Changes in the Utilization of Mental Health Care Services and Mental Health at the Onset of Medicare.

BACKGROUND: The onset of Medicare eligibility at age 65 in the U.S. is accompanied by significant changes in health insurance coverage rates. This presents a unique opportunity to study the interaction among health insurance, health care utilization, and health outcomes.

AIMS: This study examines if changes in mental health outcomes accompany the changes in health insurance coverage rates at age 65.

METHODS: 2006-2013 data from the Sample Adult and Person File components of the National Health Insurance Survey are used to explore the link between the onset of Medicare and the utilization of mental health care services and mental health. A regression discontinuity design is employed to test for changes in perceived financial barriers to mental health care, visits with mental health professionals, and self-reported mental health. In addition to identifying the overall effect, analysis is also conducted on samples that are stratified by level of education to test for heterogeneous treatment effects across socioeconomic groups.

RESULTS: The coverage changes that occur at age 65 are associated with a substantial decline in self-reported financial barriers to receiving mental health care. This effect is greatest among individuals from lower socioeconomic backgrounds. Despite the decline in the percentage of adults claiming they did not obtain mental health care services because of prohibitive costs, no significant changes in mental health visits or self-reported mental health are identified. The implementation of lower cost-sharing requirements for outpatient mental health care through the Medicare Patients and Providers Act of 2008 (MIPPA) has had no statistically significant effect on mental health visits at the age 65 cutoff for Medicare eligibility.

DISCUSSION: There is no estimated change in mental health visits, yet prohibitive costs of mental health care decline, especially among individuals from lower socioeconomic groups. These findings may be the result of newly eligible Medicare enrollees either increasing their utilization of mental health visits on the intensive margin, obtaining alternative sources of treatment for mental illness, or facing other barriers to care that are unrelated to costs. Additionally, estimates pertaining to mental health visits are imprecise, and large changes relative to age 64 means cannot be ruled out.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: There is no evidence that gaining health insurance coverage at age 65 results in increased visits with mental health professionals on the extensive margin.

IMPLICATIONS FOR HEALTH POLICY: For the previously uninsured and under-insured, the onset of Medicare coverage at age 65 results in a reduction in cost-sharing requirements for mental health care. These reductions have no clear effect on overall mental health visit rates. Although the 2010 implementation of MIPPA has gradually lowered cost-sharing requirements for outpatient mental health care, these changes have not affected mental health visits at age 65.

IMPLICATIONS FOR FURTHER RESEARCH: Future research that evaluates whether additional factors, such as residing in a mental health shortage area, can explain the imprecise estimate on mental health visits would be useful. Additionally, future studies that examine the interaction between private insurance and Medicare coverage would better explain the dynamic changes that occur at age 65, and how shifting coverage patterns interact with mental health care utilization rates.