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

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) 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: 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

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

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

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

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

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

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

9. Distribution of Adults 18-64 by Poverty Status

10. Distribution of Adults 18-64 by Health Insurance Status

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

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

13. Use of Mental Health Services Among Adults 18-64

14. Figure 2

15. Figure 3

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

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

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

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