The Impact of National Health Reform on Adults with Mental Disorders (Text Version)

On September 27, 2010, Samuel Zuvekas, Rachel L. Garfield, Judith R. Lave, and Julie Donohue made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (865 KB).

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Slide 1

The Impact of National Health Reform on Adults with Mental Disorders

Rachel L. Garfield, Ph.D.
Department of Health Policy & Management,
University of Pittsburgh Graduate School of Public Health

Samuel H. Zuvekas, Ph.D.
Agency for Healthcare Research & Quality

Judith R. Lave, Ph.D.
Julie Donohue, Ph.D.
Department of Health Policy & Management,
University of Pittsburgh Graduate School of Public Health

Slide 2

Background

• Insurance coverage important determinant of access to mental health treatment (Landerman et al 1994, Zuvekas 1999, McAlpine and Mechanic 2000, Kessler et al. 2005, Roy-Byrne et al 2009).
• Potential for significant impact of the Patient Protection and Affordable Care Act of 2010 on individuals with mental disorders:
  • <133 % of Federal Poverty Line (FPL) eligible for Medicaid.
  • 133-400% of FPL eligible for exchange subsidies.
  • Parity in Mental Health Coverage.

Slide 3

Objectives

• Examine current sources of insurance coverage and use of mental health services among adults with mental disorders.
• Simulate post-reform changes:
  • Health insurance coverage
  • Mental health treatment use

Slide 4

Data Source: MEPS

• Medical Expenditure Panel Survey (2004-2006):
  • Large nationally, representative survey
  • Key variables:
    • Health insurance coverage
    • Family income and poverty status
    • Mental health treatment use
    • Mental health status
  • Pooled to increase precision
    • N=51,080 adults aged 18-64

Slide 5

Data: Key Variables

• Mental Health Status (Adult SAQ):
  • PHQ-2 2-Item Depression Screener (PHQ-2>=3)
  • K6 General Psychological Distress (K6>=13)
• Family Income:
  • Based on Health Insurance Eligibility Units
  • <133%,133-400%, 400+ of poverty

Slide 6

Data: Key Variables (cont)

• Health Insurance Coverage:
  • Medicare (including duals)
  • Full year private
  • Full year Medicaid
  • Uninsured part-year
  • Uninsured full year
• Mental Health Treatment Use:
  • Any inpatient, hospital outpatient, ED, office or clinic visit, or prescription drug fill for mental health reason

Slide 7

Post-Reform Simulation: Insurance Coverage

• Apply CBO assumptions on takeup rates:
  • 59% decrease overall in the uninsured
  • <133% of FPL uninsured switch to Medicaid
  • >133% of FPL uninsured switch into Private coverage.
  • Enrollment in Medicare stable

Slide 8

Post-Reform Simulation: Mental Health Treatment Use

• Regression model of the impact of health insurance coverage on use of treatment:
  • Logistic regression.
  • Controls for age, race/ethnicity, sex, education, region and MSA, family income, insurance status, mental health status, physical health status, attitudes and preferences towards insurance and health care.
• Will apply CBO assumptions on take-up rates.

Slide 9

Distribution of Adults 18-64 by Poverty Status

Image: Bar graph shows the distribution of adults 18-64 by poverty status. The table below provides details.

Condition	<133 % FPL	133-400% FPL	>400% FPL
Depression or Serious Psychological Distress	39%	42%	19%
No Depression or Serious Psychological Distress	18%	41%	42%

Slide 10

Distribution of Adults 18-64 by Health Insurance Status

Image: Bar graph shows the distribution of adults 18-64 by health insurance status. The table below provides details.

Condition	Medicare	Private	Medicaid	Uninsured part year	Uninsured full-year
Depression or Serious Psychological Distress	11.3	38.4	13.1	16.2	21
No Depression or Serious Psychological Distress	1.9	66.2	4.1	11.4	16.5

Slide 11

Distribution of Adults 18-64 <133% FPL by Insurance

Image: Bar graph shows the distribution of adults 18-64 <133% FPL by insurance. The table below provides details.

Condition	Medicare	Private	Medicaid	Uninsured part year	Uninsured full-year
Depression or Serious Psychological Distress	14.7	10.8	25.2	19.9	29.4
No Depression or Serious Psychological Distress	5.2	21.2	16.2	19.2	38.1

Slide 12

Distribution of Adults 18-64 133-400% FPL by Insurance

Image: Bar graph shows the distribution of adults 18-64 133-400% FPL by insurance. The table below provides details.

Condition	Medicare	Private	Medicaid	Uninsured part year	Uninsured full-year
Depression or Serious Psychological Distress	10.4	48	6.6	16.1	18.9
No Depression or Serious Psychological Distress	1.8	62.8	2.6	13.9	18.9

Slide 13

Use of Mental Health Services Among Adults 18-64

Image: Bar graph shows the use of mental health services among adults 18-64 by insurance. The table below provides details.

Condition	Medicare	Private	Medicaid	Uninsured part year	Uninsured full-year
Depression or Serious Psychological Distress	63.70%	38.20%	48.40%	36.60%	21.50%
No Depression or Serious Psychological Distress	36.80%	11.80%	15.90%	10.30%	5.40%

Slide 14

Simulated Post-Reform Health Insurance Coverage of Currently Uninsured Nonelderly Adults by Mental Health Status

Image: Graph shows simulated coverage of currently uninsured adults by mental health status. The table below provides details.

Coverage	Depression or Serious Psychological Distress Total = 6.3 Million	No Depression or Serious Psychological Distress Total = 46.7 Million
Uninsured	40.8%	40.8%
Nongroup/other	2.4%	3.2%
Exchange	3.4%	4.5%
Employer	22.2%	29.8%
Medicaid	31.2%	21.7%

Source: Authors' analysis based on CBO projections and MEPS coverage and income data.

Slide 15

Simulated Impact of Reform on Health Insurance Coverage of Nonelderly Adults with Depression or Serious Psychological Distress

Image: Graph shows simulated impact of reform on health insurance coverage of adults with depression or serious psychological distress. The table below provides details.

Coverage	Pre-Reform	Post-Reform
Uninsured full year	21.0%	8.7%
Uninsured part year	16.2%	6.7%
Private	38.4%	48.7%
Medicaid	13.1%	24.6%
Medicare	11.3%	11.3%

Note: Dual eligibles are included in Medicare.

Source: Authors' analysis based on CBO projections and MEPS coverage and income data.

Slide 16

Simulated Impact of Reform on Mental Health Service Use: Uninsured <133% FPL

Image: Graph shows simulated impact of reform on mental health use by the uninsured. The table below provides details.

Condition	Pre-Reform (Uninsured)	Post-Reform (Medicaid)
Depression or Serious Psychological Distress	23.30%	44.70%
No Depression or Serious Psychological Distress	5.10%	12.60%

Slide 17

Simulated Impact of Reform on Mental Health Use: Uninsured 133-400% FPL

Image: Graph shows simulated impact of reform on mental health use by the uninsured. The table below provides details.

Condition	Pre-Reform (Uninsured)	Post-Reform (Private)
Depression or Serious Psychological Distress	16.60%	33.60%
No Depression or Serious Psychological Distress	5.10%	7.80%

Slide 18

Summary

• Adults with mental disorders have lower incomes and are more likely to be uninsured than their counterparts.
• Adults with mental disorders are significantly more likely to be enrolled in Medicare and/or Medicaid than those without.
• Only one-quarter of individuals with mental disorders who lack insurance coverage for the full year had any mental health service use in 2004-2006 compared to approximately half of those with coverage.
• After reform is fully implemented, we estimate 3.7 million currently uninsured individuals with mental disorders will gain coverage, with approximately one-third covered under Medicaid.
• We estimate that use of mental health treatment could double among those previously uninsured.

Slide 19

Implications

• Health reform is likely to have a significant impact on coverage and use of services among adults with mental disorders:
  • Will depend on implementation and capacity of mental health system to absorb increased demand.
• Public insurance programs that currently play a major role in financing mental health services will play an even greater role post-reform.