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theses

ETD doctoral

Background: Individuals with serious psychological distress (SPD) are significantly more likely to be uninsured or covered by Medicaid, and less likely to have private insurance than individuals with no psychological distress (NPD). They are in worse health and have greater health care needs relative to individuals with NPD, and they are more likely to have difficulties accessing all types of health care. The Affordable Care Act (ACA) sought to improve access to health care primarily through expanding health insurance coverage, which individuals with SPD often lack. Few studies have examined changes in health insurance status, health services use and access to health care among the SPD population during the time of ACA implementation. Specific aims: The goal of this dissertation is to observe changes to health insurance, health services use, and barriers to health care among individuals with serious psychological distress (SPD) during the time frame of the implementation of the Affordable Care Act (ACA) using the Medical Expenditure Panel Survey. This study aims to answer the following questions: 1a.) “How did health insurance coverage among individuals with SPD shift during ACA implementation?” 1b.) “Did health insurance coverage among individuals with mild-to-moderate psychological distress (MMPD) and no psychological distress (NPD) shift in a similar manner?” 2.) “How did the use of health services shift during ACA implementation among those with SPD and NPD?” 3a.) “How did need for health care and barriers to access of health care change during ACA implementation for individuals with SPD?” 3b.) “Did individuals with MMPD and NPD observe similar changes?”. Methods: Mental illness is measured using the Kessler 6 (K6) scale of non-specific psychological distress scale. A score of ≥13 is severe psychological distress (SPD), 12 to 8 is mild to moderate psychological distress (MMPD), and ≤7 is no psychological distress (NPD). Pooled cross-sectional data from the 2011-2016 Integrated Public Use Microdata Series IPUMS Medical Expenditure Panel Survey is analyzed. Individuals included in the sample had a score on the K6, an income ≤399% of the federal poverty level and are between the ages of 27 and 64. Descriptive statistics were conducted using 2-sided t-tests for differences in proportions in categorical variables, and adjusted Wald tests for continuous variables. To address study aims 1a & 1b, multinomial probit regression was performed to assess differences in the proportion of individuals in each insurance category in each year of ACA implementation. To address specific aim 2, four health service outcomes were assessed in each year of ACA implementation (2011-2016) including emergency room use, hospitalizations, outpatient/office-based visits, and prescriptions. Analysis of health service use was conducted using a two-part hurdle model, where the first part of the model predicted the likelihood of utilizing each type of health service (i.e. emergency room, hospital discharges, outpatient/office-based visits or prescriptions), and the second part predicted the amount of health service use conditional upon any utilization. The combined model predicted expected utilization based on the likelihood of service use and the amount. To address specific aims 3a and 3b, access to health care outcomes include the need for health care, the unmet need for health care, and having a usual place of care. The probability of accessing health care in each year during ACA implementation (2012-2016) was compared to the reference year (2011) within each psychological distress group using logistic regression models, and marginal effects were reported.

Results: Individuals with SPD did not see significant changes in enrollment in private insurance in any year relative to 2011, although they did observe a 3 and 3.4 percentage point increase in enrollment in private insurance in 2014 and 2015, respectively. Individuals with SPD do not have a higher likelihood of enrollment in Medicaid until 2015 (8.6 percentage points, p<0.001) relative to 2011 and this remains elevated in 2016 (9 percentage points, p<0.001). However, the uninsured rate for these individuals began to decline in 2014 and was 14.9 percentage points lower relative to 2011 by 2016 for those with SPD (p<0.001). Among individuals with SPD, the likelihood of having an ER visit is higher in the 2014-2016 time period than in 2011, with a 7.7 percentage point increase by 2016 (p<0.05). Similarly, the likelihood of having a prescription medication is higher in 2015 than in 2011 (4 percentage points, p<0.05). The number of hospital discharges for individuals with SPD, conditioned upon having any, increased in 2016 relative to 2011 (0.6 discharges, p<0.01). Outpatient/office-based visits, conditioned on having any, increased in 2014 & 2015 relative to 2011 (2014: 2.6 visits, p<0.1; 2015: 2.5 visits, p<0.1). Among individuals with SPD, the expected utilization is statistically significant and higher for hospital discharges in 2016 (0.12 discharges, p<0.1), outpatient/office-based visits in 2014 (2.4 visits, p<0.05) & 2015 (2.6 visits, p<0.1), and prescriptions in 2015 (4.4 prescriptions, p<0.1) relative to 2011. Each year during the time frame of ACA implementation (2012-2016) is associated with a lower probability of needing health care relative to 2011 for individuals with SPD, although this association is only statistically significant in 2013 (-6.6 percentage points, p<0.05). The unmet need for health care seems to have increased during ACA implementation for individuals with SPD. They experience a significant increased unmet need in 2013 (5.8 percentage points, p<0.05) and 2015 (5.1 percentage points, p<0.1). Not having a usual place of care is generally higher in each year relative to 2011. For individuals with SPD, there are only statistically significant increases in not having a usual place of care in 2012 (4.2 percentage points, p<0.1) and 2013 (8.1 percentage points, p<0.01).

ETD_11159

Ph.D.

Includes bibliographical references

doi:10.7282/t3-6ecp-ed45

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