The impact of telehealth cost-sharing on healthcare utilization: Evidence from high-deductible health plans.

OBJECTIVE: Evaluate whether cost-sharing decreases led high-deductible health plans (HDHP) enrollees to increase their use of healthcare. DATA SOURCES, STUDY SETTING: National sample of chronically-ill patients age 18-64 from 2018 to 2020 (n = 1,318,178). STUDY DESIGN: Difference-in-differences analyses using entropy-balancing weights were used to evaluate the effect of a policy shift to $0 cost-sharing for telehealth on utilization for HDHP compared with non-HDHP enrollees. Due to this shock, HDHP enrollees experienced substantial declines in cost-sharing for telehealth, while non-HDHP enrollees experienced small declines. Event study models were also used to evaluate changes over time. DATA COLLECTION/EXTRACTION METHODS: Outcomes included use of any outpatient care; use of $0 telehealth; use of $0 telehealth as a proportion of all outpatient care; and use of any telehealth. To test whether any differences were due to preferences for care modality versus cost-sharing, we further evaluated use of non-$0 telehealth as a placebo test. PRINCIPAL FINDINGS: There was no difference in change in overall outpatient visits (p = 0.84), with chronicall-ill HDHP enrollees using less care both before and after the policy shift. However, compared with non-HDHP enrollees, HDHP enrollees increased their use of $0 telehealth by 0.08 visits over a 9-month period, a 27% increase (95% CI 0.07-0.09, p < 0.001) and shifted 1.2 percentage points more of their care to $0 telehealth, a 15% increase (ß = 0.01, 95% CI 0.01, 0.01, p < 0.001). However, HDHP enrollees had lower uptake of non-$0 telehealth than non-HDHP enrollees (ß = -0.01, 95%CI -0.02, 0.00, p = 0.04). CONCLUSIONS: Recent-but-expiring federal legislation exempts telehealth from HDHP deductibles for care provided in 2023 and 2024. Our results indicate that extending the protections provided by this legislation could help reduce the gap in access to care for chronically-ill persons enrolled in HDHPs.

Telehealth Availability for Mental Health Care During and After the COVID-19 Public Health Emergency.

Importance: Telehealth services expanded rapidly during the COVID-19 public health emergency (PHE). Objective: To evaluate changes in availability of telehealth services at outpatient mental health treatment facilities (MHTFs) throughout the US during and after the COVID-19 PHE. Design, Setting, and Participants: In this cohort study, callers posing as prospective clients contacted a random sample of 1404 MHTFs drawn from the Substance Abuse and Mental Health Services Administration's Behavioral Health Treatment Locator from December 2022 to March 2023 (wave 1 [W1]; during PHE). From September to November 2023 (wave 2 [W2]; after PHE), callers recontacted W1 participants. Analyses were conducted in January 2024. Main Outcomes and Measures: Callers inquired whether MHTFs offered telehealth (yes vs no), and, if yes, whether they offered (1) audio-only telehealth (vs audio and video); (2) telehealth for therapy, medication management, and/or diagnostic services; and (3) telehealth for comorbid alcohol use disorder (AUD). Sustainers (offered telehealth in both waves), late adopters (did not offer telehealth in W1 but did in W2), nonadopters (did not offer telehealth in W1 or W2), and discontinuers (offered telehealth in W1 but not W2) were all compared. Results: During W2, 1001 MHTFs (86.1%) were successfully recontacted. A total of 713 (71.2%) were located in a metropolitan county, 151 (15.1%) were publicly operated, and 935 (93.4%) accepted Medicaid as payment. The percentage offering telehealth declined from 799 (81.6%) to 765 (79.0%) (odds ratio [OR], 0.84; 95% CI, 0.72-1.00; P < .05). Among MHTFs offering telehealth, a smaller percentage in W2 offered audio-only telehealth (369 [49.3%] vs 244 [34.1%]; OR, 0.53; 95% CI, 0.44-0.64; P < .001) and telehealth for comorbid AUD (559 [76.3%] vs 457 [66.5%]; OR, 0.62; 95% CI, 0.50-0.76; P < .001) compared with W1. In W2, MHTFs were more likely to report telehealth was only available under certain conditions for therapy (141 facilities [18.0%] vs 276 [36.4%]; OR, 2.62; 95% CI, 1.10-3.26; P < .001) and medication management (216 facilities [28.0%] vs 304 [41.3%]; OR, 1.81; 95% CI, 1.48-2.21; P < .001). A total of 684 MHTFs (72.0%) constituted sustainers, 94 (9.9%) were discontinuers, 106 (11.2%) were nonadopters, and 66 (7.0%) were late adopters. Compared with sustainers, discontinuers were less likely to be private for-profit (adjusted OR [aOR], 0.28; 95% CI, 0.11-0.68) or private not-for-profit (aOR, 0.26; 95% CI, 0.14-0.48) after adjustment for facility and area characteristics. Conclusions and Relevance: Based on this longitudinal cohort study of 1001 MHTFs, telehealth availability has declined since the PHE end with respect to scope and modality of services, suggesting targeted policies may be necessary to sustain telehealth access.

Availability of Mental Telehealth Services in the US.

Importance: Telehealth utilization for mental health care remains much higher than it was before the COVID-19 pandemic; however, availability may vary across facilities, geographic areas, and by patients' demographic characteristics and mental health conditions. Objective: To quantify availability, wait times, and service features of telehealth for major depressive disorder, general anxiety disorder, and schizophrenia throughout the US, as well as facility-, client-, and county-level characteristics associated with telehealth availability. Design, Settings, and Participants: Cross-sectional analysis of a secret shopper survey of mental health treatment facilities (MHTFs) throughout all US states except Hawaii from December 2022 and March 2023. A nationally representative sample of 1938 facilities were contacted; 1404 (72%) responded and were included. Data analysis was performed from March to July 2023. Exposure: Health facility, client, and county characteristics. Main Outcome and Measures: Clinic-reported availability of telehealth services, availability of telehealth services (behavioral treatment, medication management, and diagnostic services), and number of days until first telehealth appointment. Multivariable logistic and linear regression analyses were conducted to assess whether facility-, client-, and county-level characteristics were associated with each outcome. Results: Of the 1221 facilities (87%) accepting new patients, 980 (80%) reported offering telehealth. Of these, 97% (937 facilities) reported availability of counseling services; 77% (726 facilities), medication management; and 69% (626 facilities) diagnostic services. Telehealth availability did not differ by clinical condition. Private for-profit (adjusted odds ratio [aOR], 1.75; 95% CI, 1.05-2.92) and private not-for-profit (aOR, 2.20; 95% CI, 1.42-3.39) facilities were more likely to offer telehealth than public facilities. Facilities located in metropolitan counties (compared with nonmetropolitan counties) were more likely to offer medication management services (aOR, 1.83; 95% CI, 1.11-3.00) but were less likely to offer diagnostic services (aOR, 0.67; 95% CI, 0.47-0.95). Median (range) wait time for first telehealth appointment was 14 (4-75) days. No differences were observed in availability of an appointment based on the perceived race, ethnicity, or sex of the prospective patient. Conclusions and Relevance: The findings of this cross-sectional study indicate that there were no differences in the availability of mental telehealth services based on the prospective patient's clinical condition, perceived race or ethnicity, or sex; however, differences were found at the facility-, county-, and state-level. These findings suggest widespread disparities in who has access to which telehealth services throughout the US.

Evaluating the Accuracy of 2020 Census Block-Level Estimates in California.

In this study, we provide an assessment of data accuracy from the 2020 Census. We compare block-level population totals from a sample of 173 census blocks in California across three sources: (1) the 2020 Census, which has been infused with error to protect respondent confidentiality; (2) the California Neighborhoods Count, the first independent enumeration survey of census blocks; and (3) projections based on the 2010 Census and subsequent American Community Surveys. We find that, on average, total population counts provided by the U.S. Census Bureau at the block level for the 2020 Census are not biased in any consistent direction. However, subpopulation totals defined by age, race, and ethnicity are highly variable. Additionally, we find that inconsistencies across the three sources are amplified in large blocks defined in terms of land area or by total housing units, blocks in suburban areas, and blocks that lack broadband access.

Expansion of Telehealth Availability for Mental Health Care After State-Level Policy Changes From 2019 to 2022.

Importance: Although telehealth services expanded rapidly during the COVID-19 pandemic, the association between state policies and telehealth availability has been insufficiently characterized. Objective: To investigate the associations between 4 state policies and telehealth availability at outpatient mental health treatment facilities throughout the US. Design, Setting, and Participants: This cohort study measured whether mental health treatment facilities offered telehealth services each quarter from April 2019 through September 2022. The sample comprised facilities with outpatient services that were not part of the US Department of Veterans Affairs system. Four state policies were identified from 4 different sources. Data were analyzed in January 2023. Exposures: For each quarter, implementation of the following policies was indexed by state: (1) payment parity for telehealth services among private insurers; (2) authorization of audio-only telehealth services for Medicaid and Children's Health Insurance Program (CHIP) beneficiaries; (3) participation in the Interstate Medical Licensure Compact (IMLC), permitting psychiatrists to provide telehealth services across state lines; and (4) participation in the Psychology Interjurisdictional Compact (PSYPACT), permitting clinical psychologists to provide telehealth services across state lines. Main Outcome and Measures: The primary outcome was the probability of a mental health treatment facility offering telehealth services in each quarter for each study year (2019-2022). Information on the facilities was obtained from the Mental Health and Addiction Treatment Tracking Repository based on the Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Service Locator. Separate multivariable fixed-effects regression models were used to estimate the difference in the probability of offering telehealth services after vs before policy implementation, adjusting for characteristics of the facility and county in which the facility was located. Results: A total of 12 828 mental health treatment facilities were included. Overall, 88.1% of facilities offered telehealth services in September 2022 compared with 39.4% of facilities in April 2019. All 4 policies were associated with increased odds of telehealth availability: payment parity for telehealth services (adjusted odds ratio [AOR], 1.11; 95% CI, 1.03-1.19), reimbursement for audio-only telehealth services (AOR, 1.73; 95% CI, 1.64-1.81), IMLC participation (AOR, 1.40, 95% CI, 1.24-1.59), and PSYPACT participation (AOR, 1.21, 95% CI, 1.12-1.31). Facilities that accepted Medicaid as a form of payment had lower odds of offering telehealth services (AOR, 0.75; 95% CI, 0.65-0.86) over the study period, as did facilities in counties with a higher proportion (>20%) of Black residents (AOR, 0.58; 95% CI, 0.50-0.68). Facilities in rural counties had higher odds of offering telehealth services (AOR, 1.67; 95% CI, 1.48-1.88). Conclusion and Relevance: Results of this study suggest that 4 state policies that were introduced during the COVID-19 pandemic were associated with marked expansion of telehealth availability for mental health care at mental health treatment facilities throughout the US. Despite these policies, telehealth services were less likely to be offered in counties with a greater proportion of Black residents and in facilities that accepted Medicaid and CHIP.

Differences in telehealth during COVID-19 between commercial and Medicaid enrollees.

OBJECTIVES: To compare how in-person evaluation and management (E&M) visits and telehealth use differed during the COVID-19 pandemic between commercially insured and Medicaid enrollees, and to assess how insurance plan type-fee-for-service (FFS) vs managed care (MC)-and enrollee characteristics contributed to these differences. STUDY DESIGN: Retrospective cohort analysis of 2019 and 2020 data from the commercially insured California Public Employees' Retirement System (CalPERS) and the California Medicaid program (Medi-Cal). METHODS: We conducted unadjusted comparisons of per capita E&M visits and the share of visits conducted via telehealth by payer (CalPERS vs Medi-Cal) and plan type (FFS vs MC). We estimated linear regressions of telehealth use that adjusted for patient demographics, rurality, and internet access. Among Medi-Cal enrollees, we examined telehealth use differences based on race, language, and citizenship status. RESULTS: Regression-adjusted share of telehealth visits as a proportion of all E&M visits was 22.6% for CalPERS FFS patients (the reference group), 38.2% for Medi-Cal FFS patients, 46.0% for Medi-Cal MC patients, and 53.5% for CalPERS MC patients. Among Medi-Cal enrollees, telehealth use as a share of all E&M visits was higher among Spanish speakers, female enrollees, and rural enrollees. Across most demographic characteristics, Medi-Cal patients enrolled in FFS were less likely to receive telehealth compared with those enrolled in MC. CONCLUSIONS: During the first year of the COVID-19 pandemic, California MC enrollees had higher rates of telehealth use compared with FFS enrollees, regardless of insurer. Among FFS enrollees, those enrolled in Medicaid had higher rates of telehealth use compared with those insured by CalPERS. Telehealth policies should be aware of this heterogeneity, as well as its implications for equity of telehealth access.

Imputation of Race and Ethnicity in Health Insurance Marketplace Enrollment Data, 2015-2022 Open Enrollment Periods.

Information on the race and ethnicity of individuals enrolled through the HealthCare.gov Health Insurance Marketplace is critical for assessing past enrollment efforts and determining whether outreach campaigns should be modified or tailored moving forward. However, approximately one-third of insurance applicants do not complete the race and Hispanic ethnicity questions on the Marketplace application. When self-reported race and ethnicity information is missing, other information about an individual can be used to infer race and ethnicity, such as surnames, first names, and addresses, with each characteristic contributing meaningfully to the identification of six mutually exclusive racial and ethnic groups: American Indian (AI)/Alaskan Native (AN); Asian American, Native Hawaiian, and Pacific Islander (AANHPI); Black; Hispanic; Multiracial; and White. Surnames are particularly useful for distinguishing people who identify as Hispanic and AANHPI from other racial and ethnic groups. Geocoded address information is particularly useful in distinguishing Black and White individuals who frequently reside in racially segregated neighborhoods. This article presents the results of imputing race and ethnicity for Marketplace enrollees from 2015 through 2022 using the modified Bayesian Improved First Name Surname and Geocoding (BIFSG) method, developed by the RAND Corporation, which uses surnames, first names, and residential addresses to indirectly estimate race and ethnicity.

Prices Paid to Hospitals by Private Health Plans: Findings from Round 4 of an Employer-Led Transparency Initiative.

Because employer-sponsored spending comes from employee wages and benefits, employers have a fiduciary responsibility to administer benefits in the interest of participants. The lack of transparency of prices in the health care market limits the ability of employers to knowledgeably develop or implement benefit design decisions. This study uses medical claims data from a large population of privately insured individuals, including hospitals and other facilities from across the United States, and allows an easy comparison of hospital prices using a single metric. An important innovation of this study is that our data use agreements allow reporting on prices paid to hospitals and hospital systems (hospitals under joint ownership) identified by name.

Availability and Accessibility of Mental Health Services in New York City.

Mental health services are critical components of public health infrastructure that provide essential supports to people living with psychiatric disorders. In a typical year, about 20 percent of people will have a psychiatric disorder, and about 5 percent will experience serious psychological distress, indicating a potentially serious mental illness. Nationally, the use of mental health services is low, and the use of care is not equitably distributed. In the United States as a whole and in New York City (NYC), non-Hispanic white individuals are more likely to use mental health services than non-Hispanic black individuals or Hispanic individuals. The challenges of ensuring the availability of mental health services for all groups in NYC are particularly acute, given the size of the population and its diversity in income, culture, ethnicity, and language. Adding to these underlying challenges, the coronavirus disease 2019 (COVID-19) pandemic has disrupted established patterns of care. To advance policy strategy for addressing gaps in the mental health services system, RAND researchers investigate the availability and accessibility of mental health services in NYC. The RAND team used two complementary approaches to address these issues. First, the team conducted interviews with a broad group of professionals and patients in the mental health system to identify barriers to care and potential strategies for improving access and availability. Second, the team investigated geographic variations in the availability of mental health services by compiling and mapping data on the locations and service characteristics of mental health treatment facilities in NYC.

Patterns in Geographic Distribution of Substance Use Disorder Treatment Facilities in the US and Accepted Forms of Payment From 2010 to 2021.

Importance: The drug overdose crisis is a continuing public health problem and is expected to grow substantially in older adults. Understanding the geographic accessibility to a substance use disorder (SUD) treatment facility that accepts Medicare can inform efforts to address this crisis in older adults. Objective: To assess whether geographic accessibility of services was limited for older adults despite the increasing need for SUD and opioid use disorder treatments in this population. Design, Setting, and Participants: This longitudinal cross-sectional study obtained data on all licensed SUD treatment facilities for all US counties and Census tracts listed in the National Directory of Drug and Alcohol Abuse Treatment Programs from 2010 to 2021. Main Outcomes and Measures: Measures included the national proportion of treatment facilities accepting Medicare, Medicaid, private insurance, or cash as a form of payment; the proportion of counties with a treatment facility accepting each form of payment; and the proportion of the national population with Medicare, Medicaid, private insurance, or cash payment residing within a 15-, 30-, or 60-minute driving time from an SUD treatment facility accepting their form of payment in 2021. Results: A total of 11 709 SUD treatment facilities operated across the US per year between 2010 and 2021 (140 507 facility-year observations). Cash was the most commonly accepted form of payment (increasing slightly from 91.0% in 2010 to 91.6% by 2021), followed by private insurance (increasing from 63.5% to 75.3%), Medicaid (increasing from 54.0% to 71.8%), and Medicare (increasing from 32.1% to 41.9%). The proportion of counties with a treatment facility that accepted Medicare as a form of payment also increased over the same study period from 41.2% to 53.8%, whereas the proportion of counties with a facility that accepted Medicaid as a form of payment increased from 53.5% to 67.1%. The proportion of Medicare beneficiaries with a treatment facility that accepted Medicare as a form of payment within a 15-minute driving time increased from 53.3% to 57.0%. The proportion of individuals with a treatment facility within a 15-minute driving time that accepted their respective form of payment was 73.2% for those with Medicaid, 69.8% for those with private insurance, and 71.4% for those with cash payment in 2021. Conclusions and Relevance: Results of this study suggest that Medicare beneficiaries have less geographic accessibility to SUD treatment facilities given that acceptance of Medicare is low compared with other forms of payment. Policy makers need to consider increasing reimbursement rates and using additional incentives to encourage the acceptance of Medicare.

Brief Report: Medicaid Expansion and Growth in the Workforce for Autism Spectrum Disorder.

Over 700,000 children throughout the U.S. have received insurance coverage through welcome mat effects of Medicaid expansion, including children with autism spectrum disorder (ASD). Utilizing health workforce data from the Health Resources and Services Administration, we examined workforce growth (2008-2017) among three types of health providers for children with ASD as a result of Medicaid expansion: child psychiatrists, board-certified behavioral analysts (BCBAs) and pediatricians. We found that state Medicaid expansion was associated with a 9% increase in BCBAs per 100,000 children one year after enactment, a 5% increase in child psychiatrists, and was not associated with growth in pediatricians. Results indicate the importance of new policies that directly address a shortage of providers for children with ASD.

Where are US outpatient mental health facilities that serve children with autism spectrum disorder? A national snapshot of geographic disparities.

LAY ABSTRACT: There has been a rise in the observed prevalence of autism spectrum disorder among children. Existing studies show the share of counties with a treatment facility that offers care for children with autism spectrum disorder. However, no estimates exist of the share of US outpatient mental health treatment facilities that provide services for children with autism spectrum disorder. We identified key facility-level characteristics in offering mental health care for children with autism spectrum disorder. We used a telephone survey to contact almost all outpatient mental health treatment facilities in the contiguous United States. We asked the facilities if they provided mental health care for children with autism spectrum disorder. We took the results of this survey and estimated multivariable regressions to examine county- and facility-level predictors of offering services. We found that over half (50.3%) of the 6156 outpatient facilities reported offering care for children with autism spectrum disorder. Non-metro counties, counties with a lower percentage of non-White residents, counties with a higher percentage of uninsured residents, and counties with a higher poverty rate had fewer outpatient mental health treatment facilities providing care for children with autism spectrum disorder. Facilities accepting Medicaid as a form of payment, offering telehealth, and private for-profit facilities were more likely to provide services for children with autism spectrum disorder. Because only half of outpatient mental health treatment facilities offer care for children with autism spectrum disorder, public health officials and policymakers should do more to ensure that this vulnerable population has access to mental health services.

Telehealth Adoption by Mental Health and Substance Use Disorder Treatment Facilities in the COVID-19 Pandemic.

OBJECTIVE: The study examined temporal and geographic trends in telehealth availability at U.S. behavioral health treatment facilities and risk factors for not offering telehealth. METHODS: Longitudinal data on 15,691 outpatient behavioral health treatment facilities were extracted daily from the Substance Abuse and Mental Health Services Administration's Behavioral Health Treatment Services Locator between January 20, 2020, and January 20, 2021. Facilities operated by the Department of Veterans Affairs were excluded. Bivariate analyses were used to assess trends in telehealth availability in 2020 and 2021. Multivariable regression analysis was used to examine facility- and county-level characteristics associated with telehealth availability in 2021. RESULTS: Telehealth availability increased by 77% from 2020 to 2021 for mental health treatment facilities and by 143% for substance use disorder treatment facilities. By January 2021, 68% of outpatient mental health facilities and 57% of substance use disorder treatment facilities in the sample were offering telehealth. Mental health and substance use disorder treatment facilities that did not accept Medicaid as a form of payment were less likely to offer telehealth in 2021, compared with facilities that accepted Medicaid. Mental health and substance use disorder treatment facilities that accepted private insurance were more likely to offer telehealth in 2021, compared with facilities that did not accept private insurance. CONCLUSIONS: Although 2020 saw a dramatic increase in telehealth availability at behavioral health treatment facilities, 32% of mental health treatment facilities and 43% of substance use disorder treatment facilities did not offer telehealth in January 2021, nearly 1 year into the pandemic.

Ongoing Disparities in Digital and In-Person Access to Child Psychiatric Services in the United States.

OBJECTIVE: To estimate the number and geographic distribution of children and adolescents in the United States who reside in counties with neither child and adolescent psychiatrists nor sufficient Internet broadband to support telepsychiatry services. METHOD: This analysis combined data from the Health Resources and Services Administration's Area Health Resource Files on child psychiatrist workforce with Federal Communications Commission information on broadband coverage to generate a composite of in-person and digital access to child psychiatric services throughout the United States. Using multivariable fixed-effects Poisson regression analysis, we estimated the number of children and adolescents (aged 5-19 years) without access to psychiatric services and examined disparities across counties in the United States. RESULTS: We estimate that 6,035,402 children and adolescents in the United States (approximately 10%) have inadequate in-person and digital availability of child psychiatric services within their counties. Although this was true for only 3% of children and adolescents in urban counties, this applied to more than half (51%) in rural counties (adjusted odds ratio [AOR] = 2.71; 95% CI = 1.94, 3.78; p < .001). Likewise, only 3% of children and adolescents in high-income counties had insufficient digital and physical access, compared to more than 4 in 10 children and adolescents (41%) in low-income counties (AOR = 0.43; 95% CI = 0.30-0.61; p < .001). Counties with a higher density of Black and Hispanic residents had greater likelihood of service availability (p < 0.001), potentially a function of living in metropolitan communities. CONCLUSION: Although telehealth holds promise for promoting access to child and adolescent psychiatric services, large disparities in overall access to services persists in rural and low-income communities.

Population-based estimates of geographic accessibility of medication for opioid use disorder by substance use disorder treatment facilities from 2014 to 2020.

BACKGROUND: Understanding whether individuals have geographic accessibility to a substance use disorder treatment facility and a treatment facility that offers medication treatment for opioid use disorder (MOUD) can inform efforts to address the ongoing opioid crisis. METHODS: We used data from the National Directory of Drug and Alcohol Abuse Treatment Programs. First, we calculate the national share of treatment facilities that offer one type of MOUD or all forms of MOUD using a novel dataset of providers. Second, we quantify the share of counties with a treatment facility offering at least one type of MOUD. Finally, we calculate the share of the national population residing within a 10-mile radius of a treatment facility. RESULTS: The share of counties with a treatment facility offering a MOUD as a form of treatment rose from 30% to 45% from 2014 to 2020 while the share of counties with facilities offering all three forms of MOUD increased from 4% to 9%. Over 83% of the population lives within 10 miles of a facility offering MOUD treatment, and 42% of the population have a treatment facility that offers all three forms of MOUD within a 10-mile radius. Much of the difference between the county- and population-based measures is explained by more population dense areas having higher rates of facilities providing MOUD. CONCLUSIONS: While the share of facilities within a county offering a MOUD is relatively small, the share of the population within 10 miles of such a facility is higher.

Density of medical and recreational cannabis outlets: racial/ethnic differences in the associations with young adult intentions to use cannabis, e-cigarettes, and cannabis mixed with tobacco/nicotine.

BACKGROUND: Differences in access to medical versus recreational cannabis outlets and their associations with intentions to use cannabis have not yet been examined among young adults. This study compares the associations between densities of medical versus recreational cannabis outlets and young adults' intentions to use cannabis, electronic cigarettes, and cannabis mixed with tobacco/nicotine products. Racial/ethnic differences in these associations were examined. METHODS: Young adults ages 18-23 (mean age = 20.9) in Los Angeles County were surveyed online in 2018 after the legalization of recreational cannabis (n = 604). Multiple linear regressions were estimated for the entire sample and stratified by race/ethnicity. Outcomes were intentions to use cannabis, electronic cigarettes, and cannabis mixed with tobacco/nicotine in the next 6 months. Density was measured as the number of medical cannabis dispensaries (MCDs), recreational cannabis retailers (RCRs), and outlets of any type within 5 miles of respondents' homes. RESULTS: Living near more outlets of any type was not significantly associated with intentions to use in the full sample, adjusting for individual- and neighborhood-level characteristics. However, race/ethnicity-stratified models indicated that living near more outlets of any type and more RCRs were significantly associated with stronger co-use intentions among white young adults. Higher MCD density was marginally associated with stronger co-use intentions among Asian young adults. However, higher MCD density was significantly associated with lower intentions to use e-cigarettes among Hispanic young adults. CONCLUSIONS: The results suggest racial/ethnic differences in the impact of living near cannabis outlets on intentions to use. Prevention efforts targeting young adults who live near more cannabis outlets may be especially beneficial for white and Asian young adults.

Availability of Outpatient Telemental Health Services in the United States at the Outset of the COVID-19 Pandemic.

BACKGROUND: Since coronavirus disease 2019 (COVID-19) has caused dramatic changes in everyday life, a major concern is whether patients have adequate access to mental health care despite shelter-in-place ordinances, school closures, and social distancing practices. OBJECTIVES: The aim was to examine the availability of telehealth services at outpatient mental health treatment facilities in the United States at the outset of the COVID-19 pandemic, and to identify facility-level characteristics and state-level policies associated with the availability. RESEARCH DESIGN: Observational cross-sectional study. SUBJECTS: All outpatient mental health treatment facilities (N=8860) listed in the Behavioral Health Treatment Services Locator of the Substance Abuse and Mental Health Services Administration on April 16, 2020. MEASURES: Primary outcome is whether an outpatient mental health treatment facility reported offering telehealth services. RESULTS: Approximately 43% of outpatient mental health facilities in the United States reported telehealth availability at the outset of the pandemic. Facilities located in the United States South and nonmetropolitan counties were more likely to offer services, as were facilities with public sector ownership, those providing care for both children and adults, and those accepting Medicaid as a form of payment. Outpatient mental health treatment facilities located in states with state-wide shelter-in-place laws were less likely to offer telehealth, as well as facilities in counties with more COVID-19 cases per 10,000 population. CONCLUSIONS: At the onset of the COVID-19 pandemic, fewer than half of outpatient mental health treatment facilities were providing telehealth services. Our results suggest that additional policies to promote telehealth may be warranted to increase availability over the course of the COVID-19 pandemic.

Generosity of state insurance mandates and growth in the workforce for autism spectrum disorder.

LAY ABSTRACT: To improve access to health services for children with autism spectrum disorder, US states have passed laws requiring health insurers to cover autism-related care, commonly known as state insurance mandates. However, the features of mandates differ across states, with some state laws containing very generous provisions and others containing very restrictive provisions such as whether the mandates include children aged above 12 years, whether there is a limit on spending, and whether there are restrictions on the types of services covered. This study examined the relationship between generosity of mandates and growth in the health workforce between 2003 and 2017, a period during which 44 states passed mandates. We found that states that enacted more generous mandates experienced significantly more growth in board-certified behavioral analysts who provide behavioral therapy as well as more growth in child psychiatrists. We did not find differences in the growth of pediatricians, which is a less specialized segment of the workforce. Our findings were consistent across eight different mandate features and suggest that the content of legislation may be as important as whether or not legislation has been passed in terms of encouraging growth in the supply of services for children with autism spectrum disorder.

State Insurance Mandates and the Workforce for Children With Autism.

BACKGROUND: State mandates have required insurance companies to provide coverage for autism-related child health care services; however, it has not been determined if insurance mandates have improved the supply of child health care providers. We investigate the effect of state insurance mandates on the supply of child psychiatrists, pediatricians, and board-certified behavioral analysts (BCBAs). METHODS: We used data from the National Conference of State Legislatures and Health Resources and Services Administration's Area Health Resource Files to examine child psychiatrists, pediatricians, and BCBAs in all 50 states from 2003 to 2017. Fixed-effects regression models compared change in workforce density before versus one year after mandate implementation and the effect of mandate generosity across 44 US states implementing mandates between 2003 and 2017. RESULTS: From 2003 to 2017, child psychiatrists increased from 7.40 to 10.03 per 100 000 children, pediatricians from 62.35 to 68.86, and BCBAs from 1.34 to 29.88. Mandate introduction was associated with an additional increase of 0.77 BCBAs per 100 000 children (95% confidence interval [CI]: 0.18 to 1.42) one year after mandate enactment. Mandate introduction was also associated with a more modest increase among child psychiatrists (95% CI: 0.10 to 0.91) and was not associated with the prevalence of pediatricians (95% CI: -0.76 to 1.13). We also found evidence that more generous mandate benefits were associated with larger effects on workforce supply. CONCLUSIONS: State insurance mandates were associated with an ∼16% increase in BCBAs from 2003 to 2017, but the association with child psychiatrists was smaller and nonsignificant among pediatricians. In these findings, it is suggested that policies are needed that specifically address workforce constraints in the provision of services for children with autism spectrum disorder.