Article Abstract

Article Abstract

Online ISSN: 1099-176X Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 23, Issue 4, 2020. Pages: 151-182
Published Online: 1 December 2020

Medicaid Expansion and Health Insurance Coverage and Treatment Utilization among Individuals with a Mental Health Condition

Samuel H. Zuvekas,^1* Chandler B. McClellan,¹ Mir M. Ali,² Ryan Mutter³

¹Ph.D., Agency for Healthcare Research and Quality, Rockville, MD, USA
²Ph.D., Office of the Assistant Secretary for Planning and Evaluation, Washington, DC, USA
³Ph.D., Congressional Budget Office, Washington, DC, USA

* Correspondence to: Samuel H. Zuvekas, Ph.D. 5600 Fishers Lane, Rockville MD 20854, USA.
E-mail: Samuel.Zuvekas@ahrq.hhs.gov

Source of Funding: None declared.

Disclaimer: No official endorsement by the Agency for Healthcare Research and Quality (AHRQ), the Office of the Assistant Secretary for Planning and Evaluation (ASPE), or the U.S. Department of Health and Human Services (HHS) is intended or should be inferred. This paper has not been subject to the Congressional Budget Office's (CBO) regular review and editing process. The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, ASPE, CBO and HHS. No author reports any conflict of interest or financial support.

Abstract

We examine the impact of Affordable Care Act (ACA) Medicaid expansions on adults with and without mental health problems in the United States using the 2008-2017 Medical Expenditure Panel Survey (MEPS). We use the AHRQ PUBSIM model to identify low-income adults aged 19-64 who were either newly Medicaid eligible if they lived in an expansion state or would have been eligible had their state opted to expand its Medicaid program. We estimate linear probability models within a difference-in-difference framework, including an additional interaction term to test for differences among those with serious psychological distress (SPD) or probable depression (PD) compared to those without SPD/PD. We find that the ACA Medicaid expansions substantially increased insurance rates for the newly Medicaid-eligible population, regardless of mental health status, but the overall effect on insurance coverage was stronger among those with SPD/PD. In contrast, we find no effects on treatment use.

Background: The Affordable Care Act (ACA) gives states the option of expanding Medicaid coverage to low-income individuals; however, not all states have chosen to expand Medicaid. The ACA Medicaid expansions are particularly important for Americans with mental health conditions because they are substantially more likely than other Americans to have low incomes.

Aims of the Study: We examine the impact of Medicaid expansion on adults who were newly eligible for Medicaid using the 2008-2017 Medical Expenditure Panel Survey (MEPS).

Methods: We use the AHRQ PUBSIM model to identify low-income adults aged 19-64 who were either newly Medicaid eligible if they lived in an expansion state or would have been eligible had their state opted to expand its Medicaid program. We estimate linear probability models within a difference-in-difference framework. An additional interaction term allows us to test for differences among those with serious psychological distress (SPD) or probable depression (PD). Outcomes of interest are insurance coverage by type, behavioral health treatment by service (specifically, any behavioral health treatment, any specialty treatment, any psychotropic medication, any ambulatory treatment outside of an emergency department, and any emergency department treatment), quantities of behavioral health treatment services, and out of pocket spending on healthcare.

Results: Our adjusted difference-in-differences estimates indicate Medicaid expansion increased any insurance coverage by 14.2 percentage points and increased Medicaid coverage by 21.2 percentage points. Insurance coverage for individuals with SPD/PD in expansion states increased by an additional 12.9 percentage points. Medicaid expansion did not have an effect on behavioral health treatment for the newly eligible population as a whole or for the subset with SPD/PD.

Discussion: Consistent with previous Medicaid expansions, we find that the ACA Medicaid expansions substantially increased insurance rates for the newly Medicaid-eligible population, regardless of mental health status but the overall effect on insurance coverage was stronger among those with SPD/PD. The lack of an effect on treatment use suggests that providing insurance coverage alone may be insufficient to guarantee that people with mental illness will receive the treatment they need. Limitations include that our difference-in-difference estimator may not account for time-varying factors that change contemporaneously with the expansions. Our estimates may also be affected by other provisions of the ACA that went into effect at the same time as the Medicaid expansions.

Implications for Health Care Provision and Use and Implications for Health Policies: Although the ACA has resulted in increased coverage for low-income individuals, more outreach efforts may be needed to encourage individuals with mental illness to get the treatment they need.

Received 13 February 2020; accepted 9 August 2020