Article Abstract

Article Abstract

Online ISSN: 1099-176X Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 29, Issue 2, 2026. Pages: 41-56
Published Online: 1 June 2026

The Effects of Medicaid Expansion on Mental Health for White, Black, and Hispanic Americans: Estimates for 2014–2022

Timothy Brown,^1* Alison Cuellar,² Genevieve Graaf,³ Victoria R. Green,³ Jorge A. Morales Alfaro,⁴
Lonnie R. Snowden¹

¹Ph.D., University of California, Berkeley, School of Public Health, Health Policy and Management, Berkeley, CA, USA.
²Ph.D., Department of Health Administration and Policy, George Mason University, Fairfax, Virginia & National Bureau of Economic Research,
Fairfax, VA, USA.
³Ph.D.,School of Social Work, University of Texas at Arlington, Arlington, TX, USA.
⁴MPP, University of California, Berkeley, School of Public Health, Health Policy and Management, Berkeley, CA, USA.

*Correspondence to: Timothy T. Brown, PhD, School of Public Health, University of California, Berkeley, Berkeley Way West, 2121 Berkeley Way #5302, Berkeley, CA 94720-7360, USA.
Tel. +1-510-386-6235
E-mail : Timothy.Brown@berkeley.edu

Source of Funding: National Institute of Mental Health (R01 MH133807). Funding was received directly. The authors declare no affiliations with or financial support from any organization or entity with a direct financial interest in the subject matter of this paper.

Abstract

This study estimates the effects of Affordable Care Act Medicaid expansion on mental health among low-income adults overall and for Black, Hispanic, and white populations. Using 2011–2022 Behavioral Risk Factor Surveillance System data on 474,801 Medicaid-eligible adults aged 18–64, we apply staggered difference-in-differences estimators with state-clustered, small-sample-corrected inference. Eighteen of 20 equations satisfy parallel trends. Full-sample frequent mental distress fell 1.2 points (p=0.032), any activity-limiting days 2.0 points (p=0.043), and number of activity-limiting days 1.9 days (p=0.001). Among Black adults, insurance coverage rose 6.5 points (p=0.033) and poor mental health days fell 0.7 days (p=0.054). Among Hispanic adults, frequent mental distress fell 2.7 percentage points (p<0.001); controlling for medical marijuana strengthens this to 5.3 points (p=0.002), and any poor mental health days fell 5.4 points (p=0.048). Among white adults, activity-limiting days fell 1.7 days (p=0.020).

Background: The Affordable Care Act expanded Medicaid as a state option. Despite potential for Medicaid expansion to improve mental health for low-income adults, among whom Hispanic and Black adults are overrepresented, Medicaid expansion research has mostly overlooked differential mental health impacts.

Aims of the Study: This study examines whether Medicaid expansion improved mental health overall and across white, Black, and Hispanic adults.

Methods: Using 2011–2022 Behavioral Risk Factor Surveillance System data, we identified 474,801 Medicaid-eligible adults aged 18–64. State Medicaid expansions (2014–2021) were analyzed using the Callaway and Sant’Anna difference-in-differences estimator. Five mental health outcomes were examined overall and by race/ethnicity. Robustness was assessed through evaluation of 16 concurrent state-level policies against the common shocks criterion, including empirical testing of the two policies that satisfy the criterion. Validation tests assessed insurance coverage, cost barriers, elderly (age ≥65) placebo, and immigration enforcement as a moderator for Hispanics.

Results: Of 20 equations (5 outcomes across overall, Black, Hispanic, and white subsamples), 18 exhibited parallel trends. Among Hispanic adults, frequent mental distress (14+ poor mental health days) decreased by 2.7 percentage points (p < 0.001); controlling for the sole identified policy confounder (medical marijuana) strengthened this to 5.3 percentage points (p = 0.003). Any poor mental health days also decreased by 5.4 percentage points (p = 0.048). In the full sample, frequent mental distress decreased by 1.2 percentage points (p = 0.032), any activity-limiting days decreased by 2.0 percentage points (p = 0.043), and the number of activity-limiting days decreased by 1.9 days (p = 0.001). Among white adults, activity-limiting days decreased by 1.7 days (p = 0.020). Among Black adults, expansion increased insurance coverage by 6.5 percentage points (p = 0.032); the number of poor mental health days showed a reduction of 0.7 days (p = 0.054), with Black subgroup minimum detectable effects (MDEs) 1.1–2.6 times full-sample MDEs. Validation tests confirmed insurance coverage increased 7–9 percentage points and cost barriers decreased 4-5 percentage points. Of 16 concurrent state-level policies evaluated against the common shocks criterion, two satisfied both conditions for potential confounding. Including recreational marijuana policies produced results identical to baseline. Including medical marijuana policies strengthened the Hispanic result.

Discussion: Medicaid expansion reduced frequent mental distress and poor mental health days among Hispanic adults. Activity-
limiting days declined in the full sample and among white adults. Among Black adults, there were marginally significant mental health improvements. Limitations include reliance on self-reported outcomes and subgroup minimum detectable effects 1.1–2.6 times the full-sample MDEs.

Implications for Health Care Provision and Use: Medicaid is an important source of mental health treatment and may reduce disparities for Black and Hispanic Americans.

Implications for Health Policy: H.R. 1 (2025) will reduce federal Medicaid matching and create work requirements for expansion beneficiaries. Because Black and Hispanic adults rely more heavily on Medicaid under expansion, these populations may be disproportionately affected.

Implications for Further Research: Future research should disentangle contributions of coverage expansion from correlated state policies.

Received 1 November 2025; accepted 15 April 2026