Effect of the Affordable Care Act’s Young Adult Insurance Expansions on Hospital-Based Mental Health Care

Abstract

Objective Insurance coverage for young adults has increased since 2010, when the Affordable Care Act (ACA) required insurers to permit children on parental policies until age 26 as dependents. This study estimated changes in young adults’ use of hospital-based services with diagnosis codes for mental illness and substance abuse associated with the dependent coverage provision. Method Quasi-experimental comparison of national sample of non-birth hospital inpatient admissions to general hospitals (n=2,670,463 total, n=430,583 with primary behavioral health diagnosis) and California emergency department (ED) visits with behavioral health diagnoses (n=11,139,689). Data spanned 2005 to 2011. Estimates compared young adults who were and were not targeted by the ACA dependent coverage provision (19 to 25 versus 26 to 29 year olds), estimating changes in utilization before and after 2010. Primary outcomes included: quarterly inpatient admissions for primary diagnosis of any behavioral health disorder per 1000 population; ED visits with any behavioral health diagnosis per 1000 population; and payer source. Results Dependent coverage expansion was associated with 0.14 per 1000 more (p<0.001) inpatient admissions for behavioral health for 19-25 (ACA covered) versus 26-29 (then ACA uncovered) year olds. The coverage expansion was associated with 0.45 fewer behavioral health ED visits per 1000 (p=0.001) in California. The probability that inpatient admissions nationally, and ED visits in California were uninsured, decreased significantly (p<0.001). Conclusions ACA dependent coverage provisions produced modest increases in general hospital psychiatric inpatient admissions and higher rates of insurance coverage for young adult children nationally. Lower ED visit rates were observed in California.

183 The Affordable Care Act: Disparities in Emergency Department Use for Mental Health Diagnoses in Young Adults

“…In line with previous studies that have analyzed ACA effects on this population, we measured all rates as visits per 1 000 population based on US Census Bureau data. [22,26,35] We created 1 620 "cells" defi ned by sex, age (19-25 vs. 27-31), race (White, Black, Hispanic, Asian/Pacifi c Islander, Native American, or other/mixed) and quarter for 2009-2011). In each cell, the numerator refl ects the total admissions or visits for that specifi c sex-age-race-quarter group.…”

“…With this data we compared, using a difference-in-differences approach, [12,[25][26][27][28] ED use for young adults aged 19 to 25 and 27 to 31 where visits carried a primary diagnosis of a mental health disorder. The difference-in-differences approach allows us to account for time-varying factors that would have led the treatment group (aged 19 to 25 years) to experience different rates of ED care compared to the control group (aged 27 to 31 years) after the young adult dependent provision was implemented.…”

“…We determined that adults aged 27 to 31 years served as suitable controls as they carry similar lack of coverage and similar mental health concerns as those patients aged 19 to 25 years in the control group. [26] We attempted to control for time varying trends by using the difference in rates of ED use in the treatment group before and after the implementation of the young adult provision, and subtracting this number by the difference in rates of ED use in the control group before and after implementation of the young adult dependent provision.…”

“…These findings are largely consistent with other studies. [26,28,29] While 0.05 ED fewer ED visits per 1 000 people may seem modest, this reduction in visits is very significant when considering that the number of ED visits overall continues to increase on a yearly basis. It is also reasonable to postulate that this difference in number of psychiatric ED visits may also reflect a decrease in usage of the ED for other psychiatric or medical conditions which may be treated as an outpatient.…”

“…[19][20][21][22][23][24] Several studies have looked at specifically young adult patients, and use of ED for mental health reasons, also with mixed results. [25][26][27][28][29][30] Other studies have shown that expansion of access to care is not shared equally among racial, ethnic, or gender groups. [31,32] For example, one study from Stanford [25] found a relative decrease in ED visits by female and African-American patients, whereas other studies did not report such discrepancies.…”