The Affordable Care Act: Disparities in emergency department use for mental health diagnoses in young adults

doi:10.5847/wjem.j.1920-8642.2017.03.008

Abstract

Abstract:

BACKGROUND: There is little consensus as to the effects of insurance expansion on emergency department (ED) utilization for mental health purposes. We aimed to study the race specific association between the dependent coverage provision of the Affordable Care Act (ACA) and changes in young adults' usage of emergency department services for psychiatric diagnoses.

METHODS: We utilized a Quasi-Experimental analysis of ED use in California from 2009-2011 for behavioral health diagnoses of individuals aged 19 to 31 years. Analysis used a difference-in-differences approach comparing those targeted by the ACA dependent provision (19-25 years) and those who were not (27 to 31 years), evaluating changes in ED visit rates per 1 000 in California. Primary outcomes measured included the quarterly ED visit rates with any psychiatric diagnosis. Subgroups were analyzed for differences based on race and gender.

RESULTS: The ACA dependent provision was associated with 0.05 per 1 000 people fewer psychiatric ED visits among the treatment group (19-25 years) compared to the control group (27-31 years). Hispanics and Asian/Pacific Islanders were the only racial subgroups who did not see this significant reduction and were the only racial subgroups that did not see significant gains in the proportion of psychiatric ED visits covered by private insurance.

CONCLUSION: The ACA dependent provision was associated with a modest reduction in the growth rate of ED use for psychiatric reasons, however, racial disparities in the effect of this provision exist for patients of Hispanic and Asian/Pacific Islander racial groups.

Key words: Affordable Care Act, Mental health, Disparities, Health Policy

Justin Yanuck, Bryson Hicks, Craig Anderson, John Billimek, Shahram Lotfipour, Bharath Chakravarthy. The Affordable Care Act: Disparities in emergency department use for mental health diagnoses in young adults[J]. World Journal of Emergency Medicine, 2017, 8(3): 206-213.

Figures/Tables 4

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References 37

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Characteristics	Ages 19-25 (ED visit per 1 000 people^*)			Ages 27-31 (ED visit per 1 000 people^*)
Characteristics	Full sample rate (SD)	Males rate (SD)	Females rate (SD)	Full sample rate (SD)	Males rate (SD)	Females rate (SD)
Race
All Races	1.70 (0.77)	1.86 (0.85)	1.55 (0.70)	1.85 (0.85)	2.03 (1.06)	1.65 (0.72)
White	1.90 (0.26)	1.99 (0.16)	1.75 (0.14)	1.79 (0.24)	1.92 (0.17)	1.65 (0.12)
Black	2.36 (0.34)	2.36 (0.25)	2.35 (0.21)	2.75 (0.36)	2.84 (0.27)	2.65 (0.22)
Hispanic	1.07 (0.18)	1.18 (0.15)	0.99 (0.12)	1.09 (0.18)	1.19 (0.14)	0.99 (0.10)
Asian/Pacific Islander	0.36 (0.06)	0.35 (0.13)	0.34 (0.13)	0.36 (0.06)	0.35 (0.04)	0.42 (0.05)
Native American	0.60 (0.13)	0.59 (0.09)	0.61 (0.08)	0.71 (0.21)	0.62 (0.16)	0.75 (0.17)
Mixed/Other	1.73 (0.27)	1.95 (0.21)	1.52 (0.19)	2.03 (0.31)	2.25 (0.23)	1.82 (0.16)
ED visit with diagnosis (dx) of
Any psychiatric dx	1.70 (0.77)	1.86 (0.85)	1.55 (0.70)	1.85 (0.85)	2.03 (1.06)	1.65 (0.72)
Depression dx only^**	0.45 (0.08)	0.29 (0.05)	0.57 (0.17)	0.50 (0.26)	0.32 (0.11)	0.66 (0.28)
Substance use dx only	4.22 (0.50)	4.87 (0.89)	3.61 (0.40)	4.42 (0.55)	5.21 (0.94)	3.67 (0.43)
Psychosis dx only	0.55 (0.10)	0.73 (0.15)	0.45 (0.08)	0.68 (0.16)	0.82 (0.25)	0.56 (0.18)
Any other psychiatric dx	2.8 (0.34)	2.51 (0.60)	2.98 (0.70)	3.13 (0.39)	2.81 (0.64)	3.39 (0.79)
Total ED visits	158 873	87 195	71 678	109 532	60 495	49 037

Outcome	Enactment effect, 2010 (Q2-Q3)			Implement effect, 2011 (Q1-Q4)
Outcome	Enactment effect	95%CI	P	Implementation effect	95%CI	P
All ED visits	-0.01	-0.24, 0.09	0.36	-0.05	-0.08, -0.01	<0.001
ED visits by race^**
White	-0.02	-0.03, 0.00	0.11	-0.03	-0.04, -0.01	<0.001
Black	-0.03	0.00, 0.05	0.12	-0.04	-0.06, -0.03	<0.001
Hispanic	-0.01	-0.02, 0.03	0.63	0.01	-0.01, 0.03	0.51
Asian/Pacific Islander	-0.02	-0.03, 0.01	0.20	-0.02	-0.04, 0.02	0.20
Native American	0.03	-0.01, 0.10	0.15	-0.05	-0.08, -0.01	0.04
Mixed/Other	0.02	0.00, 0.04	0.09	-0.03	-0.04, -0.01	<0.001

Outcome	Coefficient estimate	Implement effect, 2011 (Q1-Q4) (95%CI)	P
Full sample
All ED visits	0.02	-0.01, 0.05	0.603
ED visits by race^**
White	0.08	0.05, 0.11	<0.001
Black	0.05	0.02, 0.08	0.003
Hispanic	0.01	-0.02, 0.04	0.694
Asian/Pacific Islander	-0.01	-0.04, 0.03	0.796
Native American	0.03	0.01, 0.10	0.04
Mixed/other	0.05	0.02, 0.08	<0.001

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