Medicaid Expansion Improves Access to Depression Care

The expansion of state Medicaid coverage was associated with a 23 percentage point increase in health insurance among adults with depression, as well as decreased cost-related delays in obtaining health care or medication, according to a study posted on August 28 in Psychiatric Services.

Medicaid expansion was also associated with an 11 percentage point boost in respondents who have a personal doctor and a reduction in the number of people who delayed care (16 percentage points) or skipped medications (18 percentage points) because of cost, according to authors Carrie E. Fry, a Ph.D. health policy student at Harvard, and colleagues.

The study involved surveys of nearly 5,000 low-income adults who screened positive for depression from three southern states: Arkansas and Kentucky, both of which expanded their Medicaid program, and Texas, which has a similar demographic makeup but did not expand. Researchers conducted phone surveys before the Medicaid expansion in 2013 and after states’ expansion (from 2015 to 2016) and compared them.

Under the Affordable Care Act, states could expand Medicaid eligibility to residents with incomes of up to 138 percent of the federal poverty level, granting new coverage to nearly 12 million people in the 34 states that expanded, according to the Kaiser Family Foundation (KFF). In these states, individuals can earn just under $16,800 a year and still qualify for Medicaid, up from $12,100 a year in states that did not expand.

Prior to expansion, only about half of eligible adults were enrolled in Medicaid. “Eligibility for Medicaid doesn’t automatically result in coverage, and the enrollment process can be especially burdensome for individuals with depression or other mental health or substance use disorders,” Fry told Psychiatric News. “Continued threats to Medicaid expansion will likely result in reduced access to health care services for people who need care the most, including adults with depression.”

The findings come as a number of states are seeking to restrict Medicaid eligibility with never-before-tried approaches such as work requirements, drug screening and testing, eligibility time limits, and cost-sharing premiums. Some states are seeking to have these restrictions applied only to their expansion populations, but some are seeking to apply them to their poorest Medicaid populations as well.

Three states—Arkansas, Kentucky, and New Hampshire—received approval from the Centers for Medicare and Medicaid Services (CMS) to require beneficiaries to work as a condition of enrollment, and 10 states now have applications with CMS pending to do the same, KFF reported.

Indiana was one of the first states to add cost-sharing premiums. Within the first two years, more than half (55 percent) of enrollees required to pay premiums failed to do so, resulting in negative consequences. Nearly 287,000 of the states’ poorest residents were moved to a more limited benefit package for failure to pay. In addition, some 60,000 expansion enrollees were either never enrolled or lost coverage. The top reasons cited by enrollees were lack of affordability and confusion over the payment process.

In Arkansas, nearly 4,400 low-income individuals were dropped from Arkansas’ Medicaid rosters last month for failure to work or report their work or community engagement activities under a restriction that began in the spring, according to a statement from Gov. Asa Hutchinson. Those individuals are now ineligible for coverage for the remainder of the calendar year.

“Personal responsibility is important,” Hutchinson said. “We will continue to do everything we can to ensure those who qualify for the program keep their coverage, but it is equally important to make sure those who no longer qualify are removed.”

Arkansas’ provision is now being challenged in court, and a similar work provision in Kentucky was invalidated by a federal district court in June and sent back to the Department of Health and Human Services to reconsider. ■