The Effects of Medicaid Eligibility on Mental Health Services and Out‐of‐Pocket Spending for Mental Health Services

Objective

Millions of low‐income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out‐of‐pocket spending.

Data Sources

Secondary data from the 1998–2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.

Study Design

Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out‐of‐pocket spending for mental health services.

Data Extraction Methods

Person‐year files were constructed including adults ages 21–64 under 300 percent of the Federal Poverty Level.

Principal Findings

Medicaid expansions significantly increased health insurance coverage and reduced out‐of‐pocket spending on mental health services for low‐income adults. Effects of expanded Medicaid eligibility on out‐of‐pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.

Conclusions

Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out‐of‐pocket mental health care spending.     

Out‐of‐school time activity participation profiles of children with physical disabilities: a cluster analysis

Objective To determine out‐of‐school activity participation profiles of school‐aged children with physical disabilities. Methods Activity participation profiles were determined by cluster analysing 427 children's responses on multiple dimensions of participation (intensity, location, companionship, enjoyment, preference) in five activity types (recreational, active physical, social, skill‐based, self‐improvement). Socio‐demographic, child, parent, family and environmental predictors of group membership were determined, along with child functioning, socio‐demographic, self‐concept and social support variables significantly associated with group membership. Results The cluster analysis revealed four groups, labelled Social Participators (a highly social and neighbourhood‐focused group), Broad Participators (a group of high participators who enjoy participation), Low Participators (a group with low enjoyment and weak preferences) and Recreational Participators (a group of younger children who participate in recreational activities with family members). The groups showed meaningful differences across a range of socio‐demographic, child, parent, family and environmental variables. Conclusions The findings support an affective and contextual view of participation, indicating the importance of motivational theory and a person–environment approach in understanding the complexity of children's out‐of‐school activity participation.     

The Rise and Fall in Out‐of‐Pocket Costs in Australia: An Analysis of the Strengthening Medicare Reforms

After a period of steady decline, out‐of‐pocket (OOP) costs for general practitioner (GP) consultations in Australia began increasing in the mid‐1990s. Following the rising community concerns about the increasing costs, the Australian Government introduced the Strengthening Medicare reforms in 2004 and 2005, which included a targeted incentive for GPs to charge zero OOP costs for consultations provided to children and concession cardholders (older adults and the poor), as well as an increase in the reimbursement for all GP visits. This paper examines the impact of those reforms using longitudinal survey and administrative data from a large national sample of women. The findings suggest that the reforms were effective in reducing OOP costs by an average of $A0.40 per visit. Decreases in OOP costs, however, were not evenly distributed. Those with higher pre‐reform OOP costs had the biggest reductions in OOP costs, as did those with concession cards. However, results also reveal increases in OOP costs for most people without a concession card. The analysis suggests that there has been considerable heterogeneity in GP responses to the reforms, which has led to substantial changes in the fees charged by doctors and, as a result, the OOP costs incurred by different population groups. Copyright © 2016 John Wiley & Sons, Ltd.     

The impact of transitional programmes on post‐transition outcomes for youth leaving out‐of‐home care: a meta‐analysis

Youth residing in out‐of‐home care settings have often been exposed to childhood trauma, and commonly report experiencing adverse outcomes after transitioning from care. This meta‐analysis appraised internationally published literature investigating the impact of transitional programme participation (among youth with a baseline age of 15–24 years) on post‐transition outcomes of housing, education, employment, mental health and substance use. A comprehensive search of sociology (e.g. ProQuest Sociology), psychology (e.g. PsycInfo) and health (e.g. ProQuest Family Health) electronic abstraction databases was conducted for the period 1990–2014. Search terms included ‘out‐of‐home care’, ‘transition’, ‘housing’, ‘education’, ‘employment’, ‘mental health’ and ‘substance use’. Nineteen studies, all from the United States, met the inclusion criteria and were included in the meta‐analysis. Living independently and homelessness were the most commonly described housing outcomes. Rates of post‐transition employment varied, while rates of post‐secondary education were low. Depression and alcohol use were commonly reported among transitioning youth. Findings of the meta‐analysis showed that attention should be given to the potential benefit of transitional programme participation on outcomes such as housing, employment and education. Moderator analyses showed that these benefits may differ based on study design, sample size and sampling unit, but not for mean age or gender. Detailed and rigorous research is needed internationally to examine the characteristics of transitional programmes resulting in more successful outcomes for youth, and whether these outcomes are sustained longitudinally.     

Out‐of‐pocket payments for public healthcare services by selected exempted groups in Serbia during the period of post‐war healthcare reforms

This paper focuses on the exemption mechanism that accompanies patient co‐payments for outpatient and inpatient hospital care in Serbia. The objective was to investigate the level and dynamics of out‐of‐pocket payments for this type of services by exempted groups (older than 65 years, younger than 15 years, unemployed, disabled and individuals with low family income) compared with that by other groups. For this purpose, we use empirical household data collected in the Serbian Living Standards Measurement Study carried out in 2002, 2003 and 2007. These years correspond to the start of the recent reforms in the Serbian healthcare sector and 1 and 5 years after the start of the reform. Our results show that people who belong to exempted groups were paying for healthcare in 2002, 2003 and 2007. They report different types of out‐of‐pocket payments for outpatient and inpatient hospital care. Thus, despite the ambition of the Ministry of Health in Serbia to promote equity in healthcare as a leading aim of the reforms, the implementation of the exemption mechanism fails to protect the targeted groups. Future exemption mechanism should be pro‐poor oriented but should also exempt those whose health status requires a frequent healthcare use. Copyright © 2013 John Wiley & Sons, Ltd.     

Descriptive study of carers' support,encouragement and modelling of healthy lifestyle behaviours in residential out‐of‐home care

Objective: Given the high prevalence of overweight/obesity among young people in residential out‐of‐home care (OOHC), and as their carers are in loco parentis, this research aimed: 1) to examine the healthy lifestyle cognitions and behaviours of residential carers; and 2) to describe resources needed to improve diet and/or physical activity outcomes for residents. Methods: Cross‐sectional data were collected from 243 residential carers. Measures included: demographics; knowledge of dietary/physical activity recommendations; self‐reported encouragement/importance of health behaviours; physical activity/screen time (at work); unit ‘healthiness’; and necessary resources for creating a healthy environment. Results: Staff placed importance on the residents eating well and being physically active. However, examination of carer knowledge found significant gaps in staff education. Three key priority areas were identified to help build a healthy food and activity environment in residential OOHC: funding, professional development and policy. Conclusion: Carer knowledge of healthy lifestyles can be improved and they need to be well resourced to ensure children in public care settings live in a healthy environment. Implications: These findings may inform the development of ongoing professional development to improve carers' health literacy, as well as policy to support dietary/activity guidelines for the OOHC sector.     

Impacts of care‐giving and sources of support: a comparison of end‐of‐life and non‐end‐of‐life caregivers in Canada

This is the second in a series of papers that deal with care‐giving in Canada, as based on data available from the Canadian General Social Survey (2007). Building on the first paper, which reviewed the differences between short‐term, long‐term and end‐of‐life (EOL) caregivers, this paper uniquely examines the caregiver supports employed by EOL caregivers when compared to non‐EOL caregivers (short‐term and long‐term caregivers combined). Both papers employ data from Statistics Canada's General Social Survey (GSS Cycle 21: 2007). The GSS includes three modules, where respondents were asked questions about the unpaid home care assistance that they had provided in the last 12 months to someone at EOL or with either a long‐term health condition or a physical limitation. The objective of this research paper was to investigate the link between the impact of the care‐giving experience and the caregiver supports received, while also examining the differences in these across EOL and non‐EOL caregivers. By way of factor analysis and regression modelling, we examine differences between two types of caregivers: (i) EOL and (ii) non‐EOL caregivers. The study revealed that with respect to socio‐demographic characteristics, health outcomes and caregiver supports, EOL caregivers were consistently worse off. This suggests that although all non‐EOL caregivers are experiencing negative impacts from their care‐giving role, comparatively greater supports are needed for EOL caregivers.     

The impact of out‐of‐pocket health expenditure on household impoverishment: Evidence from Morocco

Health financing in Morocco relies mainly on out‐of‐pocket (OoP) payments. World Health Organization (WHO) has shown that these payments can expose households to catastrophic health expenditure (hereinafter CHE) and impoverish them. The study examines the financial burden of OoP health payments on Moroccan households. Two approaches—that developed by Wagstaff and Doeslear and the one advocated by WHO—are adopted to estimate the extent of CHE. These show that 1.77% of households incurred CHE at the 40% threshold for nonfood expenditure. At the 10% threshold for total consumption expenditure, 12.8% of households incurred CHE. We find that these OoP payments have made 1.11% of Moroccan households poorer. In analyzing the determinants of CHE, we estimated an ordered probit model. It appears that any of (a) hospitalization, (b) presence of an elderly person in the household, or (c) the level of poverty increases significantly the likelihood of health expenditure becoming catastrophic. On the other hand, we find that coverage by health insurance protects against CHE.     

The Impact of Community‐Based Health Insurance on Utilization and Out‐of‐Pocket Expenditures in Lao People's Democratic Republic

Community‐based health insurance in Lao People's Democratic Republic targets the informal workforce. Estimates of the program's impact on utilization and out‐of‐pocket expenditures (OOPs) were obtained using a case‐comparison study of 3000 households (14 804 individuals) in urban and semi‐urban areas. We used propensity score matching to control for bias on observables and to account for heterogeneity. We check the sensitivity of the results using a weighted regression combined with propensity score matching, which leads to doubly robust treatment effect estimates. The results are robust across the two approaches and show that the insured have significantly higher utilization, lower OOPs and lower incidence of catastrophic expenditures, and are less likely to employ coping mechanisms. However, coverage of the scheme is extremely low, indicating negligible population level impact. Furthermore, the results show that the scheme provides greater protection to the better off than to the poor: the poor are less likely to enrol, and among the poor who are enrolled, there has been no significant impact on utilization of outpatient services, total OOPs or catastrophic expenditures. We discuss the policy implications in the context of the international debate regarding the prospects for the role of community‐based health insurance in national financing strategies. Copyright © 2013 John Wiley & Sons, Ltd.     

Differential impacts of care‐giving across three caregiver groups in Canada: end‐of‐life care,long‐term care and short‐term care

Using data from Statistic Canada's General Social Survey Cycle 21 (GSS 2007), this study explores whether differences exist in the impacts of care‐giving among three groups of caregivers providing informal care either in the caregiver's or recipient's home, or in other locations within the community: (i) those providing end‐of‐life (EOL) care (n = 471); (ii) those providing long‐term care (more than 2 years) for someone with a chronic condition or long‐term illness (n = 2722); and (iii) those providing short‐term care (less than 2 years) for someone with a chronic condition or long‐term illness (n = 2381). This study lays out the variation in sociodemographic characteristics across the three caregiver groups while also building on our understanding of the differential impacts of care‐giving through an analysis of determinants. All three groups of caregivers shared a number of sociodemographic characteristics, including being female, married, employed and living in a Census Metropolitan Area (CMA). With respect to health, EOL caregivers were found to have significantly higher levels of ‘fair or poor’ self‐assessed health than the other two groups. Overall, the findings suggest that EOL caregivers are negatively impacted by the often additional role of care‐giving, more so than both short‐term and long‐term caregivers. EOL caregivers experienced a higher proportion of negative impacts on their social and activity patterns. Furthermore, EOL caregivers incurred greater financial costs than the other two types of informal caregivers. The impacts of EOL care‐giving also negatively influence employment for caregivers when compared with the other caregiver groups. Consequently, EOL caregivers, overall, experienced greater negative impacts, including negative health outcomes, than did long‐term or short‐term caregivers. This provides the evidence for the assertion that EOL care‐giving is the most intense type of care‐giving, potentially causing the greatest caregiver burden; this is shown through the greater negative impacts experienced by the EOL caregivers when compared with the short‐term and long‐term caregivers.