How policymakers innovate around behavioral health: adoption of the New Mexico "No Behavioral Health Cost-Sharing" law.

State policymakers have long sought to improve access to mental health and substance use disorder (MH/SUD) treatment through insurance market reforms. Examining decisions made by innovative policymakers ("policy entrepreneurs") can inform the potential scope and limits of legislative reform. Beginning in 2022, New Mexico became the first state to eliminate cost-sharing for MH/SUD treatment in private insurance plans subject to state regulation. Based on key informant interviews (n = 30), this study recounts the law's passage and intended impact. Key facilitators to the law's passage included receptive leadership, legislative champions with medical and insurance backgrounds, the use of local research evidence, advocate testimony, support from health industry figures, the severity of MH/SUD, and increased attention to MH/SUD during the COVID-19 pandemic. Findings have important implications for states considering similar laws to improve access to MH/SUD treatment.

State paid sick leave mandates associated with increased mental health disorder prescriptions among Medicaid enrollees.

The United States does not have a federal paid sick leave policy. As a result, many workers, in particular lower wage workers, cannot take time off work to attend to health and family responsibilities. Fifteen states have adopted or announced paid sick leave mandates that offer employees approximately 7 days of financially protected work time each year. This time can facilitate health care use, including treatment related to mental health disorders, conditions for which treatment is time-consuming. We studied the effect of state paid sick leave mandates on prescription medications dispensed for mental health disorders using the Medicaid State Drug Utilization Database 2011-2022. We found that medications dispensed for mental health disorders increased 6% per year following adoption of a state paid sick leave mandate.

Prescription Drug Dispensing and Patient Costs After Implementation of a No Behavioral Health Cost-Sharing Law.

Importance: On January 1, 2022, New Mexico implemented a No Behavioral Cost-Sharing (NCS) law that eliminated cost-sharing for mental health and substance use disorder (MH/SUD) treatments in plans regulated by the state, potentially reducing a barrier to treatment for MH/SUDs among the commercially insured; however, the outcomes of the law are unknown. Objective: To assess the association of implementation of the NCS with out-of-pocket spending for prescription for drugs primarily used to treat MH/SUDs and monthly volume of dispensed drugs. Design, Settings, and Participants: This retrospective cohort study used a difference-in-differences research design to examine trends in outcomes for New Mexico state employees, a population affected by the NCS, compared with federal employees in New Mexico who were unaffected by NCS. Data were collected on prescription drugs for MH/SUDs dispensed per month between January 2021 and June 2022 for New Mexico patients with a New Mexico state employee health plan and New Mexico patients with a federal employee health plan. Data analysis occurred from December 2022 to January 2024. Exposure: Enrollment in a state employee health plan or federal health plan. Main Outcomes and Measures: The primary outcomes were mean patient out-of-pocket spending per dispensed MH/SUD prescription and the monthly volume of dispensed MH/SUD prescriptions per 1000 employees. A difference-in-differences estimation approach was used. Results: The implementation of the NCS law was associated with a mean (SE) $6.37 ($0.30) reduction (corresponding to an 85.6% decrease) in mean out-of-pocket spending per dispensed MH/SUD medication (95% CI, -$7.00 to -$5.75). The association of implementation of NCS with the volume of prescriptions dispensed was not statistically significant. Conclusions and Relevance: These findings suggest that the implementation of the New Mexico NCS law was successful in lowering out-of-pocket spending on prescription medications for MH/SUDs, but that there was no association of NCS with the volume of medications dispensed in the first 6 months after implementation. A key challenge is to identify policies that protect from high out-of-pocket spending while also promoting access to needed care.

TennCare Disenrollment Led To Increased Eviction Filings And Evictions In Tennessee Relative To Other Southern States.

Previous research suggests that enrolling in Medicaid reduces evictions by improving health and providing financial protection. However, previous studies have not examined whether the loss of Medicaid affects eviction outcomes. We analyzed eviction filings and completed evictions after a large, mandatory Medicaid disenrollment in Tennessee in 2005. We conducted a difference-in-differences analysis using data from the Eviction Lab at Princeton University and found that relative to other southern states, the TennCare disenrollment led to a 27.6 percent greater increase in the average annual number of eviction filings at the county level during the period 2005-09 and a 24.5 percent greater increase in the average annual number of completed evictions at the county level during that same period. Our findings have implications for the housing stability of Medicaid recipients today, many of whom are being disenrolled because of the unwinding of the Medicaid continuous enrollment provision that is occurring across the country. To protect housing stability for people disenrolled from Medicaid, policy makers may wish to consider new initiatives aimed at preventing an increase in eviction.

Evictions and psychiatric treatment.

Stable housing is critical for health, employment, education, and other social outcomes. Evictions reflect a form of housing instability that is experienced by millions of Americans each year. Inadequately treated psychiatric disorders have the potential to influence evictions in several ways. For example, these disorders may impede labor market performance and thus the ability to pay rent, or increase the likelihood of risky and/or nuisance behaviors that can lead to a lease violation. We estimate the effect of local access to psychiatric treatment on eviction rates. We combine data on the number of psychiatric treatment centers that offer outpatient and residential care within a county with eviction rates in a two-way fixed-effects framework. Our findings imply that 10 additional psychiatric treatment centers in a county lead to a reduction of 2.1% in the eviction rate.

Does paid sick leave encourage staying at home? Evidence from the United States during a pandemic.

We study the impact of a temporary U.S. paid sick leave mandate that became effective April 1st, 2020 on self-quarantining, proxied by physical mobility behaviors gleaned from cellular devices. We study this policy using generalized difference-in-differences methods, leveraging pre-policy county-level heterogeneity in the share of workers likely eligible for paid sick leave benefits. We find that the policy leads to increased self-quarantining as proxied by staying home. We also find that COVID-19 confirmed cases decline post-policy.

Medicaid reimbursement rates for primary care services and behavioral health outcomes.

We study the effects of changing Medicaid reimbursement rates for primary care services on behavioral health outcomes-defined here as mental illness and substance use disorders. Medicaid enrollees are at elevated risk for these, and other, chronic conditions and are likely to have unmet treatment needs. We apply two-way fixed-effects regressions to survey data specifically designed to measure behavioral health outcomes over the period 2010-2016. We find that higher primary care reimbursement rates reduce mental illness and substance use disorders among non-elderly adult Medicaid enrollees, although we interpret findings for substance use disorders with some caution as they may be vulnerable to differential pre-trends. Overall, our findings suggest positive spillovers from a policy designed to target primary care services to behavioral health outcomes.

Recreational cannabis and opioid distribution.

Twenty-one U.S. states have passed recreational cannabis laws as of November 2022. Cannabis may be a substitute for prescription opioids in the treatment of chronic pain. Previous studies have assessed recreational cannabis laws' effects on opioid prescriptions financed by specific private or public payers or dispensed to a unique endpoint. Our study adds to the literature in three important ways: by (1) examining these laws' impacts on prescription opioid dispensing across all payers and endpoints, (2) adjusting for important opioid-related policies such as opioid prescribing limits, and (3) modeling opioids separately by type. We implement two-way fixed-effects regressions and leverage variation from eleven U.S. states that adopted a recreational cannabis law (RCL) between 2010 and 2019. We find that RCLs lead to a reduction in codeine dispensed at retail pharmacies. Among prescription opioids, codeine is particularly likely to be used non-medically. Thus, the finding that RCLs appear to reduce codeine dispensing is potentially promising from a public health perspective.

Intended and unintended effects of e-cigarette taxes on youth tobacco use.

Over the past decade, rising youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) has contributed to aggressive regulation by state and local governments. Between 2010 and mid-2019, ten states and two large counties adopted ENDS taxes. We use two large national surveys (Monitoring the Future and the Youth Risk Behavior Surveillance System) to estimate the impact of ENDS taxes on youth tobacco use. We find that ENDS taxes reduce youth ENDS consumption, with estimated ENDS tax elasticities of -0.06 to -0.21. However, we estimate sizable positive cigarette cross-tax effects, suggesting economic substitution between cigarettes and ENDS for youth. These substitution effects are particularly large for frequent cigarette smoking. We conclude that the unintended effects of ENDS taxation may considerably undercut or even outweigh any public health gains.

The effect of cigarette and e-cigarette taxes on prescriptions for smoking cessation medications.

OBJECTIVE: To test the effect of cigarette and e-cigarette taxes on prescriptions for smoking cessation medications. DATA SOURCE: Symphony Health, IDV all-payer prescription claims data for the United States over the period 2009-2017. Prescription fills for smoking cessation products were provided at the patient's age, patient's sex, brand/generic, payment type, year, and quarter levels. STUDY DESIGN: We study the effect of state-level cigarette and e-cigarette tax rates on prescriptions for smoking cessation medications using two-way fixed effect modified difference-in-differences regressions. We also use a multiperiod difference-in-differences estimator robust to bias from dynamic and heterogeneous treatment effects with a staggered policy rollout. DATA COLLECTION/EXTRACTION METHODS: We use fills for Chantix, Zyban, and their generics, as well as Food and Drug Administration-approved nicotine replacement therapies that are paid for by insurance. PRINCIPAL FINDINGS: We observe no statistically significant change in prescription fills following an increase in the e-cigarette tax rate, though we are unable to rule out potentially large effects. However, following a $1.00 increase in the cigarette tax rate, we observe a 1052 increase in prescription fills per 100,000 adults (95% CI: 57, 2046; 4.2% increase). The effect of cigarette taxes on prescription fills was particularly large for 18-34 year-olds. CONCLUSIONS: Our findings suggest that, during a period when e-cigarettes are widely available, cigarette tax increases remain effective in increasing use of these medications, but e-cigarette taxes do not increase use of these medications.

The effect of e-cigarette taxes on prepregnancy and prenatal smoking.

E-cigarette taxes are an active area of legislation and have important regulatory implications by proxying e-cigarette accessibility. We examine the effect of e-cigarette taxes on prepregnancy and prenatal smoking using the near-universe of births to mothers conceiving between 2013 and 2019 in the United States. Using fixed effect regressions, we show that e-cigarette taxes increase prepregnancy and prenatal smoking. We also find evidence that e-cigarette taxes reduce prepregnancy and 3rd trimester e-cigarette use. Finally, we show that e-cigarette taxes increase news coverage of e-cigarettes and raise perceptions of risk of e-cigarettes.

Office-based mental healthcare and juvenile arrests.

We estimate the effect of local access to office-based mental healthcare on juvenile arrest outcomes. We leverage variation in the number of offices of physicians and non-physicians specializing in mental healthcare in a county over the period 1999-2016 in a two-way fixed-effects regression. Office-based treatment is the most common modality of mental healthcare received by juveniles. We find that 10 additional offices of physicians and non-physicians specializing in mental healthcare in a county leads a decrease of 2.3%-2.6% in the per capita costs to society of juvenile arrest. Findings are similar for arrest rates although often less precise, which suggests that accounting for social costs is empirically important. Crime imposes substantial costs on society and individuals, and interventions during early life can have more pronounced effects than those received at later stages, therefore our results imply increased juvenile access to mental healthcare may have an unintended benefit for the current and future generations.

Prenatal Substance Use Policies And Infant Maltreatment Reports.

We studied the effect of state punitive and supportive prenatal substance use policies on reports of infant maltreatment to child protection agencies. Punitive policies criminalize prenatal substance use or define it as child maltreatment, whereas supportive policies provide pregnant women with priority access to substance use disorder treatment programs. Using difference-in-differences methods, we found that total infant maltreatment reports increased by 19.0 percent after punitive policy adoption during the years of our study (2004-18). This growth was driven by a 38.4 percent increase in substantiated reports in which the mother was the alleged perpetrator. There were no changes in unsubstantiated reports after the adoption of punitive policies. We observed no changes in infant maltreatment reports after the adoption of supportive policies. Findings suggest that punitive policies lead to large increases in substantiated infant maltreatment reports, which in turn may lead to child welfare system involvement soon after childbirth in states with these policies. Policy makers should design interventions that emphasize support services and improve well-being for mothers and infants.

Prenatal substance use policies and newborn health.

We study the effect of punitive and priority treatment policies relating to illicit substance use during pregnancy on the rate of neonatal drug withdrawal syndrome, low birth weight, low gestational age, and prenatal care use. Punitive policies criminalize prenatal substance use, or define prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for termination of parental rights. Priority treatment policies are supportive and grant pregnant women priority access to substance use disorder treatment programs. Our empirical strategy relies on administrative data from 2008 to 2018 and a difference-in-differences framework that exploits the staggered implementation of these policies. We find that neonatal drug withdrawal syndrome increases by 10%-18% following the implementation of a punitive policy. This growth is accompanied by modest reductions in prenatal care, which may reflect deterrence from healthcare utilization. In contrast, priority treatment policies are associated with small reductions in low gestational age (2%) and low birth weight (2%), along with increases in prenatal care use. Taken together, our findings suggest that punitive approaches may be associated with unintended adverse pregnancy outcomes, and that supportive approaches may be more effective for improving perinatal health.

Institutions For Mental Diseases Medicaid Waivers: Impact On Payments For Substance Use Treatment Facilities.

The Institutions for Mental Diseases (IMD) exclusion prohibits use of federal Medicaid funds to treat enrollees ages 21-64 in psychiatric residential treatment facilities that have more than sixteen beds. In 2015 the federal government created a streamlined application pathway for state waivers of this rule to allow Medicaid coverage for substance use disorder (SUD) treatment in residential facilities. Nine states received IMD waivers during the period 2015-18. Using data from the 2010-18 National Survey of Substance Abuse Treatment Services, we examined changes in residential and outpatient SUD treatment facilities' acceptance of Medicaid and other types of health coverage, as well as self-pay arrangements and provision of charity care, after states' adoption of IMD waivers. Acceptance of Medicaid increased 34 percent at residential treatment facilities and 9 percent at intensive outpatient facilities two years after waiver implementation. Delivery of medications for opioid use disorder did not increase in residential facilities post waiver but did increase to some extent in outpatient facilities. Our findings suggest that IMD waivers may be an important tool for advancing access to a full continuum of SUD treatment for Medicaid enrollees.

Do expansions in adolescent access to public insurance affect the decisions of substance use disorder treatment providers?

We apply a mixed-payer economy model to study the effects of changes in the generosity of children's public health insurance programs - measured by Medicaid and Children's Health Insurance Program income thresholds - on substance use disorder (SUD) treatment provider behavior. Using government data on specialty SUD treatment providers over the period 1997-2011 combined with a two-way fixed-effects model and local event study, we show that increases in the generosity of children's public health insurance induce providers to participate in some, but not all, public markets. Our effects appear to be driven by non-profit and government providers. Non-profit providers also appear to increase treatment quantity slightly in response to coverage expansions.

Information and sin goods: Experimental evidence on cigarettes.

We test the importance of information source on consumer choice in the context of sin goods, specifically electronic and tobacco cigarettes, among adult smokers. We proxy choice with intentions to vape and quit smoking in the next 30 days. We experimentally vary the information source: government, private companies, physicians, and no source. Our findings suggest that information source matters in the context of cigarettes choice for adult smokers. Private companies appear to be an important information source for cigarettes among adult smokers.

Marijuana legalization and disability claiming.

We study the effect of recent legalization of recreational marijuana use laws (RMLs) in the United States on new applications and allowances for Social Security Disability Insurance and Supplemental Security Income over the period 2001-2019. We combine administrative caseload data from the Social Security Administration with state policy changes using two-way fixed-effects methods. We find that RML adoption increases applications for both benefits. However, there is no change in allowances post-RML. We provide suggestive evidence that the observed changes in applications post-RML are driven by increases in marijuana misuse and selective migration, and decreases in unemployment.

Insurance expansions and adolescent use of substance use disorder treatment.

OBJECTIVE: To provide evidence on the effects of expansions to private and public insurance programs on adolescent specialty substance use disorder (SUD) treatment use. DATA SOURCE/STUDY SETTING: The Treatment Episodes Data Set (TEDS), 1996 to 2017. STUDY DESIGN: A quasi-experimental difference-in-differences design using observational data. DATA COLLECTION: The TEDS provides administrative data on admissions to specialty SUD treatment. PRINCIPAL FINDINGS: Expansions of laws that compel private insurers to cover SUD treatment services at parity with general health care increase adolescent admissions by 26% (P < .05). These increases are driven by nonintensive outpatient admissions, the most common treatment episodes, which rise by 30% (P < .05) postparity law. In contrast, increases in income eligibility for public insurance targeting those 6-18 years old are not statistically associated with SUD treatment. CONCLUSIONS: Private insurance expansions allow more adolescents to receive SUD treatment, while public insurance income eligibility expansions do not appear to influence adolescent SUD treatment.

The effect of increased cost-sharing on low-value service use.

We examine the effect of a value-based insurance design (VBID) program implemented at a large public employer in the state of Oregon. The program substantially increased cost-sharing for several healthcare services likely to be of low value for most patients: diagnostic services (e.g., imaging services) and surgeries (e.g., spinal surgeries for pain). Using a difference-in-differences design coupled with granular, administrative health insurance claims data over the period 2008-2012, we estimate the change in low-value service use among beneficiaries before and after program implementation relative to a comparison group not exposed to the VBID. Our findings suggest that the VBID significantly reduced the use of targeted services, with an implied elasticity of demand of -0.22. We find no evidence that the VBID led to substitution to non-targeted services or increased overall healthcare costs. However, we also observe no evidence that the program led to cost-savings.