Abstract
This study evaluates changes in access to care for adults by mental health status using data from a national sample.
The Patient Protection and Affordable Care Act (ACA) expanded health insurance to approximately 21 million Americans through health insurance reforms (eg, guaranteed issue, adjusted community rating, preexisting condition exclusion bans, and dependent coverage extensions), expansions in Medicaid, and subsidies for marketplace coverage.1 The ACA also expanded mental health coverage through mental health parity reforms and the provision of essential health benefits, which include mental health services. Early ACA-related research found increases in mental health treatment and reductions in uninsured adults with mental illness.2,3,4 This study builds on previous research and evaluates changes in access to care for adults by mental health status using data from a national sample.
Methods
Data for this study come from the 2012, 2013, and 2015 National Health Interview Survey, a cross-sectional and nationally representative health survey of the civilian, noninstitutionalized population. Our final sample included 77 095 adults aged 18 to 64 years. We relied on the K6 scale of Kessler et al5 for nonspecific psychological distress, a 6-item screening instrument widely used to assess mental illness in epidemiologic studies. The screening instrument asked how often during the previous 30 days the respondent felt nervous, hopeless, worthless, so sad that nothing could cheer him/her up, restless or fidgety, and that everything was an effort. Using this 24-point scale, we identified adults between the 5- and 12-point threshold as being symptomatic of moderate mental illness (MMI) and those at the 13-point threshold or higher as symptomatic of severe mental illness (SMI); adults between the 0- and 4-point threshold were considered to have no mental illness.6 This study was deemed to be exempt from review by the Vanderbilt University Institutional Review Board; therefore, informed consent was not required. All data were deidentified.
We used descriptive statistics to characterize the study sample. Then we evaluated unadjusted and adjusted changes in access to care between 2012 and 2013 (before ACA) and 2015 (after ACA) for each K6 subgroup using 7 dimensions of health care access: (1) no health insurance, (2) no usual source of care, (3) delayed medical care because of cost in the prior 12 months, (4) forgone medical care because of cost in the prior 12 months, (5) forgone prescription medications because of cost in the prior 12 months, (6) forgone mental health care because of cost in the prior 12 months, and (7) saw a mental health professional in the prior 12 months. Adjusted estimates were obtained from logistic regression models that controlled for sociodemographic characteristics. All analyses were conducted using Stata statistical software, version 14 (StataCorp) with survey weights and White SEs robust to heteroscedasticity.
Results
Of the 77 095 nonelderly adults studied (mean [SD] age, 40.7 [8.6] years; 41 910 [50.9%] female and 35 185 [49.1%] male), those with SMI were more likely to be unemployed, have low income, and have poor or fair health (Table 1). After sociodemographic factors were controlled for, there was a decrease in uninsured adults with no mental illness (−6.2 percentage points; 95% CI, −7.0 to −5.5), MMI (−8.5 percentage points; 95% CI, −10.3 to −6.8), and SMI (−9.3 percentage points; 95% CI, −13.1 to −5.5) (Table 2). Having no usual source of care (−3.5 percentage points; 95% CI, −5.3 to −1.6), delayed medical care (−4.5 percentage points, 95% CI, −6.2 to −2.8), forgone medical care (−3.3 percentage points, 95% CI, −5.0 to −1.6), and forgone prescription medications (−3.6 percentage points; 95% CI, −5.4 to −1.9) significantly decreased for adults with MMI. Forgone prescription medications (−6.8 percentage points; 95% CI, −11.5 to −2.0) and forgone mental health care (−8.0 percentage points; 95% CI, −11.7 to −4.3) decreased for adults with SMI.
Table 1. Characteristics of US Nonelderly Adults by Mental Health Status, National Health Interview Surveya.
| Characteristic | No. (%) of Patients | |||||
|---|---|---|---|---|---|---|
| No Mental Illness | Moderate Mental Illness | Severe Mental Illness | ||||
| 2012-2013 (n = 41 624) |
2015 (n = 18 518) |
2012-2013 (n = 9065) |
2015 (n = 4683) |
2012-2013 (n = 2197) |
2015 (n = 1008) |
|
| Weighted sample | 41 624 (80.3) | 18 518 (77.9) | 9065 (16.1) | 4683 (18.2) | 2197 (3.6) | 1008 (3.9) |
| Age group, y | ||||||
| 18-25 | 6099 (17.7) | 2517 (17.6) | 1418 (19.4) | 709 (18.07) | 194 (11.8) | 123 (18.0) |
| 26-34 | 8834 (19.5) | 3857 (19.4) | 1888 (19.5) | 981 (20.01) | 359 (16.7) | 151 (18.2) |
| 35-44 | 8902 (20.7) | 3908 (20.8) | 1839 (19.7) | 931 (19.02) | 469 (20.1) | 208 (18.9) |
| 45-54 | 8849 (22.2) | 3997 (21.8) | 2026 (22.6) | 1066 (23.18) | 595 (27.5) | 253 (20.7) |
| 55-64 | 8940 (20.0) | 4239 (20.5) | 1894 (18.8) | 996 (19.73) | 580 (23.9) | 273 (24.2) |
| Sex | ||||||
| Male | 19 625 (50.5) | 8829 (50.6) | 3658 (43.7) | 1911 (44.5) | 799 (39.7) | 363 (39.9) |
| Female | 21 999 (49.5) | 9689 (49.4) | 5407 (56.3) | 2772 (55.5) | 1398 (60.3) | 645 (60.1) |
| Race/ethnicity | ||||||
| White | 23 818 (64.2) | 10 921 (62.3) | 5221 (64) | 2814 (63.9) | 1269 (66.6) | 625 (64.4) |
| Black | 6434 (12.2) | 2505 (12.3) | 1502 (13.5) | 693 (13.5) | 360 (12.8) | 137 (12.2) |
| Hispanic | 7954 (16.7) | 3537 (17.6) | 1711 (16.6) | 863 (16.8) | 461 (16.1) | 196 (18.0) |
| Other/multiple | 3418 (7.0) | 1555 (7.7) | 631 (6.0) | 313 (5.9) | 107 (4.5) | 50 (5.4) |
| Marital status | ||||||
| Married | 19 411 (54.8) | 8916 (55.8) | 3059 (42.8) | 1692 (44.5) | 608 (37.8) | 290 (34) |
| Living with a partner | 2947 (8.0) | 1315 (7.9) | 787 (10.4) | 440 (10.6) | 185 (10.7) | 80 (10.1) |
| Divorced, separated, widowed | 7240 (11.4) | 3175 (11.1) | 2246 (17.0) | 1048 (15.8) | 803 (26.3) | 332 (23.8) |
| Never married | 11 927 (25.6) | 5073 (25.1) | 2957 (29.6) | 1495 (29.1) | 595 (24.9) | 305 (32.0) |
| Missing | 99 (0.2) | 39 (0.1) | 16 (0.1) | 8 (0.1) | 6 (0.3) | 1 (0.1) |
| Region of residence | ||||||
| Northeast | 6806 (18.2) | 2918 (17.2) | 1395 (15.8) | 762 (16.4) | 354 (16.0) | 165 (14.1) |
| Midwest | 8554 (22.4) | 3880 (22.2) | 1828 (23.3) | 998 (24.0) | 424 (23.9) | 197 (23.3) |
| South | 15 287 (36.6) | 6352 (36.9) | 3237 (35.5) | 1598 (35.9) | 853 (40.0) | 365 (36.8) |
| West | 10 977 (22.9) | 5368 (23.8) | 2605 (25.5) | 1325 (23.7) | 566 (20.3) | 281 (25.8) |
| Educational attainment | ||||||
| Less than high school | 5133 (11.3) | 2010 (10.2) | 1557 (16.2) | 699 (13.5) | 593 (24.9) | 236 (26.3) |
| High school graduate | 10 022 (24.6) | 4235 (23.0) | 2353 (26.2) | 1164 (25.0) | 687 (32.8) | 289 (28.6) |
| Some college | 13 197 (31.8) | 5911 (31.5) | 3131 (34.9) | 1607 (35.4) | 687 (31.7) | 360 (33.1) |
| College graduate | 8629 (21.3) | 3994 (22.2) | 1336 (15.0) | 796 (17.2) | 145 (7.0) | 73 (7.2) |
| Graduate education | 4509 (10.6) | 2306 (12.7) | 657 (7.2) | 405 (8.5) | 73 (2.9) | 48 (4.4) |
| Missing | 134 (0.3) | 62 (0.5) | 31 (0.5) | 12 (0.4) | 12 (0.7) | 2 (0.5) |
| Family income relative to the federal poverty guidelines, % | ||||||
| 0-138 | 9825 (18.6) | 3974 (17.3) | 3422 (30.2) | 1581 (27.6) | 1299 (50.4) | 533 (44.9) |
| 139-200 | 4339 (10.0) | 1911 (9.5) | 1278 (14.4) | 619 (13.4) | 286 (13.9) | 148 (16.1) |
| 201-399 | 11 892 (29.3) | 5352 (29.0) | 2384 (28.6) | 1253 (28.5) | 374 (21.8) | 196 (21.7) |
| ≥400 | 15 568 (42.1) | 7281 (44.2) | 1981 (26.8) | 1230 (30.5) | 238 (13.9) | 131 (17.3) |
| Employment status | ||||||
| Employed | 31 089 (74.8) | 14 134 (76.5) | 5298 (59.2) | 2893 (62.8) | 712 (31.2) | 364 (36) |
| Unemployed | 2405 (5.9) | 739 (4.0) | 928 (10.3) | 352 (7.8) | 274 (13.2) | 105 (11.4) |
| Not in labor force | 8106 (19.3) | 3633 (19.4) | 2832 (30.5) | 1437 (29.4) | 1210 (55.5) | 539 (52.7) |
| Missing | 24 (0.1) | 12 (0.1) | 7 (0.1) | 1 (0.01) | 1 (0.01) | 0 (0.0) |
| Number of chronic conditionsb | ||||||
| 0 | 25 094 (61.2) | 11 133 (61.8) | 3973 (46.0) | 2102 (48.1) | 598 (28.7) | 254 (29.5) |
| 1 | 9784 (23.3) | 4496 (24.1) | 2363 (25.9) | 1213 (25.4) | 525 (23.3) | 251 (26.9) |
| ≥2 | 6144 (14.1) | 2806 (13.7) | 2557 (26.1) | 1327 (25.8) | 1008 (45.2) | 484 (41.9) |
| Missing | 602 (1.4) | 83 (0.4) | 172 (2.0) | 41 (0.7) | 66 (2.8) | 19 (1.6) |
| Reported health status | ||||||
| Excellent or very good | 28 145 (69.3) | 12 530 (69.5) | 3868 (46.0) | 2107 (48.2) | 428 (21.3) | 224 (25.5) |
| Good | 10 186 (23.8) | 4580 (23.9) | 2899 (31.0) | 1489 (31.6) | 577 (26.5) | 254 (24.6) |
| Fair or poor | 3283 (6.9) | 1406 (6.6) | 2288 (22.9) | 1086 (20.2) | 1190 (52.1) | 530 (49.9) |
| Missing | 10 (0.03) | 2 (0.01) | 10 (0.1) | 1 (0.001) | 2 (0.1) | 0 (0.0) |
Data are from the 2012, 2013, and 2015 National Health Interview Survey among adults 18 to 64 years of age. Data are unadjusted estimates and are weighted to represent the general nonelderly adult population.
Chronic conditions include cancer, hypertension, coronary heart disease, stroke, chronic obstructive pulmonary disease, asthma, diabetes, arthritis, hepatitis, and weak or failing kidneys.
Table 2. Changes in Health Insurance Coverage and Access to Care by Mental Health Status, 2012-2015a.
| Mental Health Status | No. (%) of Patients | Unadjusted Difference | Adjustedb Difference | |||
|---|---|---|---|---|---|---|
| 2012-2013 | 2015 | Percentage Points (95% CI) | P Valuec | Percentage Points (95% CI) | P Valuec | |
| No mental illness | ||||||
| No health insurance coverage | 8674 (18.9) | 2473 (12.0) | −6.9 (−7.7 to −6.2) | <.001 | −6.2 (−7.0 to −5.5) | <.001 |
| No usual source of care | 8462 (19.0) | 3269 (16.9) | −2.1 (−2.9 to −1.2) | <.001 | −1.5 (−2.3 to −0.8) | <.001 |
| Delayed medical care because of cost | 4415 (9.0) | 1448 (6.3) | −2.7 (−3.3 to −2.1) | <.001 | −2.4 (−3.0 to −1.8) | <.001 |
| Forgone medical care because of cost | 3243 (6.6) | 1028 (4.2) | −2.4 (−2.8 to −1.9) | <.001 | −2.1 (−2.6 to −1.7) | <.001 |
| Forgone prescription medications because of cost | 2538 (5.6) | 814 (3.9) | −1.7 (−2.1 to −1.3) | <.001 | −1.5 (−1.9 to −1.1) | <.001 |
| Forgone mental health care because of cost | 428 (0.9) | 163 (0.7) | −0.2 (−0.4 to 0.04) | .11 | −0.1 (−0.3 to 0.1) | .18 |
| Saw mental health professional | 2080 (4.8) | 1026 (5.3) | 0.5 (0.03 to 1.0) | .04 | 0.5 (0.04 to 1.1) | .03 |
| Moderate mental illness | ||||||
| No health insurance coverage | 2376 (25.0) | 708 (14.9) | −10.1 (−11.9 to −8.3) | <.001 | −8.5 (−10.3 to −6.8) | <.001 |
| No usual source of care | 1981 (22.2) | 825 (17.8) | −4.4 (−6.2 to −2.5) | <.001 | −3.5 (−5.3 to −1.6) | <.001 |
| Delayed medical care because of cost | 2372 (23.1) | 912 (17.3) | −5.8 (−7.6 to −4.0) | <.001 | −4.5 (−6.2 to −2.8) | <.001 |
| Forgone medical care because of cost | 1892 (18.3) | 720 (13.7) | −4.6 (−6.3 to −2.9) | <.001 | −3.3 (−5.0 to −1.6) | <.001 |
| Forgone prescription medications because of cost | 1838 (19.7) | 706 (14.8) | −4.9 (−6.7 to −3.1) | <.001 | −3.6 (−5.4 to −1.9) | <.001 |
| Forgone mental health care because of cost | 673 (6.7) | 281 (5.6) | −1.1 (−2.3 to 0.02) | .05 | −0.7 (−1.9 to 0.5) | .23 |
| Saw mental health professional | 1795 (18.8) | 941 (17.9) | −0.9 (−2.7 to 0.7) | .26 | −0.7 (−2.4 to 1.0) | .42 |
| Severe mental illness | ||||||
| No health insurance coverage | 630 (28.6) | 175 (18.6) | −10.0 (−13.9 to −6.2) | <.001 | −9.3 (−13.1 to −5.5) | <.001 |
| No usual source of care | 498 (21.7) | 187 (20.5) | −1.2 (−5.4 to 3.0) | .57 | −1.8 (−5.7 to 2.2) | .38 |
| Delayed medical care because of cost | 801 (32.0) | 313 (27.7) | −4.3 (−8.6 to 0.1) | .05 | −3.1 (−7.4 to 1.1) | .15 |
| Forgone medical care because of cost | 738 (30.1) | 288 (24.8) | −5.3 (−9.6 to −1.1) | .01 | −3.8 (−7.9 to 0.02) | .07 |
| Forgone prescription medications because of cost | 833 (38.5) | 312 (29.8) | −8.7 (−13.7 to −3.7) | .001 | −6.8 (−11.5 to −2.0) | .01 |
| Forgone mental health care because of cost | 529 (24.8) | 177 (16.3) | −8.5 (−12.3 to −4.8) | <.001 | −8.0 (−11.7 to −4.3) | <.001 |
| Saw mental health professional | 881 (39.8) | 391 (35.7) | −4.1 (−9.4 to 1.2) | .13 | −4.1 (−9.2 to 1.0) | .11 |
Data are from the 2012, 2013, and 2015 National Health Interview Survey among adults aged 18 to 64 years.
Adjusted estimates are regression adjusted and controlled for age, sex, race/ethnicity, marital status, educational level, income relative to federal poverty guidelines, employment status, health status, number of chronic conditions, and US Census region of residence.
P values are from 2-tailed t tests.
Discussion
Access to care has improved for adults with MMI and SMI in recent years. Of importance, forgone mental health care decreased significantly for individuals with SMI. However, gaps in access persist. We did not find improvements in having a usual source of care, delayed medical care because of cost, or seeing a mental health professional for adults with SMI, which may be attributable to factors not fully addressed by the ACA, such as high cost sharing and continued shortages in mental health.
Limitations
Study limitations include the cross-sectional design, possible confounders, and changing demographics.
Conclusions
Future reforms should consider expanding access to care for adults with SMI, with a focus on strengthening the mental health care system.
References
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