.

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.

Impact of the affordable care act on utilization of benefits of eye care and primary care examinations

Purpose

To determine the impact of the Affordable Care Act (ACA) on utilization of benefits of both eye care and primary care examinations in individuals who did not have health insurance prior to the ACA.

Methods

Patients examined in an urban eye clinic from 2017 to 2018 were invited to participate. Patients were classified into two groups: Insured Group, who had health insurance before and after the ACA; The ACA Group, who had insurance only after the ACA. Patients were surveyed on how often they were examined by their eye care and primary care physicians before and after the ACA. The care utilization frequency was categorized into 3 levels: Frequent Care Use, Rare Care Use, and Never. To test the utilization of benefits frequency difference between two groups, the z-ratio was calculated.

Results

A total of 4,355 patients were enrolled with 87.1% in the Insured Group and 12.9% in the ACA Group. After the ACA implementation, the percentage of “Frequent Care Use” of the eye care and primary care in the ACA Group patients significantly increased from 31.2% and 53.7% to 57.9% and 74.9%, respectively (P<0.001), but were significantly lower than those in the Insured Group (76.6% and 93.9%, P < 0.001).

Conclusion

The ACA significantly improved utilization of benefits of eye care and primary care for individuals in the ACA Group. Although improved, those patients who received health insurance through the ACA still had lower utilization of benefits than those in the Insured Group.

Understanding the Interplay Between Health Disparities and Epigenomics

Social epigenomics has emerged as an integrative field of research focused on identification of socio-environmental factors, their influence on human biology through epigenomic modifications, and how they contribute to current health disparities. Several health disparities studies have been published using genetic-based approaches; however, increasing accessibility and affordability of molecular technologies have allowed for an in-depth investigation of the influence of external factors on epigenetic modifications (e.g., DNA methylation, micro-RNA expression). Currently, research is focused on epigenetic changes in response to environment, as well as targeted epigenetic therapies and environmental/social strategies for potentially minimizing certain health disparities. Here, we will review recent findings in this field pertaining to conditions and diseases over life span encompassing prenatal to adult stages.

Transition Cliffs for Young Adults with Anxiety and Depression: Is Integrated Mental Health Care a Solution?

Young adulthood is a major transition period, particularly challenging for those with mental disorders. Though the prevalence of depressive and anxiety disorders is especially high, young adults are less likely to receive mental health treatment than younger and older individuals. Reasons for this mental health treatment gap are multifold and range from individual- to system-level factors that must be taken into consideration when addressing young adult mental health needs. Studies in adults and adolescents have shown that integrated care in primary care settings is an effective model of treatment of mental disorders. After providing an overview of the mental health treatment gap in this developmental period, the argument is made for research focused on integrated care models specifically tailored for young adults that takes into consideration the various needs and challenges that they face and addresses the mental health treatment gap in young adulthood.

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.

Mental Health Treatment Among Individuals Involved in the Criminal Justice System After Implementation of the Affordable Care Act

OBJECTIVE

The objective of this study was to assess changes in health insurance coverage and mental health treatment among individuals with and without involvement in the criminal justice system after implementation of key provisions of the Affordable Care Act (ACA).

METHODS

Data from the National Survey on Drug Use and Health were used to assess changes in coverage, mental health treatment, and payer between 2011-2013 and 2014-2017 for nonelderly adults (ages 19 to 64) with and without criminal justice involvement in the past year who reported serious psychological distress. Multivariable logistic regression was used to obtain adjusted estimates.

RESULTS

The weighted sample represented, on average, 2.0 million individuals with criminal justice involvement (total unweighted N=3,688) and 20.9 million without criminal justice involvement (total unweighted N=33,872) in each study year. Following implementation of the ACA's key provisions, health insurance coverage increased by 13.4 percentage points (95% CI=8.5-18.3) among individuals with past year criminal justice involvement and by 8.1 percentage points (95% CI=6.9-9.4) among those without. Receipt of any mental health treatment did not change significantly among individuals with criminal justice involvement (-3.4 percentage points [95% CI=-8.0 to 1.1]), whereas it increased significantly in the general population (2.2 percentage points [95% CI=0.4-3.9]).

CONCLUSIONS

Despite an increase in health insurance coverage for people with criminal justice involvement, there was no increase in mental health treatment following implementation of the ACA's key provisions. Health insurance coverage is necessary, but not sufficient, to expand access to mental health treatment for individuals involved in the criminal justice system.

The Effects of Federal Parity on Mental Health Services Use and Spending: Evidence From the Medical Expenditure Panel Survey

OBJECTIVE

This study evaluated the effects of the federal Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 on the use of outpatient and clinic-based mental health services and spending on those services.

METHODS

Data came from the 2005-2013 Medical Expenditure Panel Survey. The analytic sample included adults ages 26-64 who were continuously enrolled in employer-sponsored insurance for a calendar year (N=66,602 person-year observations). A difference-in-differences study design was used to compare changes in outcomes before and after implementation of the MHPAEA between people whose insurance plan was or was not affected by the law.

RESULTS

The federal parity law was not significantly associated with changes in the likelihood of using mental health services, the amount of mental health services used, or total or out of-pocket spending for mental health services. The law was marginally significantly associated with a shift toward more use of mental health specialty services rather than primary care services among individuals who used ambulatory mental health care.

CONCLUSIONS

Consistent with other research using different study designs and data, this study found that the MHPAEA had at most small effects on patterns of mental health services use and spending through 2013. Understanding whether these effects were small because most employer-sponsored plans were already parity compliant or because plans were noncompliant with the law has major implications for mental health policy and parity enforcement.

Trends in Serious Psychological Distress and Outpatient Mental Health Care of US Adults

IMPORTANCE

Reports of a recent increase in US outpatient mental health care raise questions about whether it has been driven by rising rates of psychological distress and whether mental health treatment has become either more or less focused on people with higher levels of distress.

OBJECTIVE

To characterize national trends in serious psychological distress and trends in outpatient mental health service use by adults with and without serious psychological distress.

DESIGN, SETTING, AND PARTICIPANTS

The 2004-2005, 2009-2010, and 2014-2015 Medical Expenditure Panel Surveys (MEPS) were nationally representative surveys taken in US households. The analysis was limited to participants 18 years or older. Dates of this analysis were February 2018 to April 2018.

MAIN OUTCOMES AND MEASURES

Annual national trends in the percentages of adults with serious psychological distress (Kessler 6 scale score ≥13), outpatient mental health service use (outpatient visit with a mental disorder diagnosis, psychotherapy visit, or psychotropic medication), and type of psychotropic medication use (antidepressants, anxiolytics/sedatives, antipsychotics, mood stabilizers, and stimulants). Age- and sex-adjusted odds ratios of the associations of survey period with the odds of serious psychological distress, outpatient mental health service use, and outpatient mental health service use were stratified by level of psychological distress.

RESULTS

The analysis involved 139 862 adult participants from the 2004-2005, 2009-2010, and 2014-2015 MEPS, including 51.67% women, 48.33% men, 67.11% white adults, and 32.89% nonwhite adults, with an overall mean (SE) age of 46.41 (0.14) years. Serious psychological distress declined overall from 4.82% (2004-2005) to 3.71% (2014-2015), including significant declines among young (3.94% to 3.07%), middle-aged (5.52% to 4.36%), and older adults (5.24% to 3.79%); men (3.94% to 3.09%) and women (5.64% to 4.29%); and major racial/ethnic groups (white, 4.52% to 3.82%; African American, 5.12% to 3.64%; Hispanic, 6.03% to 3.55%; and other, 5.22% to 3.26%). Overall, the percentage of adults receiving any outpatient mental health service increased from 19.08% (2004-2005) to 23.00% (2014-2015) (adjusted odds ratio, 1.25; 95% CI, 1.17-1.34). Although the proportionate increase in outpatient mental health service use for adults with serious psychological distress (54.17% to 68.40%) was larger than that for adults with less serious or no psychological distress (17.26% to 21.08%), the absolute increase in outpatient mental health service use was almost completely the result of growth in outpatient mental health service use by individuals with less serious or no psychological distress.

CONCLUSIONS AND RELEVANCE

The recent increase in outpatient mental health service use occurred during a period of decline in serious psychological distress. Adults with less serious psychological distress accounted for most of the absolute increase in outpatient mental health service use, while adults with serious psychological distress experienced a greater relative increase in outpatient mental health service use.

Understanding healthcare burden and treatment patterns among young adults with schizophrenia

BACKGROUND

Schizophrenia is a serious public health problem that affects ∼1% of the US population.

AIMS

To examine treatment patterns and evaluate healthcare resource utilization (HRU) and costs among young adults (18-35 years) with schizophrenia who were early in the disease.

MATERIALS AND METHODS

Patients aged 18-64 years with ≥2 schizophrenia diagnoses in the identification period (January 1, 2012-September 30, 2015) and continuous enrollment for ≥12 months pre- and post-index date were identified from the OptumInsight Clinformatics DataMart. Demographics, clinical characteristics, HRU, costs, and treatment patterns were compared between schizophrenia and non-schizophrenia "controls" cohorts and between young (18-35 years) and older adults (36-64 years) with schizophrenia.

RESULTS

Among 9,889 schizophrenia patients, 23.70% were young adults (aged 18-35), had higher all-cause per-patient-per-year (PPPY) costs ($22,338 vs $7,332; p < .0001), higher inpatient costs ($8,857 vs $1,289; p < .0001), and longer inpatient length-of-stay (LOS) (5.0 vs 0.4 days, p < .0001; adjusted incidence rate ratio [aIRR] = 12.8; 95% confidence interval [CI] = 11.5-14.3) than controls. Among young adults with schizophrenia, there were more mental-health-related and fewer non-mental-health-related diagnoses compared to older adults with schizophrenia; 63.40% were male. Young adults with schizophrenia incurred higher inpatient costs ($15,692 vs $10,274; p < .0001) and longer inpatient LOS (9.6 vs 5.9 days, p < .0001; aIRR = 1.6; 95% CI = 1.4-1.8) compared to older adults with schizophrenia. A substantial proportion of patients were treated with oral antipsychotics vs long-acting injectables in both cohorts (young adults: 98.72% vs 9.71%; older adults: 98.10% vs 13.31%).

LIMITATIONS

Claims data are collected for payment and not research. The presence of a prescription claim does not indicate medication was consumed or taken as prescribed.

CONCLUSIONS

The economic burden for schizophrenia patients is substantial, especially among young adults. Based on this analysis, further research is warranted to better understand the association between adherent treatment patterns earlier in the disease and long-term health outcomes among patients with schizophrenia.

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.

Effects of the Affordable Care Act on Private Insurance Coverage and Treatment of Behavioral Health Conditions in Young Adults

OBJECTIVES

To assess changes in private insurance coverage and behavioral treatment of people aged 19 to 25 years and 26 to 35 years following the 2010 Affordable Care Act (ACA) dependent care provision and 2014 insurance reforms.

METHODS

We extracted data from the 2008 to 2016 US National Surveys on Drug Use and Health. We used an adjusted difference-in-differences approach to assess effects of age group on change in coverage. Replications in subgroups with serious psychological distress or substance use disorders also assessed change in mental health and substance use treatment.

RESULTS

Between 2008 to 2010 and 2011 to 2013, the increase in coverage of the younger group significantly differed from the decrease in the older group, but the 2 groups did not significantly differ between 2011 to 2013 and 2014 to 2016 (+3.2 percentage points; P < .001; and +3.8 percentage points; P < .001). Similar trends occurred among the distressed subgroups and the younger but not older substance use subgroup who reported no significant coverage changes in either period. A minority in the distressed (31.4%-45.4%) and substance use (5.1%-8.5%) subgroups received treatment.

CONCLUSIONS

Although implementation of the ACA provisions coincided with coverage gains for young adults, challenges persist in engaging those with mental health and substance use problems in treatment.

Utilization and Economic Contribution of Psychiatric Mental Health Nurse Practitioners in Public Behavioral Health Services

INTRODUCTION

Expanded insurance coverage through the Affordable Care Act and parity in behavioral health coverage have increased demand for services. Yet there is a persistent shortage in the behavioral health workforce. Psychiatric Mental Health Nurse Practitioners (PMHNPs) may be part of the solution to shortages but are not yet fully utilized. The purpose of this study was to describe how PMHNPs are utilized, identify barriers to full utilization, and assess PMHNPs' economic contribution in public behavioral health systems.

METHODS

This study used a mixed methods approach, selecting counties for use of PMHNPs, geography, population size, rural/urban, and availability of financial data. The authors conducted 1- to 2-day site visits in 2014-2015 including semi-structured interviews with management and clinical leaders and collected PMHNP staffing and billing data. Thematic analysis of interview data was conducted and aggregate staffing and billing data were analyzed to determine net PMHNP financial contribution.

RESULTS

The primary billed service for PMHNPs is medication management. Barriers to full utilization included system-level barriers to hiring PMHNPs, lack of role-appropriate job descriptions, confusion related to scope of practice/supervision requirements, and challenges in recruitment and retention. Fiscal analysis showed a positive net contribution from PMHNP services.

CONCLUSIONS

PMHNPs can make a significant contribution to behavioral healthcare delivery, particularly in public mental health settings, yet greater understanding of their role and addressing barriers to practice is needed.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

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.

Racial and Ethnic Disparities Among the Remaining Uninsured Young Adults with Behavioral Health Disorders After the ACA Expansion of Dependent Coverage

BACKGROUND

In 2010, the Affordable Care Act (ACA) extended eligibility for dependent coverage under private health insurance. Emerging evidence shows that young adults, including those with behavioral health disorders (BHDs), have benefited from this expansion.

OBJECTIVE

The objective of this study is to explore the population characteristics of the remaining uninsured individuals with and without BHDs and to examine whether the factors that contribute to racial and ethnic disparities in the likelihood of being uninsured were different after the implementation of the ACA provision that extended insurance eligibility for young adults in 2010.

DESIGN

We use cross-sectional data analysis.

PARTICIPANTS

We use a nationally representative dataset of the non-institutionalized civilian population in the Medical Expenditure Panel Survey from 2007 to 2012.

METHODS

We compare population characteristics of the remaining uninsured individuals ages 19-25, before and after the implementation of the ACA expansion in 2010. We use multivariate logistic regression to estimate the predictors (such as family income and English proficiency) that are associated with the likelihood of having no health insurance. We utilize the Fairlie decomposition method to examine the factors that contribute to racial (non-Latino White (White) vs. non-Latino African-American (African-American)) and ethnic (non-Latino White (White) vs. Latino) differences in the probability of being uninsured. Finally, we apply our analysis among populations with and without BHDs respectively, to examine the differences in the predictors of being uninsured between these two groups.

RESULTS

Among individuals with BHDs, after adjusting for covariates, the estimated probabilities of being uninsured for Whites were 0.21 and 0.16 pre- and post- the ACA expansion, respectively. The predicted probabilities of being uninsured for Latinos were 0.29 and 0.26 and for African-American were 0.19 and 0.17 pre- and post- the ACA expansion, respectively. The ethnic disparity between Whites and Latinos was 19 %. The racial disparity was moderate. Reductions in the uninsured rate of individuals without BHDs were observed as well. However, the ethnicity disparity remained at 19 % and the racial disparity increased by 5 %. Overall, our decomposition model explained 63-89 % of the racial and ethnic disparities in insurance coverage. The major factor associated with the ethnic disparity among those with BHDs was the immigrant status of Latinos, and the major factor associated with racial disparity was geographic location. The major factor associated with the ethnic disparity among those without BHDs included the immigrant status of Latinos, lack of English proficiency, and geographic location, whereas the major factor associated with racial disparity was family income.

DISCUSSION

Our study presents health insurance coverage trends among racial and ethnic minorities after the implementation of insurance expansion, a major provision of the ACA. It is important for policy makers to be aware of differences among the remaining uninsured as they evaluate ways to improve healthcare access and affordability.

What's at Stake in U.S. Health Reform: A Guide to the Affordable Care Act and Value-Based Care

The U.S. presidential election of 2016 accentuated the divided perspectives on the Patient Protection and Affordable Care Act of 2010, commonly known as Obamacare. The perspectives included a pledge from then candidate Donald J. Trump to "repeal and replace on day one"; Republican congressional leaders' more temperate suggestions in the first weeks of the Trump administration to "repair" the Affordable Care Act (ACA); and President Trump's February 5, 2017 statement-16 days after inauguration-that a Republican replacement for the ACA may not be ready until late 2017 or 2018. The swirling rhetoric, media attention, and the dizzying rate of U.S. health and payment reforms both within and outside of the ACA makes it difficult for nurses, both United States and globally, to discern which health policy issues are grounded in the ACA and which aspects reflect payer-driven "volume to value" reimbursement changes. Moreover, popular and controversial elements of the ACA-for example, the clause that prohibits insurance carriers to deny coverage to those with preexisting health conditions and the more controversial individual mandate that bears Supreme Court support as a constitutional provision-are paired in ways that might be unclear to those unfamiliar with nuances of insurance rate determination. To support nurses' capacity to maximize their impact on health policy, this overview distills the 906-page ACA into major themes and describes payment reform legislation and initiatives that are external to the ACA. Understanding the political and societal forces that affect health care policy and delivery is necessary for nurses to effectively lead and advocate for the best interests of their patients.

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.

Did the Affordable Care Act's Dependent Coverage Expansion Affect Race/Ethnic Disparities in Health Insurance Coverage?

OBJECTIVE

To test the impact of the dependent coverage expansion (DCE) on insurance disparities across race/ethnic groups.

DATA SOURCES/STUDY SETTING

Survey data from the National Survey of Drug Use and Health (NSDUH).

STUDY DESIGN

Triple-difference (DDD) models were applied to repeated cross-sectional surveys of the U.S. adult population.

DATA COLLECTION/EXTRACTION METHODS

Data from 6 years (2008-2013) of the NSDUH were combined.

PRINCIPAL FINDINGS

Following the DCE, the relative odds of insurance increased 1.5 times (95 percent CI 1.1, 1.9) among whites compared to blacks and 1.4 times (95 percent CI 1.1, 1.8) among whites compared to Hispanics.

CONCLUSIONS

Health reform efforts, such as the DCE, can have negative effects on race/ethnic disparities, despite positive impacts in the general population.

Young Adult Insurance Coverage And Out-Of-Pocket Spending: Long-Term Patterns

The Affordable Care Act appears to have improved health insurance coverage for young adults (ages 18-30). But data from twenty national surveys conducted between 1977 and 2013 paint a more complex picture, showing coverage rates lower in 2013 than they were thirty-six years earlier. Racial and ethnic disparities in coverage have declined recently, while out-of-pocket expenditures remain low for most young adults.

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.

Health Insurance Trends and Access to Behavioral Healthcare Among Justice-Involved Individuals-United States, 2008-2014

BACKGROUND

A large proportion of justice-involved individuals have mental health issues and substance use disorders (SUD) that are often untreated due to high rates of uninsurance. However, roughly half of justice-involved individuals were estimated to be newly eligible for health insurance through the Affordable Care Act (ACA).

OBJECTIVE

We aimed to assess health insurance trends among justice-involved individuals before and after implementation of the ACA's key provisions, the dependent coverage mandate and Medicaid expansion, and to examine the relationship between health insurance and treatment for behavioral health conditions.

DESIGN

Repeated and pooled cross-sectional analyses of data from the National Survey on Drug Use and Health (NSDUH).

PARTICIPANTS

Nationally representative sample of 15,899 adults age 19-64 years between 2008 and 2014 with a history of justice involvement during the prior 12 months.

MAIN MEASURES

Uninsurance rates between 2008 and 2014 are reported. Additional outcomes include adjusted treatment rates for depression, serious mental illness, and SUD by insurance status.

KEY RESULTS

The dependent coverage mandate was associated with a 13.0 percentage point decline in uninsurance among justice-involved individuals age 19-25 years (p < 0.001). Following Medicaid expansion, uninsurance declined among justice involved individuals of all ages by 9.7 percentage points (p < 0.001), but remained 16.3 percentage points higher than uninsurance rates for individuals without justice involvement (p < 0.001). In pooled analyses, Medicaid, relative to uninsurance and private insurance, was associated with significantly higher treatment rates for illicit drug abuse/dependence and depression.

CONCLUSION

Given the high prevalence of mental illness and substance use disorders among justice-involved populations, persistently elevated rates of uninsurance and other barriers to care remain a significant public health concern. Sustained outreach is required to reduce health insurance disparities between individuals with and without justice involvement. Public insurance appears to be associated with higher treatment rates, relative to uninsurance and private insurance, among justice-involved individuals.

Characteristics of Young Adults Enrolled Through the Affordable Care Act-Dependent Coverage Expansion

PURPOSE

The purpose of this study was to examine sociodemographic and health care-related characteristics of young adults covered through the Affordable Care Act (ACA)-dependent coverage expansion.

METHODS

Our sample consisted of 36,802 young adults aged 19-25 years from 2011 to 2014 National Health Interview Survey. Sociodemographic differences among young adults with the four insurance types were described: privately insured under parents, privately insured under self/spouse, publicly insured, and uninsured. Multivariable logistic models were fitted to compare those covered under parent with those covered through other traditional insurance types, in terms of the following outcomes: health status, health behaviors, insurance history and experience, access to care, care utilization, and receipt of preventive service, controlling for sociodemographic factors.

RESULTS

Young adults who were covered under their parents' insurance were most likely to be college students and non-Hispanic whites. These young adults also had more stable insurance, better access to care, better care utilization patterns, and reported better health status, compared to their peers.

CONCLUSIONS

The beneficiaries of the ACA-dependent coverage expansion were more likely to be college students from families with high socioeconomic status. Coverage under parents was associated with improved access to care and health outcomes among young adults. The enrollees through the ACA represent the healthiest subgroup of young adults and those with the best care utilization patterns, suggesting that the added cost relative to premium for insurers from this population will likely be minimal.

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.

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.

Substance Use Patterns Through Early Adulthood: Results for Youth With and Without Chronic Conditions

INTRODUCTION

Adolescence and emergent adulthood are periods of peak prevalence for substance use that pose risks for short- and long-term health harm, particularly for youth with chronic medical conditions (YCMC) who are transitioning from adolescence to adulthood. As there have been no nationally representative studies of substance use during this period for these medically vulnerable youth, the authors sought to examine onset and intensification of these behaviors for a national sample of youth with and without chronic conditions.

METHODS

Longitudinal data are from 2,719 youth between the ages of 12 and 26 years interviewed from 2002 to 2011 for the Panel Study of Income Dynamics, Child Development and Transition to Adulthood Supplements, a nationally representative, population-based survey. Multivariate generalized linear mixed models were used to estimate patterns of alcohol, tobacco, and marijuana use during adolescence and emergent adulthood for youth with and without chronic conditions, adjusting for potential confounders.

RESULTS

Overall, 68.8%, 44.3%, and 47.8% of youth reported ever trying alcohol, tobacco, and marijuana, respectively. Among users, 42.2%, 73.4%, and 50.3% of youth reported binge drinking, regular cigarette use, and recent marijuana use, respectively. YCMC were more likely to engage in any and heavier substance use; transition years and early adulthood were periods of peak risk for YCMC compared with their healthy peers.

CONCLUSIONS

Substance use among YCMC during adolescence and emergent adulthood is a substantial concern. Increased prevention and case detection are in order to address these behaviors and promote optimal health outcomes for medically vulnerable youth.

Common and Costly Hospitalizations Among Insured Young Adults Since the Affordable Care Act

PURPOSE

To describe the most prevalent and costly inpatient hospitalizations in a national cohort of privately insured young adults since the Affordable Care Act.

METHODS

Cross-sectional study of a national administrative data set of privately insured young adult (18-30 years) beneficiaries hospitalized from January 2012 to June 2013. The most prevalent diagnosis categories for young adult hospitalizations are presented as percentages of all young adult hospitalizations by gender and age group (18-21, 22-25, and 26-30 years). Mean and median out-of-pocket costs by diagnosis category and gender are calculated based on deductible, copay and coinsurance payments.

RESULTS

We analyzed 158,777 hospitalizations among 4.7 million young adult beneficiaries; young adults accounted for 18.3% of privately insured hospitalizations across all ages. Top diagnoses for young adult female hospitalizations were pregnancy related (71.9%) and mental illness (8.9%). Top diagnoses for young adult male hospitalizations were mental illness (39.3%) and injuries and poisoning (14.0%). Mean and median total out-of-pocket costs for any young adult hospitalization were $1,034 and $700, respectively (mean deductible payment = $411). The most expensive out-of-pocket hospitalizations were for dermatologic diseases (e.g., skin infections) with means of $1,306 for females and $1,287 for males.

CONCLUSIONS

This study establishes a baseline for the ongoing assessment of the most common and costly hospitalizations among privately insured young adults in the United States under the Affordable Care Act. The substantial burden of potentially avoidable hospitalizations (e.g., mental health, injury, and poisonings) supports resource allocation to improve outpatient services, mental health access, and public health prevention strategies for young adults.

Availability and Accessibility of Student-Specific Weight Loss Programs and Other Risk Prevention Health Services on College Campuses

BACKGROUND

More than one third of college students who are overweight or obese are in need of weight loss programs tailored to college students. However, the availability and accessibility of these programs is unknown.

OBJECTIVE

The aim of this study is to examine the availability and ease of access to weight loss programs for students at 10 universities with the largest undergraduate enrollment.

METHODS

The 10 public universities with the largest student bodies with a mean (SD) undergraduate enrollment of 41,122 (7657) students were examined. The websites of the universities were assessed to determine the availability of weight loss programs. Services for high-risk health needs common to university campuses (ie, alcohol and other drugs, victim services, sexual health, and eating disorders) were searched.

RESULTS

Of the universities searched, 3 (30%, 3/10) offered weight loss programming, however, none met the predetermined criteria. Comparatively, all schools (100%, 10/10) offered no-cost and continual enrollment programming for the other high-risk health needs.

CONCLUSIONS

There are limited weight loss services available to undergraduate students compared with other university services. Collaboration between existing college health service providers is suggested for the delivery of appropriate programming for overweight and obese undergraduates wanting to lose weight.

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.

Effect of Medicaid Expansions on Health Insurance Coverage and Access to Care among Low-Income Adults with Behavioral Health Conditions

OBJECTIVE

To examine the effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions.

DATA SOURCES/STUDY SETTING

Nine years (2004-2012) of individual-level cross-sectional data from a restricted-access version of National Survey on Drug Use and Health.

STUDY DESIGN

A quasi-experimental difference-in-differences design comparing outcomes among residents in 14 states that implemented Medicaid expansions for low-income adults under the Section §1115 waiver with those residing in the rest of the country.

DATA COLLECTION/EXTRACTION METHODS

The analytic sample includes low-income adult respondents with household incomes below 200 percent of the federal poverty level who have a behavioral health condition: approximately 28,400 low-income adults have past-year serious psychological distress and 24,900 low-income adults have a past-year substance use disorder (SUD).

PRINCIPAL FINDINGS

Among low-income adults with behavioral health conditions, Medicaid expansions were associated with a reduction in the rate of uninsurance (p < .05), a reduction in the probability of perceiving an unmet need for mental health (MH) treatment (p < .05) and for SUD treatment (p < .05), as well as an increase in the probability of receiving MH treatment (p < .01).

CONCLUSIONS

The ongoing implementation of Medicaid expansions has the potential to improve health insurance coverage and access to care for low-income adults with behavioral health conditions.

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.