A new study published in Health Affairs shows that cost-sharing parity for Mental Health and Substance Use Disorders (MHSUD) was associated with an increased receipt of outpatient MHSUD treatment among white beneficiaries but increased less among minority beneficiaries, exacerbating existing disparities.
Approximately 20% of older adults in the United States experience a mental illness, a substance use disorder, or both, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).[1] At the same time, people 65 and older are more likely to report that they “rarely” or “never” received the social and emotional support they needed compared to adults 50-64 (12.2% versus 8.1%).[2] Meanwhile, anxiety and mood disorders among Black and Hispanic older adults are either similar or higher in prevalence compared with White counterparts, and depressive symptoms are more severe for Black and Hispanic older adults. [3]
Prior studies indicated that poverty and out-of-pocket spending significantly contributed to racial and ethnic disparities in accessing MHSUD specialty services.[4] The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) introduced cost-sharing parity for MHSUD services. It resulted in co-insurance being gradually reduced from 50% in 2009 to 20% from 2014 onward.
This study examined 50% of all Medicare claims data from 2008-18 for traditional Medicare beneficiaries 65 and older. Researchers analyzed four types of outcomes: outpatient MHSUD visits, fills for MHSUD medication prescriptions, acute MHSUD events such as trips to the emergency department, and MHSUD treatment spending.
Researchers found that the proportion of beneficiaries with one or more annual MHSUD outpatient visits increased between 2008 and 2018 across all racial and ethnic groups, with higher use among those able to access free care versus the cost-sharing reduction. In both categories, White beneficiaries were more likely than minority beneficiaries to have a MHSUD visit. The study highlights the fact that among those filling MHSUD prescriptions, a large portion had unmonitored use (80% among American Indian/Alaska Native beneficiaries to 87% for Asian beneficiaries). Furthermore, White beneficiaries with the cost-sharing reduction were most likely to have a visit to the emergency department or hospitalization with a MHSUD diagnosis. This beneficiary population also had the highest levels of average MHSUD spending compared with other racial and ethnic groups.
The authors of the study posited that the findings “raise critical questions about why the benefits of” the cost-sharing parity policy aided White beneficiaries more than minority beneficiaries. It was concluded that attention must be paid to potential structural barriers to MHSUD for racial and ethnic minority older adults. “Racism and discrimination,” according to the authors, “could continue to limit access to and use of services by minority beneficiaries.”
January 19, 2023 – C. St. John
[1] Everett, A. Bringing Awareness to the Mental Health of Older Adults. Substance Abuse and Mental Health Services Administration. (May 20, 2019). Available at: https://www.samhsa.gov/blog/bringing-awareness-mental-health-older-adults
[2] Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors; 2008. Available at: https://www.cdc.gov/aging/pdf/mental_health.pdf
[3] Fung, V., Price, M., McDowell, A., Nierenberg, A. A., Hsu, J., Newhouse, J. P., & Cook, B. L. Coverage Parity and Racial and Ethnic Disparities in Mental Health and Substance Use Care Among Medicare Beneficiaries. Health Affairs, 42(1), 83–93. (2023). Available at: https://doi.org/10.1377/hlthaff.2022.00624
[4] Ibid.