Literature Collection

BACKGROUND: The Affordable Care Act (ACA) aimed to expand mental health service use in the US, by expanding access to health insurance. However, the gap in mental health utilization by race and ethnicity is pronounced: members of racial and ethnic minoritized groups remain less likely to use mental health services than non-Hispanic White individuals even after the ACA. AIMS OF THE STUDY: This study assessed the effect of the Affordable Care Act (ACA) on mental health services use in one large state (California), and whether that effect differed among racial and ethnic groups. Also, it tested for change in racial and ethnic disparities after the implementation of the ACA, using four measures of mental health care. METHODS: Using pooled California Health Interview Survey (CHIS) data from 2011-2018, logistic regression and Generalized Linear Models (GLM) were estimated. Disparities were defined using the Institute of Medicine (IOM) definition. Primary outcomes were any mental health care in primary settings; in specialty settings, any prescription medication for mental health problems, and number of annual visits to mental health services. RESULTS: Findings suggested that the change in Hispanic-non-Hispanic White disparities in prescription medication use under the ACA was statistically significant, narrowing the gap by 7.23 percentage points (p<.05). However, the disparity in other measures was not significantly reduced. DISCUSSION: These findings suggest that the magnitude of the increase in primary and specialty mental health services among racial and ethnic minorities was not large enough to significantly reduce racial and ethnic disparities. One possible explanation is that non-financial factors played a role, such as language barriers, attitudinal barriers from home culture norms, and systemic barriers due to mental health professional shortages and a limited number of mental health care providers of color. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Integrated approaches that coordinate specialty and primary care mental health services may be needed to promote mental healthcare access for members of racial and ethnic minoritized groups. IMPLICATIONS FOR HEALTH POLICIES: Federal and state policies aiming to improve mental health services use have historically given more weight to financial determinants, but this has not been enough to significantly reduce racial/ethnic disparities. Thus, policies should pay more attention to non-financial determinants. IMPLICATIONS FOR FURTHER RESEARCH: Assessing underlying mechanisms of non-financial factors that moderate the effectiveness of the ACA is a worthwhile goal for future research. Future studies should examine the extent to which non-financial factors intervene in the relationship between the implementation of the ACA and mental health services use.

BACKGROUND: Patient-centered medical homes are expected to reduce expenditures by increasing the use of primary care services, shifting care from inpatient to outpatient settings, and reducing avoidable utilization. Under the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, Medicare joined Medicaid and commercial payers in 8 states to support ongoing patient-centered medical home initiatives. OBJECTIVE: To evaluate the effects of the MAPCP Demonstration on health care utilization and expenditures for Medicare beneficiaries. RESEARCH DESIGN: We used difference-in-differences regression modeling to estimate changes in utilization and expenditures before and after the start of the MAPCP Demonstration, comparing beneficiaries engaged with MAPCP Demonstration practices to beneficiaries engaged with primary care practices that were not medical homes. Qualitative data collected during annual site visits provided contextual information on participating practices to inform interpretations of the demonstration outcomes. SUBJECTS: Fee-for-service Medicare beneficiaries attributed to MAPCP Demonstration practices or to comparison group practices. MEASURES: Medicare claims were used to measure total Medicare expenditures and utilization and expenditures for inpatient, emergency room, primary care, and specialist services. RESULTS: Despite the transformation of practices over the demonstration period, there was minimal evidence of a shift to more efficient utilization of health care services, and only 1 state saw a statistically significant reduction in total per-beneficiary expenditures. CONCLUSIONS: Although the MAPCP Demonstration did not have strong, consistent impacts on utilization and expenditures, this evaluation provides insights that may be useful for the design of future health care transformation models.