Low-income households across the US are more likely to be uninsured or under-insured. Medicaid Expansion paves a path for low-income Americans to obtain access to care. Working-aged underinsured individuals tend to get later medical care and too little care–resulting in poorer health outcomes. Even insured individuals may delay necessary care because of cost. A 2018 survey found 45% of respondents delayed or avoided care, with 86% of that group having at least some health insurance coverage.
These stresses have only gotten worse. Estimates produced this year indicate that of individuals who are at high-risk from COVID-19 infection, nearly 17% of them are uninsured. Furthermore, pandemic-related job losses are likely to drastically increase the number of people without health insurance. Additionally, there has been an upward trend with mental health problems during the pandemic.
Current Status of Medicaid Expansion
As of November 2020, 39 states have adopted Medicaid Expansion. 12 states are still debating Medicaid Expansion. The states that have implemented Medicaid Expansion have enrolled millions of low-income citizens. In California alone, 10 million citizens have enrolled.
Legislative leaders in states that have not expanded often express the potential financial burden of expansion as being the primary roadblock. Some states, including Arizona and Nevada, have adopted the “circuit-breaker” approach. The circuit-breaker approach allows the states to offer the expansion benefit only if the federal government maintains the minimum match; for example, Virginia [pdf] opted for no less than 90% federal match.
According to an analysis by the Kaiser Family Foundation, in most states, the total number of adults who have enrolled in Medicaid due to the ACA expansion of the program has tracked closely with the number of adults in the expansion group made newly eligible for Medicaid by the ACA Medicaid expansion. However, there is a difference between these two groups in other states, such a New York and Massachusetts.
Medicaid Expansion and Mental Health Care
A recent Medical Care research article analyzed how Medicaid Expansion has affected the use of mental health care. Among patients who utilized mental health services, the study evaluated four key areas: emergency department visits, hospital stays, prescription fill, and outpatient visits.
Outpatient visits among expanded states on average increased from 0.894 visits to 1.502 visits. On the flip side, mental health visits on average increased from 0.438 to 0.502 among non-expanded states. Among the four categories evaluated, only outpatient visits had a statistical significance based on the adjusted difference-in-difference (DID) model. These changes represent an increase of 168% for expansion states and 115% for non-expansion states. Trends for prescription refills, emergency department visits, and inpatient stays did not have any statistical significance.
Additionally, the article has assessed the outpatient mental visits stratified by racial and ethnic groups, and results for Non-Hispanic white and Hispanic groups were statistically significant. Adjusted DID estimate for white increased by 0.905 visits per person, and adjusted DID estimate for Hispanics increased by 0.533 visits per person. These results indicate a potential worsening of disparities in mental health utilization.
But why is this important?
Especially now, mental health care is extremely important. Furthermore, patients seeking mental health care more often utilize emergency services, which isn’t ideal. The primary risk factors for emergency mental health care are the lack of outpatient treatment options. Results from this study by Breslau and colleagues suggest that Medicaid Expansion has increased the use of outpatient treatment but did not show statistically significant results for emergency room visits. The trends seem to illustrate potential positive trajectories in mental health care with the expansion of Medicaid.
Dinesh Pal Mudaranthakam