ACA: Better Access to Mental Health Care for Young Adults

Deborah Brauser

February 19, 2015

Dependent coverage provisions in the Patient Protection and Affordable Care Act (ACA) appear to have improved access to mental health care for young adults, new research suggests.

Investigators at the University of Minnesota School of Public Health, in Minneapolis, found that the legislation has led to "modest increases" in psychiatric inpatient admissions nationally and to lower emergency department (ED) visits in California among young adults aged 19 to 25.

The comparative study examining young adults targeted by the provision vs those not targeted because of their older age showed that the younger group had higher rates of insurance coverage and 0.14 more overall inpatient admissions for psychiatric diagnoses per 1000 (or an increase of 14 percentage points) than the older group.

In addition, those between 19 and 25 years of age in California had 0.45 fewer ED visits per 1000 vs their older counterparts in the state.

"As the ACA expands insurance coverage to millions of Americans, it is crucial to understand the effects of new coverage on patterns of care and spending," the investigators, led by Ezra Golberstein, PhD, assistant professor in the Division of Health Policy and Management, write.

Although they note that their findings are useful now, "future research will assess whether these patterns will hold as the ACA expands insurance more broadly."

The study was published in the February issue of the American Journal of Psychiatry.

Major Questions

According to the investigators, 29% of young adults did not have health insurance in 2009. The first major provision of the ACA required insurance companies to extend coverage to dependents until they reached age 26, a provision that went into effect September 2010.

"Since then, insurance coverage has risen by 3 to 10 percentage points for 19- to 25-year-olds, originating largely from private insurance coverage," write the researchers.

"As the ACA's implementation continues, the major questions shift from tracking uninsurance rates to understanding changes in access to care and health care use."

Although coverage has increased for mental health care, the implications for young adults have been "poorly understood," note the investigators.

A recent study, reported by Medscape Medical News, showed a significant decline in inpatient admissions for any behavioral health disorder among young adults in Massachusetts after the state's 2006 health reform.

However, the current investigators note that those findings may not generalize to the ACA dependent coverage expansion.

For their study, they sought to examine the link between the ACA provision and "changes in young adults' use of hospital-based services for substance use disorders and non-substance use psychiatric disorders."

The researchers examined data for a national sample of 430,583 psychiatric inpatient admissions between 2005 and 2011 and a sample of 11,139,689 ED visits with psychiatric diagnoses during the same time span in California.

That state was chosen because of its population size and because its discharge databases included specialty mental health and substance use facilities.

Large Gains in Coverage

Results showed that after the dependent coverage provision went into effect, inpatient admissions to nonspecialty hospitals for any psychiatric diagnosis increased significantly for the group of 19- to 25-year-olds vs the group of 26- to 29-year-olds (P < .001).

In addition, the provision was linked to significant increases in inpatient admission rates for all of the primary psychiatric diagnostic categories.

Although national inpatient admissions were significantly greater for both younger men and women (0.20 and .07 more admissions per 1000, respectively) vs their older counterparts, the increase was significantly larger for men (P < .001 vs P = .004 for women).

The younger men also had significant increases in admissions in each psychiatric category vs older men, whereas the younger women's increases were only significant for depression and psychosis admissions.

When examining California-only data, the younger group had significantly fewer ED visits than the older group (P < .001) after the coverage expansion. Interestingly, this decrease remained significant when assessing the women only (0.81 fewer visits per 1000 than the older women, P < .001) but not when assessing the men only.

For the younger group vs the older group, the probability that national inpatient admissions and California ED visits were uninsured decreased significantly after expansion (by .029 and .039, respectively; P < .001 for both).

"For young adults, a group with significant psychiatric service needs and a group likely to experience large gains in coverage as a result of the ACA, inpatient care for psychiatric diagnoses rose, [ED] use...fell, and the proportion of hospital-based services that were uninsured dropped," summarize the investigators.

Important First Step

Haiden A. Huskamp, PhD, from the Department of Health Care Policy at Harvard Medical School, in Boston, Massachusetts, writes in an accompanying editorial that the findings on mental health service use are consistent with recent research on overall health service utilization.

"The combination of decreased psychiatric [ED] use and increased psychiatric inpatient admissions would clearly point to increased access to care attributable to the policy change if accompanied by increases in outpatient mental health service use," she writes.

However, she notes that the investigators were not able to examine the provision's impact on outpatient use because of a lack of data and that a study assessing this is now needed.

Dr Huskamp points out that the study also raises several other important questions for future research, including long-term insurance status for these young adults and whether the new source of coverage actually improves outcomes in those with psychiatric disorders.

"The Golberstein et al study is an important early step in understanding the impact of these changes for young adults with mental health service needs," she writes.

But the extent to which changes brought about by the Mental Health Parity and Addiction Equity Act and the ACA translate into better quality of care "remains to be seen," Dr Huskamp concludes.

The authors and Dr Huskamp report no relevant financial relationships.

Am J Psychiatry. 2015;172:182-189, 113-114. Abstract, Editorial

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